A U S T R A L I A N N U R S I N G & M I D W I F E RY J O U R N A L VOLUME 22, NO. 3
SEPTEMBER 2014
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Editorial Lee Thomas, ANMF Federal Secretary It’s been a busy couple of months. Assistant Federal Secretary Annie Butler and I have been attending Annual Delegate Conferences and professional days across the country. I’ve enjoyed this time immensely as it’s been a great opportunity to get reacquainted with many of you and speak one-on-one about issues that concern you. The last professional days and Delegates’ Conference that I attended was in my home town Adelaide - lovely to see so many familiar faces and some new ones too. At this conference I took the opportunity to speak about something close to my heart- aged care. As many of you are well aware we campaigned long and hard to improve wages for nurses and carers in the sector, resulting in a workforce supplement. However the money allocated for the supplement disappeared abruptly when the coalition government took power last year. This funding has now gone back into general revenue, which effectively means there is no transparency about how we can access this money. So unfortunately this means we are now back at the begging bowl when bargaining for the sector. Currently, wages in aged care for a registered nurse is around $261 less on average nationally than nurses working in public or private hospitals. It’s an absolute disgrace and we will not give up in trying to fix this situation. The removal of the dementia and severe behaviour supplement is another significant issue that has recently arisen in this sector. While the supplement has been assigned to be ‘repurposed’, it is absolutely imperative this money stays in the sector and clearly earmarked for people who have the most
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severe and most challenging behaviours. Hence the ANMF will be looking to work with Alzheimer’s Australia, COTA and other organisations about ensuring this supplement is maintained. As I said at the Adelaide Delegates’ Conference, and I reiterate to you, the union as an organisation respects and knows the importance of aged care, the workers and the care that you provide in the sector. We will therefore continue to campaign for change for better outcomes in terms of wages, staffing and skill mix. Ultimately this is because we all want to ensure that the resident, the care recipient, continues to receive high quality care, and therefore we will continue to lobby to this end. Another area of important work being done by the professions is in remote and rural locations. Working in harsh conditions at times can be very challenging, but as you will read in this month’s feature many of the nurses and midwives working in these areas are up for the challenge. This month’s Focus section looks at infection control practices and the research that is being done in this area. The Federal Professional team report is about their recent work around cultural safety and respect, which you can read about on page 23. As a sign off I want to take this opportunity to thank everyone who has supported our online healthcare emergency campaign - ‘Lies, Cuts and Broken Promises’. Your support will ensure we overturn the detrimental budget cuts made to healthcare and education at the last Budget. If you have not done so already I urge you to pledge your support by going to: www.anmftakeaction.org.au
September 2014 Volume 22, No.3 1
Australian Nursing & Midwifery Federation National Office www.anmf.org.au
Canberra
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Editorial
Melbourne & ANMJ
Level 1, 365 Queen Street, Melbourne Vic 3000 Phone (03) 9602 8500 Fax (03) 9602 8567 Email anmfmelbourne@anmf.org.au
Federal Secretary Lee Thomas
Assistant Federal Secretary Annie Butler
Editor: Kathryn Anderson Production Manager: Cathy Fasciale Level 1, 365 Queen Street, Melbourne Vic 3000 Phone (03) 9602 8500 Fax (03) 9602 8567 Email anmj@anmf.org.au
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Australian Capital Territory Branch Secretary Jenny Miragaya Office address Unit 3, 36 Botany Street, Phillip ACT 2606 Postal address PO Box 1995, Woden ACT 2606 Ph: (02) 6282 9455 Fax: (02) 6282 8447 E: anmfact@anmfact.org.au
Northern Territory
South Australia
Victoria
Branch Secretary Yvonne Falckh Office address 16 Caryota Court, Coconut Grove NT 0810 Postal address PO Box 42533, Casuarina NT 0810 Ph: (08) 8920 0700 Fax: (08) 8985 5930 E: info@anmfnt.org.au
Branch Secretary Elizabeth Dabars Office address 191 Torrens Road, Ridleyton SA 5008 Postal address PO Box 861 Regency Park BC SA 5942 Ph: (08) 8334 1900 Fax: (08) 8334 1901 E: enquiry@anmfsa.org.au
Branch Secretary Lisa Fitzpatrick Office address ANMF House, 540 Elizabeth Street, Melbourne Vic 3000 Postal address PO Box 12600 A’Beckett Street Melbourne Vic 8006 Ph: (03) 9275 9333 Fax (03) 9275 9344 Information hotline 1800 133 353 (toll free) E: records@anmfvic.asn.au
The Australian Nursing & Midwifery Journal is delivered free monthly to members of ANMF Branches other than New South Wales, Queensland and Western Australia. Subscription rates are available on (03) 9602 8500. Nurses who wish to join the ANMF should contact their state branch. The statements or opinions expressed in the journal reflect the view of the authors and do not represent the official policy of the Australian Nursing & Midwifery Federation unless this is so stated. Although all accepted advertising material is expected to conform to the ANMF’s ethical standards, such acceptance does not imply endorsement. All rights reserved. Material in the Australian Nursing & Midwifery Journal is copyright and may be reprinted only by arrangement with the Australian Nursing & Midwifery Federation Federal Office Note: ANMJ is indexed in the CUMULATIVE INDEX to NURSING AND ALLIED HEALTH LITERATURE and the INTERNATIONAL NURSING INDEX ISSN 2202-7114
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New South Wales
Queensland
Tasmania
Western Australia
Branch Secretary Brett Holmes Office address 50 O’Dea Avenue, Waterloo NSW 2017 Ph: 1300 367 962 Fax: (02) 9662 1414 E: gensec@nswnma.asn.au
Branch Secretary Beth Mohle Office address 106 Victoria Street West End Qld 4101 Postal address GPO Box 1289 Brisbane Qld 4001 Phone (07) 3840 1444 Fax (07) 3844 9387 E: qnu@qnu.org.au
Branch Secretary Neroli Ellis Office address 182 Macquarie Street Hobart Tas 7000 Ph: (03) 6223 6777 Fax: (03) 6224 0229 Direct information 1800 001 241 (toll free) E: enquiries@anmftas.org.au
Branch Secretary Mark Olson Office address 260 Pier Street, Perth WA 6000 Postal address PO Box 8240 Perth BC WA 6849 Ph: (08) 6218 9444 Fax: (08) 9218 9455 1800 199 145 (toll free) E: anf@anfwa.asn.au
2 September 2014 Volume 22, No. 3
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.
CIRCULATION 96,450 Source: BCA verified audit, March 2014
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Contents
Volume 22, No 3.
News
5
World 16 Feature 18
18
Professional 23
Nursing beyond the bush
Legal 27
Reflections 24 Tech talk
Feature
Clinical update
25
28
Focus 32 Education 44 Calendar 47 Mail 48
5
News
Funding for dementia research but cuts to dementia care?
25
Tech talk
Printing a new way to personalised health
28
Clinical update
High flow nasal cannula oxygen therapy for infants and young children with bronchiolitis
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32
Focus
Infection control
September 2014 Volume 22, No.3 3
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News Nurses and midwives commence industrial action over wage freeze Tasmanian nurses and midwives have commenced industrial action in response to the state government’s plan to freeze their agreed career structure, conditions and wages. The planned action, which includes doing unpaid administration work that usually occurs in hospitals after hours, was commenced 25 August as ANMJ was going to print. Members voted to take the action after the state government announced it was legislating a 12 month wage and increment freeze for all public sector employees. Australian Nursing & Midwifery Federation (ANMF) Tasmanian Branch Secretary Neroli Ellis said the ANMF was very
disappointed the government had broken long held industrial principles by overriding the industrial relations system through legislation rather than negotiating to vary the agreements. “Nurses and midwives progress on annual increments through the base grade positions capped at eight years and this career progression is implemented across Australia. By holding back annual progression, a grade three nurse year four will be meaningless and again disadvantage Tasmanian nurses and midwives. “The government has not carefully considered this impact and it shows a blatant disregard to nurses and midwives at a time when they are working continuous double shifts to support safe patient care and prop up our health system.”
Funding for dementia research but cuts to dementia care? New Dementia Research Team Grants worth up to $6.5million each will be offered by the government over five years. The government announced the grants a few days after 1 August when the Dementia and Severe Behaviours Supplement (DSBS) was axed. Shadow Minister for Ageing Shayne Neumann said as aged care providers were now unable to access the extra funding support provided by the DSBS they would have to reassess whether they could afford to invest in dementia-specific initiatives.
ANMF Federal Secretary Lee Thomas speaking at the ANMF (SA Branch) Delegates Conference and professional Days
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Australian Nursing & Midwifery Federation (ANMF) Federal Secretary Lee Thomas said research into dementia was welcomed but the care of those already living with the condition was as equally important. “To alleviate dementia questions into prevention, cures and care need to be answered through
The Joint Unions Rally in Hobart
research no doubt, however it is crucially important that we look after those already afflicted with the disease by ensuring they are properly cared for.” Speaking at the ANMF (SA Branch) Professional day last month Ms Thomas said the government had announced the DSBS funding was to be ‘repurposed’. “It is unclear at this stage what ‘repurpose’ means, but it’s absolutely imperative that the money stays in the sector, earmarked for those people who have the most severe and most challenging behaviours. The ANMF will be lobbying to ensure these people are continued to be supported.” Ms Thomas said she was also alarmed that the federal government was scrapping the aged care payroll tax reimbursement that was paid to aged care providers. “I am very concerned money will continue to go from the sector at a time that we can least afford it.” Ms Thomas affirmed the ANMF would continue to campaign for the sector to ensure better outcomes and high quality care for those requiring aged care services. September 2014 Volume 22, No.3 5
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Outstanding nurse, outstanding future. If you’re just as motivated about patient care as you are about health reform, then postgraduate nursing at QUT is the best way to an outstanding career.
You can be confident that you’ll learn from influential leaders in Australian nursing, and that our courses are informed by QUT nursing research which is independently ranked as above world standard. Flexible external and part-time options are available.
Find out how to send your career skywards at QUT’s online postgraduate options evening, Wednesday 15 October. Register now at www.qut.edu.au/postgraduate-nursing CRICOS No.00213J © QUT 2014 HLT-14-1221 20334
If you are a clinician, manager, policy maker or quality manager in health care, you probably see the need for change every day. Do you think, with the right skills you could make a difference? The Joanna Briggs Institute is offering the Evidence-Based Clinical Fellowship Program to help empower you to improve patient outcomes and give you and your career, the LEAP forward you know you deserve. This course will give you the skills to: Lead your team in an Evidence implementation project of your design, Audit for improvement in health outcomes, and, Publish your findings. To find out more visit: www.joannabriggs.org
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News
Courtesy the ANMF (SA Branch).
Union aid providing better lives globally The day registered nurse Dr Helen McCue found herself in Beirut, lying on a small mattress on a cold cement floor in a bombed out hospital used as a Palestine refugee camp, was the day she decided to create the union humanitarian movement - Union Aid Abroad-APHEDA. Thirty two years ago Dr McCue (pictured) was employed as a nurse consultant with the World Health Organization (WHO) in Lebanon in the Middle East, where she worked on a unit responsible for Palestine refugees. Dr McCue said during that time a horrific massacre took place in the camp where over 2,000 women and children were brutally slaughtered over two nights by Lebanese Christian militia overseen by the Israeli army. “Shocked and sickened by this war crime and the failure of the United Nations to protect these refugees I resigned and went to Beirut and worked as a nurse volunteer at the camp.” While working at the camp Dr McCue was confronted by the survivors of the massacre, all suffering physical and psychological wounds. Living and working in the community it soon became apparent there was a need to rehabilitate the shattered workers themselves. “Many doctors and nurses had been killed; many imprisoned by the Israelis or disappeared. While the international community provided immediate post humanitarian anmf.org.au
relief, no aid organisation was helping to skill or reskill nurses and other health workers. I strongly felt that Australia should be doing much more.” As a committed Australian Nursing Federation member, Dr McCue returned to Australia in 1983 with the idea of setting up a trade based union humanitarian organisation. The aim of the organisation was to support humanitarian efforts and mobilise workers who were struggling for the key rights of freedom, security, peace, education and health. Gaining the support of the ACTU, Union Aid Abroad-APHEDA was born and now has the financial support of 85 unions, including the ANMF, and individual memberships. Union Aid Abroad-APHEDA has multiple projects across the globe, which includes workers skill training schemes in education and health and occupational support and safety. “Occupational safety has been one of our major areas of developing assistance. We are one of the only development agencies in Australia who is working in this area such as improving OHS in the use of pesticides in the agricultural sector, industrial accidents, safety issues in mining and the dangerous use of chemicals.” Health initiatives such as nurses assisting nurses through the nurse link program and other health programs have been supported
by ANMF Branches. These include the construction of health facilities in disaster regions, family planning and work on HIV and AIDS. “Through all these projects Australian nurses have practically or through funding specific projects have significantly transformed both practising care and education globally,” Dr McCue said. The countries APHEDA works in include Afghanistan, Cambodia, Cuba, East Timor, Indonesia, Laos, South Africa, Sri Lanka, Thai-Burmese border, the Middle East, the Pacific and the Philippines. Dr McCue said Union Aid Abroad-APHEDA’s global work would not have been possible without the collective commitment of the Australian Trade Union movement including nurses. “Across the globe hundreds of thousands of people have benefited from this work and hundreds of nurses and health workers now have access to training which has improved practise of care.” Dr McCue spoke at the ANMF (SA Branch) professional day last month to a standing ovation. Immediately after the presentation, nurses and midwives at the event raised $1,300 in gold coin donations for Union Aid Abroad-APHEDA. The ANMF (SA Branch) matched the donations in full and any other donations made from members over the following two weeks. To learn more about APHEDA or to donate go to: www.apheda.org.au September 2014 Volume 22, No.3 7
News
According to Donna the CHIA credential demonstrates that candidates meet the health informatics core competencies to perform safely and effectively as health informatics professional in a broad range of settings.
Nurse informatics expert recognised Aged care nurse Donna Barton (pictured) is the first nurse in Australia to become a Certified Health Informatician Australasia (CHIA). Donna, who works as a health informatics manager, was accepted for CHIA on the basis of her resume and experience. “Fortunately I was accepted and then I spent a few months of hard study. There are six domains of expertise and some 52 competencies within.”
An app driven by midwives An app that will help improve information midwives give to new mothers to be has been developed as a result of a health communication study from the Adelaide University. The three year study revealed that midwives at a South Australian hospital have already been trying to raise the level of health literacy among their patients by providing informal advice and printed material. However a more standardised approach was needed to make this role effective and improve health. Adelaide University’s research midwife Julie Dalton said the study indicated women were keen for mobile technology, such as a phone app. “All pregnant
8 September 2014 Volume 22, No. 3
The certification came about because of the lack of formal recognition for health informatics skills in the Australian health workforce, particularly for nurses, Donna said. “CHIA is a unique program for health informatics. It has been developed by the Health Informatics Society of Australia, the Australasian College of Health Informatics and the Health Information Management Association of Australia.” Donna said to gain the certification was an important step for nurse informatics specialists and for nursing. “To build a 21st century workforce we will need nurses that are competent in managing information, interpreting the information and delivering care in an e-heath world. Nurses will need to understand the use of devices, new technologies and e-tools.” As nurses are the largest cohort in healthcare settings, Donna said they are well placed to drive e-health and its adoption. “Nurses will be playing a major role in facilitating and empowering
women seem to have a mobile phone, regardless of their socio-economic grouping. What we found was that they were keen for mobile technology, like a phone app because they want information that is easy to read easy to understand, but also very relevant to their own situation to where they are living rather than getting information from the internet overseas and finding it a bit confusing.” Ms Dalton said as a consequence of the research an app was developed that was engaging, free and easy to access information. “We are currently trialling the app for pregnant women between 12 weeks and 22 weeks, which looks at how the mother to be is changing and how their baby is developing.” The app also looks at common problems the woman might experience and gives information about diet, exercise and relaxation.
people to be involved in their own care management, they will be advocates for older folk and others to have accessibility to their healthcare information by introducing them to the emerging technologies.” Donna believes that nurses will assist in the challenges for consumers around advocacy and social inclusion and therefore will need to understand social media and its use in the profession. “Participatory health promotes consumer and patient engagement and the use of self-monitoring devices and ambient technologies and apps must be understood fully by the future workforce.” Gaining the certification has given Donna a great sense of achievement. “I am an older RN in my 50’s and I have worked in the aged care sector in operational roles. I am a hospital trained nurse and it’s important to me to encourage all those in my age group to see that our skills and expertise are very much needed and can be used in the future workforce.” Donna said she wants to mentor young nurses to embrace the use of information and communication technologies to get the best outcomes for patients in any healthcare setting. “Perhaps some will become nurse informaticians.”
Ms Dalton said an important aspect of the app is giving information about trusted websites. “If they want to seek more information we are sending them to relevant Australian websites that talk about what is done here rather than what is done in America.” Additionally the app provides relevant phone numbers to support services such as quit line, the drug and alcohol support services and multiple birth services, Ms Dalton said. In the future Ms Dalton would like to develop an app for women that would be applicable from the time of conception to the first hospital appointment. “I would also like an app that is designed with the core information about pregnancy and birth, but also tailored with specific information for each hospital.”
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When pain is gone, playing resumes.
Nothing starts to work faster on pain and fever † 1–6
Children’s Panadol® works fast to relieve pain and fever caused by teething, headache, earache, immunisation, and symptoms of cold and flu.7
Refers only to non-prescription medicines and is based on the liquid paracetamol formulation given at a dosage of 15 mg/kg. References: 1. Celebi S et al. Indian Journal of Pediatrics 2009;76:287–91. 2. Autret-Leca E et al. Current Medical Research and Opinion 2007;23:2205–2211. 3. Walson PD et al. American Journal of Diseases of Children 1992;146:626–632. 4. Clark E et al. Pediatrics 2007;119:460–467. 5. Hamalainen ML et al. Neurology 1997;48:103–107. 6. Schachtel BP et al. Clinical Pharmacology and Therapeutics 1993;53:593–601. 7. Children’s Panadol Approved Product Information, last updated November 2009. Children’s Panadol® contains paracetamol. For the temporary relief of pain and fever. CHILDREN’S PANADOL is a registered trade mark of the GlaxoSmithKline group of companies. GlaxoSmithKline Consumer Healthcare, 82 Hughes Avenue, Ermington NSW 2115 Australia. 08/14 GSK1260/UC.
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Mercy Health is a Catholic organisation grounded in a 2,000-year tradition of caring for others. Founded by the Sisters of Mercy, Mercy Health employs over 5,000 people who provide acute and sub-acute hospital care, aged care, mental health programs, maternity and specialist women’s health services, early parenting and home care services, and health-worker training and development. Mercy Health employs people from many cultures and backgrounds who, irrespective of their beliefs, share a common bond to care for those in need. An opportunity exists for a motivated and experienced Registered Nurse with Post Graduate qualifications in Perioperative nursing, to become part our leadership team within the Perioperative Services Department. • Our unit caters for women who require specialist surgical care in Obstetrics, Urogynaecology, Reproductive Medicine, Gynaecological Oncology, Endosurgery and General Gynaecology.
As a highly organised and motivated team member, you will possess excellent clinical and interpersonal skills coupled with a strong customer care focus. With a varied and interesting surgical mix, your ability to work collaboratively within our multi-disciplinary team will enable you to embrace the diversity that this role offers. This is a fantastic opportunity to join an award winning organisation and take the next step in your career. Attractive salary packaging benefits and a wide range of health and wellbeing initiatives are available. To be the successful candidate you must meet the position requirements as well as provide a current Police Record and Working with Children Check. Enquiries to: Louise Alexander, Nurse Unit Manager, Perioperative Services on 8458 4108 Quote Ref No: MHW 04
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For more information and to apply please visit www.careers.mercy.com.au
News Nurse involvement in IT systems equals better outcomes Involving nurses in the development of clinical informatics systems is key to the acceptability, fidelity and usability, according to a nurse informatics specialist from Deakin University.
Speaking at the Nursing Informatics Conference held in Melbourne last month, Dr Bernice Redley (pictured) from Deakin University spoke about the clinical informatics systems project and ongoing research being conducted at one of Melbourne’s major hospital through the School of Nursing at Deakin University and with an organisation called Smart Board. Dr Redley said the purpose of the system was to help reduce the patient to safety risk and replace the current paperwork nursing documentation system. “The aim is around supporting quality and safety of nursing processes with the focus on acceptability, usability and fidelity because we recognise that these had the greatest implications for patient safety. What we don’t want to be doing is introducing a system that can compromise patient safety.” To assure the system’s success the developers had to find ways to engage nurses so that they would accept it as part of their work practices. “Traditionally nurses are reasonably poor at adopting contemporary IT systems.
Evidence in the literature suggests that systems aren’t really tailored to fit in a way that nurses’ work,” said Dr Redley. As a consequence Dr Redley said they took a different approach to developing the system. Rather than making data collection a priority, the system was created to help nurses do their work foremost. “Nurses are very busy people. Every minute of every day is consumed with what they do. So what IT system should be doing is supporting nurses to get their work done more efficiently and in a timely way rather than distracting them and taking away their time.” From the initial trial of the system 96% of nurses engaged with its implementation, Dr Redley said. “There have been significant increases in documentation, increased time doing nurse assessments and there has been time released for the nurses and it has also prompted some work practices. “By implementing this program we demonstrated fidelity in work practices. We demonstrated high levels of usability and also demonstrated enhancement to work practices.”
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Reference: 1. Children’s Panadol Approved Product Information, last updated November 2009. Childrens Panadol® contains paracetamol. For the temporary relief of pain and fever. CHILDRENS PANADOL is a registered trade mark of the GlaxoSmithKline group of companies. GlaxoSmithKline Consumer Healthcare, 82 Hughes Avenue, Ermington NSW 2115 Australia. 08/14 GSK1154/UC/NEW. CHANZ/CHPAN/0269/14a.
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*Guidelines recommend paracetamol for the first-line treatment of pain and fever in children.1 References: 1. NSW Department of Health. Policy Directive: Paracetamol Use. Accessed at http://www.health.nsw.gov.au/policies/pd/2009/PD2009_009.html on September 2012. 2. Children’s Panadol Approved Product Information, last updated November 2009. 3. NSW Department of Health. Infants and children: Acute management of fever. Clinical Practice Guidelines, 2nd edition, 2010. Available at: http://www.ciap.health.nsw.gov.au. Accessed September 2012. Childrens Panadol® contains paracetamol. For the temporary relief of pain and fever. CHILDRENS PANADOL is a registered trade mark of the GlaxoSmithKline group of companies. GlaxoSmithKline Consumer Healthcare, 82 Hughes Avenue, Ermington NSW 2115 Australia. 07/14 GSK1261/UC.
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News Birthweight improves for Indigenous babies Low birthweight babies born to Aboriginal and Torres Strait Islander mothers has significantly fallen, according to the latest report by the Australian Institute of Health and Welfare (AIHW). Matron Grace Wilson (centre) with staff of the 3rd AGH in Cairo, 1916. Photo courtesy of the Australian War Memorial
Scholarship honours WW1 nurse and midwife World war one nurses are being remembered with the launch of a $30,000 scholarship for past Australian Defence Force (ADF) nurses or for nurses serving in the reserve forces to undertake postgraduate studies. The Matron Grace Wilson RSL SED Scholarship, offered by the RSL in conjunction with the University of Queensland (UQ), honours Queensland nurse and midwife Grace Wilson for providing her mettle treating ANZAC casualties on the Greek Island Lemos during World War One. Ms Wilson, who served with the Australian Imperial Force, said the conditions where she treated ANZAC casualties was “too awful for words”. RSL South Eastern District President and former Royal Australian Army Nursing Corps member, Wendy Taylor said the scholarship recognised the contributions of all ADF nurses at home and abroad
during war and peacekeeping missions. “The Matron Grace Wilson RSL SED Scholarship aligns with the mission of the RSL to preserve the memory of the fallen and appeal to younger veterans entering the healthcare system. The creation of this scholarship assists in preserving the memory of those brave service personnel for future generations.” Acting Head of the School of Nursing and Midwifery Associate Professor Christine Neville said the scholarship would play an exciting role in addressing the growing need for continued nursing education across a wider sector. “Nurses are a crucial part of the Australian Defence Force as they provide and manage the health needs of the nation’s defence community across a wide range of contexts.” Applications for the scholarship can be made at: www.nursing-midwifery.uq.edu.au
Follow-up care for Indigenous remains poor The uptake of Indigenous-specific health assessments is on the rise, but follow-up care remains poor, according to recent research. Researchers from the Menzies School of Health Research and the University of Melbourne identified follow up care for Indigenous Australians remained problematic with many barriers identified, despite an $850 million Indigenous Chronic Disease Package (ICDP) introduced by the government in 2010 to tackle the issue. Researchers examined barriers and enablers to delivery and billing of follow-up care over the first three years of the ICDP. They
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found barriers to care included lack of information provided to patients about why they needed follow-up care. The frequent movement of Indigenous people, limited access to transport, cost of access, and other out-of-pocket expenses were other limiting factors. A need for cultural awareness training was also identified due to negative past experiences, including racist attitudes of health service staff, particularly receptionists. At the health service level interviews revealed the health service providers felt
While Indigenous mothers are still twice as likely as non-Indigenous mothers to have babies born of low birthweight (12.6% and 6.0% respectively), AIHW analysis showed that the low birthweight rate amongst babies of Indigenous mothers dropped by almost one tenth (9%) between 2000 and 2011, according to the Birthweight of babies born to Indigenous mothers report. AIHW spokesperson Dr Fadwa Al-Yaman said low birthweight was associated with a range of adverse health outcomes, including fetal and neonatal death and morbidity, and the development of chronic disease later in life. According to Dr Al-Yaman a range of factors are associated with birthweight, including maternal smoking during pregnancy, antenatal care and pre-term births. “Half of all Indigenous mothers who gave birth in 2011 reported smoking during pregnancy compared with 12% of non-Indigenous mothers. The smoking rate among Indigenous mothers fell from 54% in 2005 to 50% in 2011- with greater fall in the rate among non-Indigenous mothers - highlighting considerable scope for further improvements.”
short consultation times meant they had limited time opportunities to explain the importance of follow-up care to their patients. Additionally the shortage of GPs, allied health professionals, Aboriginal Health Workers (AHWs) and practice nurses constrained referrals. “Overcoming barriers to follow-up and strengthening enablers is vital to achieving health benefits from the large financial and human resource investments in health assessments,” the authors wrote. “Strategies will need to be tailored to local circumstances. Our findings point to the need to support health services in developing systems and organisational capability to undertake follow-up of health assessments.
September 2014 Volume 22, No.3 13
KEEPING THE GRASS GREENER: resilience in the workplace with Dr Lisa Engel D. Psych, November 2014 in Melbourne For the third consecutive year, Lisa Engel, a Health Psychologist and Diabetes Educator, is delivering a workshop to assist health professionals reconnect with their work. ‘Keeping the Grass Greener’ will provide a reflective space as well as practical strategies to manage the demands of work. In cost cutting and budget conscious environments it has never been more important for health professionals to develop creativity, self-compassion and influence at work. Learn ‘real-world’ techniques to achieve these qualities. DAY 1: • Resilience • Understanding your emotions • Responding to stress rather than reacting • Knowing and managing the inner critic
DAY 2: • Understanding and avoiding burnout • Managing internal and external busyness • How to say, “No” with compassion and without blame • Values clarification
DATES: Day 1 Monday November 10th 2014 Day 2 Monday November 17th 2014 COST: One day $295: Two days $395 VENUE: Carson Conference Centre, ANF, 540 Elizabeth St Melbourne
DOWNLOAD A REGISTRATION FORM AT: www.lisaengel.com.au OR telephone 0439 036 847 ***Last Day to Register: Monday 27th October 2014*** 12 hours of professional development
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*Guidelines recommend paracetamol for the first-line treatment of pain and fever in children.8 † Refers only to non-prescription medicines and is based on the liquid paracetamol formulation given at a dosage of 15 mg/kg. References: 1. Celebi S et al. Indian Journal of Pediatrics 2009;76:287–91. 2. Autret-Leca E et al. Current Medical Research and Opinion 2007;23:2205–2211. 3. Walson PD et al. American Journal of Diseases of Children 1992;146:626–632. 4. Clark E et al. Pediatrics 2007;119:460–467. 5. Hamalainen ML et al. Neurology 1997;48:103–107. 6. Schachtel BP et al. Clinical Pharmacology and Therapeutics 1993;53:593–601. 7. Children’s Panadol Approved Product Information, last updated November 2009. 8. NSW Department of Health. Policy Directive: Paracetamol Use. Accessed at http://www.health.nsw.gov.au/policies/pd/2009/PD2009_009.html on September 2012. Children’s Panadol® contains paracetamol. For the temporary relief of pain and fever. CHILDREN’S PANADOL is a registered trade mark of the GlaxoSmithKline group of companies. GlaxoSmithKline Consumer Healthcare, 82 Hughes Avenue, Ermington NSW 2115 Australia. 06/14 GSK1153/UC.
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News Women economic empowerment and leadership boosted in Asia A program aimed at giving women more economic influence in the Association of Southeast Asian Nations (ASEAN) arena has received a $1million funding boost from the Australian government. The Oxfam program, Women’s Economic Empowerment and Leadership in ASEAN, will be implemented by Oxfam’s partner the International Women’s Rights Action Watch Asia Pacific.
New health service for the Northern Territory The Northern Territory has launched two new health services. One that will help tackle rates of cancer in women living in remote areas and another that will provide dental care for children in NT’s first ever paediatric dental clinic.
Ms Lambley said in the next six months it was hoped that the BreastScreenNT Bus would have the capacity to screen 800 women in remote communities. “In 2015 the service will aim to have the capacity for 1,350 women to be screened in remote communities.”
The breast screening service, the BreastScreenNT bus, will give remote women the opportunity to have breast screens closer to home.
The other new NT service launched last month was a paediatric dental clinic that has the capacity to treat 27 children per day.
NT’s Minister for Health Robyn Lambley said remote women have always had to travel hundreds or sometimes 1,000 kilometres to have a breast screen, and some did not access the service at all. “Thanks to the BreastScreen Bus they will no longer have to put up with the tyranny of distance, and it will encourage more women to access the test.”
Ms Lambley said the purpose built facility in Casuarina will provide a child friendly atmosphere and encourage more kids with parents to access dental services. “Encouraging more Territory families to participate in their children’s oral health by attending dental visits is an important part of this.”
Ms Lambley said the bus would visit 20 remote communities on a two-year cycle, with women from neighbouring communities encouraged to attend. The bus will provide screening services in Barunga, Katherine, Tennant Creek and Nhulunbuy, to complement services in Darwin, Alice Springs and Palmerston.
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Ms Lambley said research from 2010 shows the NT has the second highest rate of tooth decay in six year old children at 61% “This rate of decay has risen sharply among NT children since 2001, when the rate was at 52%.” It is hoped the new clinic will help reduce these rates.
“THIS PROGRAM AIMS TO STRENGTHEN WOMEN’S RIGHT’S ORGANISATIONS, SO THEY CAN BETTER INFLUENCE LAWS AND POLICIES IN THE ASEAN ECONOMIC COMMUNITY TO PROMOTE WOMEN’S ECONOMIC EMPOWERMENT AND LEADERSHIP IN BOTH THE FORMAL AND INFORMAL SECTOR.” Oxfam Australia’s East Asia Regional Manager Wayne Gum welcomed the commitment of $1million over four years, saying it would help strengthen women’s engagement with ASEAN bodies and the private sector. “Women must be heard to achieve inclusive economic growth, and this is a welcome recognition of the economic and political role of women in this region particularly with the move to an ASEAN Economic Community in 2015.” The program will build on existing skills within the women’s rights organisations, strengthening advocacy in areas such as economic leadership and empowerment, with a focus on achieving social justice for women and sustainable development. “This program aims to strengthen women’s right’s organisations, so they can better influence laws and policies in the ASEAN economic community to promote women’s economic empowerment and leadership in both the formal and informal sector,” Mr Gum said. September 2014 Volume 22, No.3 15
World Nurses staying in the workforce longer The number of registered nurses working in the US has surpassed forecasts made a decade ago, according to a US study. While government authorities predicted the size of the workforce would peak at 2.2 million in 2012, the number of nurses working in the US had grown to 2.7 million, 500,000 more than projected twelve years earlier, according to the study published in the journal Health Affairs. A surge in new nursing graduates and existing registered nurses staying in the workforce 2.5 years longer than in past decades has been attributed for the increase, study lead for the research David Auerbach said.
Co-author of the research Professor Peter Buerhaus said the trend of delayed retirement was not expected. A decade ago researchers forecasted a nursing shortage based on stagnant enrolments in nursing schools and the coming retirement of baby boomer nurses. The increase in nursing graduates as well as the trend to stay in the workforce longer was due to the recent economic recession that occurred in the US, the authors said. Professor Buerhaus said having additional and more seasoned registered nurses in the workforce would help provide access to care to the millions of people who were gaining health insurance via the new US Affordable Care Act. “Because the majority of RNs who are over age 50 have accumulated many years of wisdom and experience, their impact on the delivery of care will be important and timely.”
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Industrial action over a 0.7% payrise Nearly 12,000 New Zealand Public Service Association (PSA) health worker members have voted to strike after being offered a 0.7% pay increase per year and no movement on other issues including training. The health workers, located in every District Health Board (DHB) across New Zealand, include mental and public health nurses, physiotherapists, anaesthetic technicians, dental therapists, administrative staff and a number of other occupational groups. PSA National Secretary Richard Wagstaff said members took their duty very seriously and that it was a huge step for them to even consider taking such strong action. “DHB staff work hard to keep New Zealanders healthy, but their own wellbeing is put under increasing strain by these insulting offers.”
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World Mr Wagstaff said that the government had indicated that there would be even less money on the table next year, which indicated the continuation of the systemic underfunding of the health system. “Budget documents say DHBs expect a 17% increase in demand over the ten years to 2021, but they won’t give funding to match and they’re planning to squeeze it out of staff. Our members are asking to be fairly recognised for the hard work they put in to keep our health system running – an annual pay rise shouldn’t start with a decimal point.” The strike action was planned when the ANMJ was going to print.
Planned registration fee hike comes under fire The UK Nursing and Midwifery Council’s (NMC) plan to increase nurses’ and midwives’ registration fees from
£100 to £120 has come under fire from nursing and midwifery unions. The fees were already increased two years ago from £76 to £100 despite consultation that was overwhelmingly against the rise. The Royal College of Nursing (RCN), the Royal College of Midwives (RCM) and UNISON (UK’s largest trade union) have all submitted a response against the latest fee hike. In addition UNISON conducted a survey of members which showed all respondents opposed the fee increase. UNISON’s head of nursing Gail Adams said the proposal was unfair and disproportionate. “Our members are very angry and have unanimously rejected the proposals. They’re angry that the NMC appears unable to live with the current income and it’s unacceptable to expect nurses and midwives to pay for this.”
Ms Adams said the UNISON survey also showed that a fee rise would have a damaging impact on older nurses and midwives by affecting their decision to return to work on reduced hours. “The NHS and patients cannot afford to lose so much valuable skill and experience from the service.” RCM’s Chief Executive Cathy Warwick said that their members see in real terms a reduction in their earnings and are therefore more inclined than ever before to examine whether or not the costs such as their registration fees are value for money. “They feel that they are paying for the past failures of the NMC and for a small number of registrations who are coming before fitness to practice hearings. They want to see more work coming out of the NMC which helps the majority of registrants who are doing their best to deliver high quality care.”
NURSING
BEYOND THE BUSH 18 September 2014 Volume 22, No. 3
anmf.org.au
Feature Rural and remote nursing varies from the greenery of the bush to the searing heat, red dust and dangerous camp dogs of the outback. But many nurses and midwives who venture off the beaten track find the positives far outweigh the challenges, writes Karen Keast. Registered nurse Sue Ellen Kovack will never forget the night she was working on her own in the clinic at Maningrida, an Indigenous community in the heart of the Arnhem Land region of the Northern Territory, 500 kilometres east of Darwin. She received a call alerting her to a vehicle roll-over about 20 kilometres away. The ambulance was sent out and Sue Ellen began preparing the clinic’s rooms, ready to take in any injured patients. “Then someone came in and said - ‘no, it’s nothing, it was just me’, and he had a broken hand,” she recalls. “He wasn’t giving me much information and I kind of relaxed a bit. Then about a half hour later I heard this noise outside. I opened the door and all of these people were coming at me covered in cuts and abrasions - it ended up there were 17 people in that vehicle roll-over.” Sue Ellen called in the entire nursing team for what turned out to be a 24-hour shift, in which six people were evacuated. “One man came in, he had blood pouring down his face and all over his shirt .I went to assist him and he said - ‘no, I’m fine, I wasn’t in the accident, I was driving by’. He had blood all over him from carrying a buffalo and he wasn’t even in the accident.”
Going rural and remote Originally from Canada, Sue Ellen is one of Australia’s estimated 3,000-strong nursing and midwifery workforce at the coal face of remote primary healthcare, working with mainly Indigenous people living in some of the most isolated and disadvantaged communities in the nation. Renowned as specialist generalists, remote area nurses provide care across the life span, from before the cradle right through to the grave. Australia is home to a diverse rural and remote workforce that extends beyond the rural bush and the outback to nurses working at island tourist resorts and those at mine sites, oil rigs and ships at sea. It takes a special kind of person to go rural and remote. Nurses have to be flexible, resourceful, dedicated, resilient and anmf.org.au
passionate about their work. Their practice in this specialised healthcare field features unique challenges, both personally and professionally, but it’s also an incredibly fulfilling and rewarding career path. Christopher Cliffe, the CEO of CRANAplus, the peak body for remote health practitioners, says remote nursing in Australia is similar to working in the developed world. “I like the obvious challenges that are in your face and the fact that you can actually get in there and do something about it, you finish a day absolutely exhausted but gosh it’s rewarding. “I have to say the biggest plus to me personally, besides travelling this amazing country, is the people you get to work with and the people you get to meet - they are just wonderful. It’s hard work but without a doubt, you get an awful lot more from it than what you put in.” Nurses working remote not only face the cultural differences when it comes to caring for Indigenous communities but also their overwhelming healthcare needs. A recent Australian Institute of Health and Welfare report shows Indigenous Australians are twice as likely to die from coronary heart disease and almost three times as likely to die from chronic obstructive pulmonary disease than non-Indigenous Australians. Sue Ellen Kovack spent seven years living and working in Maningrida, and most of that time she worked in chronic disease management. “There were probably around 1,200 people or more that were chronic disease patients on some kind of medication that all needed to be seen on a three monthly basis. It was a heavy job but I felt I was alive - it was busy, busy, busy.” Now a fly-in fly-out agency nurse based in Cairns, where she works two-week stints in locations such as the Cocos Islands and Tiwi Islands, Sue Ellen says safety was one of the main challenges she faced while working remote. Sue Ellen was unable to swim due to the crocodile infested waters. She also found it difficult to go walking, due to the risk of dog attacks. “I was challenged many times September 2014 Volume 22, No.3 19
Feature
CHRISTOPHER CLIFFE
SUE ELLEN KOVACK
the CEO of CRANAplus
Registered nurse
and surrounded by camp dogs but I was very lucky not to get bitten. I had to swing my way out with a stethoscope and you always carry a dog stick. Once you hit the ground they will all attack.” Regardless Sue Ellen is glad she works remote. “You certainly find out what you’re made of.”
Workplace safety Working in the bush throws up a range of safety issues, from the threat of camp dogs and feral pigs to vehicle accidents in the harsh terrain. Two years ago, an experienced remote area nurse was killed when the ambulance she was driving rolled while transporting patients to an airstrip. As a voice for the remote health workforce, CRANAplus wants policy-makers and employers to strengthen the nation’s unique, innovative and cost-effective model of remote healthcare delivery. CRANAplus’ CEO Christopher Cliffe says safe work practices, such as training and orientation, are vital. “It’s concerning for us that we still hear about remote area nurses who head out bush for their first stint without any orientation, without any clarity about where they’re going and what the cultural risks are.” Remote area nurses are also prone to working with limited resources, face inadequate housing and can often burnout. 20 September 2014 Volume 22, No. 3
When it comes to looking after our remote workforce, Mr Cliffe says it is not rocket science. “You get them out regularly, you engage with your staff regularly, you make sure that they’ve got good accommodation and safe work practices, that they’re given time out and that they can continue to professionally learn and maintain their skills . “It would be nice to see a much more national and concerted effort and a lot more funding going into acknowledging that this is a unique area of healthcare in Australia. We can do it really well; we don’t need to just put a GP in every remote town because that ain’t going to work. We just need to acknowledge the model we have got and remunerate it appropriately and support it appropriately.” Many remote nurses are also confronted with conflict in the workplace. Mr Cliffe says a large number of callers to CRANAplus’ Bush Support Services, a free 24-hour, seven day a week telephone counselling service, report experiencing workplace bullying. CRANAplus recently launched a bullying app that equips remote healthcare professionals with a user-friendly resource right at their fingertips, in a bid to combat bullying. Workplace violence is also a major concern in rural and remote areas due to a range of general risk factors, such as a lack of
DR ROBYN AITKEN
Northern Territory Acting Chief Nursing and Midwifery Officer
anonymity, cultural issues, mandatory reporting requirements and the distance between nurses and their management and support. The Australian Nursing & Midwifery Federation (ANMF) last year joined forces with CRANAplus, and several peak organisations representing doctors, police and teachers, to establish the Working Safe in Rural and Remote Australia Project. As part of the project, the workingsafe. com.au website showcases a range of strategies employers and health professionals can adopt to prevent violence and bolster workplace safety. ANMF senior federal professional officer Julianne Bryce says the website is a hub of information. “It shows research that’s been undertaken but also some examples of how communities have undertaken projects to improve safety. We’ve been speaking to government about the next phases of the project which would include not only some online learning but also a reporting database proposal that we’ve put up with the Australian Institute of Criminology.”
Advocacy and support Ms Bryce, who also represents rural and remote ANMF members on the council of the National Rural Health Alliance, knows how important it is to support nurses and anmf.org.au
Feature
WORKPLACE VIOLENCE IS ALSO A MAJOR CONCERN IN RURAL AND REMOTE AREAS DUE TO A RANGE OF GENERAL RISK FACTORS, SUCH AS A LACK OF ANONYMITY, CULTURAL ISSUES, MANDATORY REPORTING REQUIREMENTS AND THE DISTANCE BETWEEN NURSES AND THEIR MANAGEMENT AND SUPPORT. Sue Ellen Kovack at work.
midwives working in the bush and outback. “I like to say that the further rural and remote you go, the last woman standing will be a nurse. We know they’re out there and it’s about making the most of supporting the people that are really choosing to go rural and to stay in communities, so they can do the best job that they can.” It is also imperative to assist the next generation of nurses wanting to venture into rural and remote work, Julianne adds. “We still have challenges around having the infrastructure to support undergraduate placement. That comes at a cost and some of those universities that are facilitated, their challenges are that there’s no accommodation for the nursing students, so students are staying in a tent in a caravan park in order to do a placement. If people don’t get to have that experience then it reduces the chances of them going into rural and remote.”
Staying connected Growing numbers of nurses and midwives are utilising telehealth to overcome vast distances in rural and remote practice. The ANMF, as part of the Nursing and Midwifery Telehealth Consortia, has been involved in creating telehealth professional practice standards and guidelines to help assist nurses, nurse practitioners and midwives in the provision of healthcare through telehealth technology. Ms Bryce says the guidelines will be released in a user-friendly e-book format while the anmf.org.au
federation has also developed a free online education program that nurses and midwives can access through the ANMF website. “The data that we have is showing that nurses and midwives are involved in telehealth but obviously we would like to see that increase. We see it as really valuable - it’s not necessarily providing the care differently, it’s about using the technology to support that.”
can use to overcome isolation and to connect with their colleagues. “You totally individualise it to who you want to hear from, who you want to talk to, what your interests are, what your needs are - it’s a really great supplement. It’s not the be all and end all but if they want or need connections regardless of where they are, it’s a really efficient way to get them.”
Social media is also playing an important part in bridging distances when it comes to networking.
Remote education
NSWNMA professional officer Angela Garvey, who lives in regional New South Wales, finds Twitter keeps her connected to nurses and midwives on the land. When Angela attended the last National Rural Health Alliance conference, she followed the organisation’s tweets throughout the conference, introducing her to a wider network of health professionals. “I tapped into a lot of rural and regional people who were there at that conference tweeting but also people who weren’t able to attend who were following the tweets. “Twitter has given me a much more meaningful appreciation of the day to day issues rural nurses face. People get this idea that if it’s only 140 characters it must be meaningless but it’s just not - it’s revolutionary.” Ms Garvey says Twitter is a quick and easy social media platform nurses and midwives
While experienced remote area nurses are seeking education to support and develop their practice in the specialised field, early career nurses are also pursuing remotespecific education. Dr Robyn Aitken is the Northern Territory Acting Chief Nursing and Midwifery Officer, who played a lead role in establishing the Masters of Nursing (Nurse Practitioner) program at the Centre for Remote Health, and now Charles Darwin University. She says early career nurses and midwives are increasingly looking to develop their skills and knowledge before immersing themselves in the reality of practice. Dr Aitken says the unique Masters program features a focus on primary healthcare, cultural safety and Indigenous health. “The contribution that the program makes to the unique requirement for ‘closing the gap’ and addressing the health outcomes of Aboriginal people, no matter what setting they are in, is really critical. September 2014 Volume 22, No.3 21
Feature “Nurses also learn about their own cultural background and becoming culturally safe and culturally responsible in a structured way. Nurses do learn about culture on the job but they may learn it by making lots of mistakes and also learn it under circumstances that potentially lead to a phenomenon that’s now starting to be researched as cultural shock. The importance of courses like this one, which focus on nursing within a unique cultural environment, is that the context of care within which clinical skills take place is front and centre rather than clinical skills being learnt in isolation from the practice setting.”
“REMOTE WORK IS NOT JUST A JOB - IT’S YOUR WHOLE LIFE.” Vanessa Page at Derby
The program is not alone. CRANAplus also offers a large suite of resources and short courses to help prepare nurses and midwives interested in going remote.
Immense rewards It was the romance of the outback that lured eligible midwife and nurse practitioner Vanessa Page. “I was thinking about station life and maybe meeting a station manager or something…I hadn’t had any exposure to Indigenous health prior to this. So I headed up to Alice Springs and worked in intensive care for a year, which is where I was exposed to Indigenous health for the first time and got quite absorbed in it.” Vanessa hasn’t looked back. She found her romance when she met her partner David Kelley, a helicopter mustering pilot, and they now have a son, Jim, aged 17 months. After completing her midwifery training to complement her remote area nursing, Vanessa discovered her calling in women’s and maternal health. Also passionate about educating the remote workforce, Vanessa is one of the CRANAplus Maternity Emergency Care (MEC) course facilitators. Vanessa completed the Master of Remote Health Practice: Nurse Practitioner program, the same program that Robyn helped to establish, while she was working at Mutitjulu, an Aboriginal community at the base of Uluru. She later moved to Fitzroy Crossing, a small town in the Kimberley region of Western Australia, where she worked as the 22 September 2014 Volume 22, No. 3
community midwife for two years. It was a unique experience, where Vanessa had the responsibility of single-handedly managing up to 50 complex antenatal and postnatal women at any one time. An eligible midwife and an endorsed nurse practitioner, Vanessa now works at Derby Hospital, about 250 kilometres west of Fitzroy Crossing, as a clinical midwife but is working with the hospital to create a nurse practitioner position, where her scope of practice will be women’s and maternal health. Vanessa says the biggest challenges of working remote are the isolation, both personally and professionally, and working within a different culture, where English is not the first language. “While I was working at Mutitjulu in central Australia, I completed a local Pitjantjatjara language course run by the local women, which was necessary really to be able to do my work. Learning to be culturally safe while managing highly complex patients was all part of the challenge - Indigenous Australians are so unwell and face so many social issues.”
person piled up in the back of a troupe, with 15 odd Indigenous women and children, to go hunting for witchetty grubs and honey ants near Kata Tjuta, also known as The Olgas. “I love working with Indigenous women, particularly during labour and birth, but they also have their challenges,” Vanessa says. “Once I had to pick up an intoxicated lady in the ambulance from out on the Derby marsh who thought she was in labour. When we got back to the labour ward, where she was being monitored on the CTG machine, she proceeded to tell me about the snake she had in her bag. I didn’t know whether to believe her or not, so I handed her the weighty bag so that she could show me. Much to my surprise and amusement she dived into the bag and pulled out this massive black-headed python and informed me that she was going to eat it for dinner! The midwife taking over from me was petrified of snakes and refused to look after her until the snake was out of sight, so with a bit of a laugh we put the snake back in her bag and put the bag outside. You don’t see that in the big smoke!”
But Vanessa says the rewards are immense, from the provision of continuity of care to the autonomous work, where you are able to assess, diagnose and treat under extraordinary circumstances.
Vanessa describes remote work as enriching. “I think I have felt every emotion possible while working out bush. Your role is so diverse because you are not only a nurse but also a taxi driver, counsellor, social worker, vet and administration officer, just to name a few.
There is also the many memorable experiences, such as being the only white
“Remote work is not just a job - it’s your whole life.” anmf.org.au
Professional Cultural safety and respect Julianne Bryce and Elizabeth Foley, Federal Professional Officers Recently we attended a cultural safety and respect workshop in Canberra hosted by our colleagues at the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM). The facilitators, Sharon Gollan (a Ngarrindjeri woman) and Kathleen Stacey led us through an extremely thought provoking, and at times confronting, two days of workshopping. The workshop focussed on participants reflecting on our ‘whiteness’ and the impact of our white culture on this country’s First Nation’s peoples - Aboriginal and Torres Strait Islanders. We were confronted with the privilege our ‘whiteness’ affords us in being part of the dominant culture in this society; the fact that we will not be discriminated against because of our skin colour; that we grow up with expectations of entitlements, often without thinking that others don’t share that privilege. We were taken on a journey of the hideous pain and suffering inflicted on Aboriginal and Torres Strait Islander peoples in this country from colonisation to present day. While we can’t rewrite history or undo the wrongs of the past, we can commit to learning from the deep injustices of former generations and the perpetuation of discrimination by our generation. We can, and must, recognise racism; name it; and do all we can to establish zero tolerance of racism in our working lives, as nurse and midwives, and in the community. Accordingly the policies and procedures we develop in our health and aged care facilities must demonstrate that we will not tolerate racism in any guise. This means taking extra steps to ensure services are accessible to and will be provided to all individuals and communities. Taking seriously the effort to Close the Gap in health equality by arguing for additional funds for Aboriginal and Torres Strait Islander peoples. Enabling Aboriginal and Torres Strait Islander peoples to manage their own health and aged care services. And, above all, RESPECTING Aboriginal and Torres Strait Islander peoples in decision making. All of this will lead to safer and fairer health and aged care for Aboriginal anmf.org.au
and Torres Strait Islander Australians. As the ANMF federal office professional team, we commit to embedding cultural respect for Aboriginal and Torres Strait Islander peoples in all our national policies, position statements, and guidelines documents. Over past months we’ve been revising the Federal Office Reconciliation Action Plan (RAP). We’ve been assisted enormously in this by Faye Clarke (a Gunditjmara, Wotjaboluk and Ngarrindjeri woman, ANMF member and CATSINaM Board director) and Robyn Coulthard (then federal professional officer and ANMF member). Throughout this revision work we’ve declared that we don’t want the RAP to just be words on a page, a document that just sits on a shelf and makes us feel good that we are an organisation with a RAP! Rather, we want the document to guide us in working with our CATSINaM colleagues, to establish good relationships with our Aboriginal and Torres Strait Islander nurse and midwife members and encourage their involvement in our work, to foster respect among our broader membership for Aboriginal and Torres Strait Islander peoples, to promote understanding of the rights of Aboriginal and Torres Strait Islander peoples, and to show leadership to the nursing and midwifery professions in respect and working towards health equality for Aboriginal and Torres Strait Islander Australians. While Australia is a relatively wealthy country, nurses and midwives know too well that poverty pervades our communities. It’s
a shocking and inexcusable fact that the greatest levels of poverty in this country exist in some Aboriginal and Torres Strait Islander communities. We want to remind all our nursing and midwifery members that 12-18 October 2014 is Anti-Poverty Week. For the past decade Australia has dedicated a whole week in October to activities which aim to strengthen public understanding, concern and action about the hardship and injustice of poverty, both in Australia and around the world. On your behalf, the ANMF makes an annual donation to support this national anti-poverty awareness raising campaign. We’ve been advertising Anti-Poverty Week in the ANMJ, and, although it’s still a month away, we’re alerting you ahead of time to visit the website: www.antipovertyweek. org.au Here you’ll find information and ideas for activities you can do in your health or aged care workplace or in your local community. Nurses and midwives hold a position of trust in our society and we should use this position of influence to advocate for a fairer share of resources and better access to essential services, for all people, but especially for our First Nation’s people. We encourage our members to develop relationships with Aboriginal and Torres Strait Islander peoples which are respectful of diversity of experience and cultural heritage. It is only through an improved understanding of Aboriginal and Torres Strait Islander peoples that we will be able to address health inequalities, reduce pockets of poverty, and provide safe culturally respectful care. September 2014 Volume 22, No.3 23
Reflections
Medical/surgical nursing in the home: District Nurse Advanced RN Linda Pesudovs with client Mrs Elaine Clements
Medical / surgical nursing in the home Linda Pesudovs Mention medical/surgical nursing – or med-surg nursing and chances are people will conjure up the mental picture of a hospital environment. So, just for a moment, let’s walk away from the wards and pull up a chair in the comfort of a patient’s home.
on their compression stockings day in/ day out in their own homes. Indeed, a good proportion of my day is involved in teaching people about new treatments the hospital has prescribed or healing their wounds after surgery. These clients are the ones who, when they are independent with their care, or are healed, are discharged from our service to return to their normal lives.
Granted, the home may not be a place you would expect medical/surgical nursing to occur, but for the community nurse, this is an everyday occurrence. And for the broader health industry (not to mention the client) that’s probably a very good thing.
The most common new treatment that I see is type 2 diabetics who are commenced on insulin injections. With the massive pressures on hospital staff we are able to plug some of the patient education gaps. Using the pen delivery devices and injection sites and timetables are just a couple of examples of where we can help.
Med-surg is the traditional starting point for all nurses training. Being hospital trained many years ago that is exactly where I started. This general training gives a broad base where all nursing specialties stem from. Nowadays I’m a community nurse, helping and caring for all types of people who need all types of nursing. I am not just there to give someone tablets or put 24 September 2014 Volume 22, No. 3
In the comfort of a client’s own home I teach clients how, when and where to inject their prescribed doses; I also liaise with their GPs to modify insulin doses. This is common when people return to their own eating habits. Included with this education is the importance of daily monitoring of blood sugar levels and the signs and symptoms of hypoglycaemia, a
rare but possible event when injecting with insulin and delayed food intake. The surgical side of community nursing mainly involves healing various surgical wounds ranging from wounds having broken down for multiple reasons to those that are infected. Delayed healing times are a major factor in addressing these wounds. When wounds are properly covered with dressings most people can go about their normal daily lives so they do not need to be restricted to a hospital bed. In the much more comfortable surroundings of their own home, I can visit them, on average, three times a week to change dressings and monitor wound progress. Again, being in contact with the GP is important when any concerns arise with the healing wound. Overall a person who is in their own familiar surroundings responds better and faster thereby the learning of new tasks and healing are enhanced and normality for them is restored. Linda Pesudovs, RN, is a District Nurse Advanced, based at the RDNS Springvale site in Melbourne anmf.org.au
Tech Talk Printing a new way to personalised health Gurney Khera By now people would have some awareness of 3-Dimensional (3-D) printers, which are sold at major retail outlets. But just exactly what is this new technology and how may it impact the medical and nursing sphere? 3-D printing is a process for making a three-dimensional object of almost any shape from a 3D model or other electronic data source primarily through an ‘additive processes’ in which successive layers of material are laid on top of each other under computer control. A 3-D printer is a type of industrial robot which creates or ‘prints’ a given part based on a supplied design and its fascinating to watch a 3-D printer in action. 3-D designs may be created with a computer-aided design package or via a 3-D scanner. The manual modelling process of preparing data for 3-D computer graphics is similar to sculpting. Based on this, threedimensional models of the scanned object can then be produced. A 3-D printer follows the designs to lay down successive layers of liquid, plastic, glass, ceramics, paper, powder or metals to build the model from a series of cross-sections. These layers are joined or automatically fused to create the final shape. The primary advantage of this technique is its ability to create almost any shape or geometric feature. “Three-dimensional printing makes it as cheap to create single items as it is to produce thousands and thus undermines economies of scale. It may have as profound an impact on the world as the coming of the factory did....But the technology is coming, and it is likely to disrupt every field it touches.” The Economist, 10 February 2011 A recent invention is a 3D-printed plastic brace or cast that follows the contours of an individual’s arm. A young New Zealand design graduate Jake Evill broke his hand during a fight, resulting in a plaster cast for a few months. He realised how non-user friendly the cast was. “Wrapping an arm in two kilos of clunky, and soon to be smelly anmf.org.au
and itchy, plaster in this day and age seemed somewhat archaic to me,” he said. So he designed his own, called the Cortex cast, which is a 3D-printed brace that follows the contours of the arm, an exoskeleton that is lightweight, waterproof, washable, ventilated and recyclable, based on the tiny lattice-shaped structures that form the inner tissue of a bone. “It was this honeycomb structure that inspired the Cortex pattern because, as usual, nature has the best answers,” he said. Patients would have their fracture x-rayed and the injured limb 3D-scanned. A computer would then determine the optimal pattern and structure of the cast which is then sent off to be 3-D printed in a nylon plastic. The resulting cast is typically only 3mm thick and under 500grams and relatively inexpensive costing around $100 to print. It is then snap locked around the injured hand or arm during the healing process. 3-D printing has also been used to print patient specific implants and devices for medical use. Some successful examples include a 3-D printed titanium pelvis implanted into a British patient, a titanium lower jaw transplanted to a Dutch patient, and a plastic 3-D tracheal splint for an American infant. Hearing aids and dental implants are also expected to be major products using custom 3D printing technology. In March 2014, surgeons in Swansea used 3-D printed parts to rebuild the face of a motorcyclist who had been seriously injured in a road accident. One of the most important developments in 3-D printing over the past two years is the creation of low-cost 3D printable prosthetic hands. Beginning with Richard Van As and Ivan Owen’s partnership to make functional
Photo courtesy of A‘ Design Award & Competition
3-D printed fingers, the movement to bring down the price of prosthetics has flourished and an increasing number of people have been helped. A new international Master’s Degree in biofabrication will be jointly offered in Australia by the Queensland University of Technology (QUT) and the University of Wollongong. QUT Institute of Health and Biomedical Innovation bio-fabrication research lead Professor Dietmar W Hutmacher said the applications of 3D technology could eventually end the need for organ donations, but a more immediate application of the technology was the use of 3D-printed biodegradable scaffolding to create replacement bones for patients. This is an exciting new technology which has the potential to vastly improve medical outcomes for patients with innovative custom design of prosthetics and replacement body parts or aids. Nurses and midwives will encounter this very soon in leading hospitals and clinics and will be at an advantage if they become familiar with the technology and its uses. There may be opportunities for leading nurses and midwives to be involved in the design of many new products using 3-D technologies. For further reading on examples of how 3-D printing is being used in the medical sphere see: http://3dprintingindustry.com/medical/ References The Economist, (2011) The Printed World, The Economist Newspaper Limited, Feb 2011, UK
Gurney Khera B.E, B.Sc (computer scientist) is an IT Specialist and Consultant September 2014 Volume 22, No.3 25
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Institution of the Year 2014
Legal Right to an assisted death in the spotlight Linda Starr Euthanasia comes from a Greek term – eu meaning good or pleasant and thanatos – death, for example, when someone has control over their death – where they die, who will be with them, having adequate pain relief and symptom control. However, for many this is not possible as illness takes over health and suffering becomes unbearable and unmanageable. It is on these occasions the question of a person’s right to an assisted death often resurfaces. However, historically these discussions have been immersed in emotional rhetoric with little advancement in policy development nor resolution of difficult legal and social contentions. Australia was the first country in the world to pass legislation that made provision for an assisted death, when the Rights of the Terminally Ill Act (NT) was passed in 1995. Although this did not provide an enforceable right to an assisted death, it did provide those with a terminal illness who were subject to unbearable suffering with no alternative treatment options, a means for an assisted death. Four people died using these provisions before the Commonwealth Government, using their Constitutional powers to make law for the Northern Territory, passed the Euthanasia Laws Act in 1997, prohibiting assisted death or voluntary euthanasia (McIlwrath J & Maddern B). Suicide ceased to be a crime in the late 1960’s, although the offence to aid and abet someone to commit suicide has been retained in all Australian jurisdictions. It is interesting to note that whilst guilty verdicts have been handed down for this crime, the courts have tended to take into account the tragic and distressing circumstances, considering these cases to be ones ‘where justice may be tempered with mercy’ (R v Maxwell). Voluntary euthanasia has recently attracted more publicity following the deaths of two men who took their own lives in separate incidents as described below. Both of these men had made contact with Dr Nitschke, Australia’s leading Voluntary Euthanasia anmf.org.au
advocate and founder of Exit International, a euthanasia group. They had also attended his workshops and purchased his books on voluntary euthanasia. These deaths have also attracted the attention of the police and the regulatory authority. In July 2014 the South Australian Board of the Medical Board of Australia suspended Dr Nitschke on grounds that he ‘posed a serious risk to the health and safety of the public’, following the suicide of 45 year old Nigel Brayley in May 2014. Brayley died after consuming the illegally imported euthanasia drug pentobarbital: he did not have a terminal illness. His friends believed he was depressed, and had been, since his wife’s tragic death. It was their view that Dr Nitschke owed Brayley a duty of care compelling him to refer Brayley to a psychiatrist for treatment. However, after his death it was revealed that Brayley was living in fear of being charged with his wife’s murder, following police investigations into her death when she fell from the top of a quarry while taking photographs (Smith P 2014). Was Brayley a candidate for voluntary euthanasia? In Dr Nitschke’s view this was a ‘clear case of rational suicide’ an individual exercising their right to die: “If a 45 year old comes to a rational decision to end his life, researches it in the way he does, meticulously and decides that – now is the time I wish to end my life, they should be supported. And we did support him in that.” However, the regulatory authority disagreed viewing this as a breach of his duty to ‘protect and promote the health of individuals in the community’. In the other case a 67 year old terminally ill man took his own life in the presence of his family. In 2013 Mr Bromson, was a candidate for a seat in the Senate for the Voluntary Euthanasia party, had a rare terminal bone cancer and had been living with chronic excruciating pain for some time. He met Dr Nitschke who advised him on how to obtain the euthanasia drug
and even tested it for its purity but denied encouraging or discouraging him from using it. Police are investigating this death to determine if this was an assisted death and so, unlawful. Dr Nitschke’s premises have been subject to a raid by police who seized some items including lap top computers. Both he and family members who were present at Mr Bromson’s death are being questioned by police. No charges have been laid as yet (Williams T 2014). As the law currently stands both the police and the regulatory authority have a legal obligation to take action and conduct their own inquiries into these matters once they are reported to them. Clearly there are some significant differences in these two cases – the age of the men, the presence or absence of a terminal illness with uncontrollable symptoms and the mental capacity to make these decisions. As long as this offence stays on the statute books it will be a crime to assist someone to die. However, the degree of moral blame that could be apportioned to those involved may differ on a case by case basis as stated by Justice Coldrey: At the one end of the spectrum may be placed a person who assists or encourages a person to commit suicide in order to inherit property or for some other ulterior motive; at the other end, there is the individual who supplies potentially lethal medication to a terminally ill person, perhaps a loved one who is in extreme pain and who wishes to end that suffering at the earliest possible opportunity (R v Maxwell). These cases illustrate the need for laws that protect life and the need to exercise compassionate and rational thought: a time to move beyond emotional rhetoric to reconsider the need for law reform. References McIlwrath J & Maddern B. 2010. Health Care and the Law. 5th ed. Law Book Co. Australia R v Maxwell [2003] VSC 278 Smith P. 2014. Nitschke’s actions over man’s death ‘reprehensible’. Australian Doctor, 4 July 2014. Williams T. 2014. Police raid but no charges laid. The Advertiser, 2 August 2014. P 35.
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 September 2014 Volume 22, No.3 27
Clinical update
28 September 2014 Volume 22, No. 3
anmf.org.au
Clinical update High flow nasal cannula oxygen therapy for infants and young children with bronchiolitis Danielle Hanlon Bronchiolitis is the most common cause of lower respiratory tract infection and the leading reason for hospitalisation among infants in developed countries (Cambonie et al 2008: 1865). The majority of bronchiolitis illness is attributed to respiratory syncytial virus (RSV) and is characterised by bronchiole obstruction with oedema, cellular debris and mucous, resulting in symptoms of increased work of breathing, tachypnoea, tachycardia, cough, rhinorrhoea, wheeze, fever and often hypoxaemia (Teshome, Gattu & Brown 2013: 1020). Since there is no therapeutic option available for the treatment of bronchiolitis, management is based on supportive care for the symptoms, which can lead to dehydration and respiratory distress leading to exhaustion and respiratory arrest (Cambonie et al 2008). An emerging method to support breathing is using blended, heated, humidified air and oxygen, through nasal cannulae at flow rates higher than two litres per minute. This is known as high-flow nasal cannula therapy and it allows the comfortable delivery of these high flow rates, which may improve ventilation, and may lead to a reduced need for invasive respiratory support (Beggs, Wong, Kaul, Ogden & Walters 2014: 2). High flow nasal cannula (HFNC) therapy enables the delivery of an oxygen-air mixture that is heated and humidified at higher inspired gas flows of up 30 litres/minute (although usually flow rates much less than this is required). The goal of HFNC is to meet anmf.org.au
or exceed a patient’s spontaneous inspiratory effort, and therefore create a reservoir of oxygen within the nasopharynx by washing out the nasopharyngeal dead space and providing a form of positive airway pressure (Beggs et al 2014; Walter 2013). A review of the literature was conducted, using five peer reviewed articles to ascertain if it is advantageous to use high flow nasal cannula oxygen therapy in the treatment of infants and children younger than two years old admitted to hospital with bronchiolitis. The use of high flow, humidified oxygen therapy was compared to the use of standard nasal cannula dry oxygen at levels of two litres and less. A search of the literature was conducted using CIAP, The Cochrane Review Register, Informit, CINAHL, Clinicaltrials.gov and Australian New Zealand Clinical Trials Registry. A PICO format was used to develop the research question, population included infants and young children, newborn to two years old, diagnosed with bronchiolitis. The intervention was the use of high flow nasal cannula oxygen therapy (heated and humidified) compared to supplemental oxygen therapy given by conventional nasal prongs, or low flow nasal cannula oxygen therapy. The outcome being the use of high flow nasal cannula oxygen therapy is more effective in the management/ treatment of infants and young children with bronchiolitis, when compared to low flow supplemental oxygen therapy. A word list was formulated to search the available data, keywords included infants, children, paediatric, bronchiolitis, respiratory syncytial virus, lower respiratory tract infection, high flow nasal cannula/nasal prong, low flow nasal cannula/nasal prong, oxygen therapy. The search results were limited to only peer reviewed articles, with restrictions to include articles from between 2005 and 2014, to ensure only current literature was collected.
The five studies included in the literature review consisted of three retrospective chart reviews, with 113 to 298 children aged less than 24 months (Abboud et al 2012; Schibler et al 2011; McKiernan, Chua, Visintainer & Allen 2010) and two prospective observational studies, with 25 and 21 (respectively) infants aged less than 6 months (Milesi et al 2013; Arora, Mahajan, Zidan & Sethuraman 2012). The umbrella objective of the retrospective chart reviews was to determine if the introduction of heated humidified high flow nasal cannula therapy was associated with decreased rates of intubation in infants and young children with bronchiolitis (McKiernan et al 2010). Identification of any laboratory and clinical variables that may have predicted the failure of high flow nasal cannula therapy among the study participants with bronchiolitis was also examined (Abboud et al 2012), along with looking at the change in ventilatory practice in the five years after the introduction of high flow nasal prong therapy in infants (Schibler et al 2011). In the two physiological studies, the main objective was to determine if high flow nasal cannula therapy in bronchiolitis generated nasopharyngeal pressures or positive airway pressures at different flow rates and the clinical significance of these pressures (Milesi et al 2013; Arora et al 2012). Respiratory support in infants and children with moderate to severe symptoms of bronchiolitis has in the past included the use of supplemental low flow oxygen, continuous positive airway pressure (CPAP) and intubation with mechanical ventilation (McKiernan et al 2010). It is a commonly acknowledged point among the literature that the flow rates of standard or low flow nasal cannula oxygen are well below patients’ spontaneous inspiratory flow rates and do not provide an adequate amount of airway pressure or wash out the carbon dioxide rich gas within the anatomical dead space (Milesi et al 2013; Abboud et al 2012; Arora et al 2012; Schibler et al 2011; McKiernan et al 2010). September 2014 Volume 22, No.3 29
Clinical update
All research is in agreeance that using CPAP to avoid the need for intubation has been common practice, and CPAP has been shown to improve clinical scores, decrease respiratory rate and improve ventilation (McKiernan et al 2010: 634). The theories of the mechanisms of action of CPAP include the reduction of airway resistance, improved functional residual capacity and prevention of gas trapping in hyperinflated lungs (Arora et al 2013: 1179). However this agreeance is also evident across the literature in the limitations and disadvantages of the use of CPAP, including difficulty keeping the device insitu, difficulty maintaining an adequate seal, noise issues with the device, it is often poorly tolerated by infants and children and has the potential for septal erosion and nasal damage (Milesi et al 2013; Arora et al 2012; McKiernan et al 2010).
RESPIRATORY SUPPORT IN INFANTS AND CHILDREN WITH MODERATE TO SEVERE SYMPTOMS OF BRONCHIOLITIS HAS IN THE PAST INCLUDED THE USE OF SUPPLEMENTAL LOW FLOW OXYGEN, CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) AND INTUBATION WITH MECHANICAL VENTILATION (MCKIERNAN ET AL 2010) High flow nasal cannula therapy has many advantages over other forms of oxygen therapy including the heating and humidification of inspired gas mixture to reduce the risk of damage to the upper airway mucosa, the oxygen concentration can be titrated to the patients’ needs, it is better tolerated by the patient, decreased nasal trauma, ease of use by nursing staff. It is less invasive so infants and children can still feed/drink and move around their cot/bed, it decreases the patient risk of potential airway damage or ventilatory-associated infection, and has the potential to decrease the patients’ requirements for sedation, as well as allowing children to be nursed outside of the intensive care environment, thus reducing costs associated with care (Milesi et al 2013; 30 September 2014 Volume 22, No. 3
Abboud et al 2012; Arora et al 2012; Schibler et al 2011: McKiernan et al 2010). The three retrospective chart reviews (Abboud et al 2012; Schibler et al 2011; McKiernan et al 2010) were conducted within children’s hospitals, two in the United States and one in Australia. All three were conducted within the paediatric intensive care unit, infants and children were admitted from either the emergency department or the general paediatric wards. All infants and children meeting the inclusion criteria were included and data was collected on patient characteristics and clinical variability. All three studies used the Fisher Paykel heated humidified high flow nasal cannula system to provide the HFNC therapy. McKiernan et al and Schibler et al both started infants and children on the maximum flow rates for the system used and that was 8 litres/minute and weaned flows down depending on clinical condition, whereas Abboud et al adjusted flow rates to minimise the patients’ work of breathing and to maintain an oxygen saturation level of equal to and above 92%, these flow rates ranged from 4 to 8 litres/minute. Laboratory data including white blood cell count, capillary blood gas (both before and after initiation of HFNC) and respiratory cultures were sent (Abboud et al 2012). More importantly ventilatory parameters and physiological variables such as heart rate, respiratory rate, SpO2, inspired oxygen fraction (FiO2) when HFNC initially started and SpO2/FiO2 ratio after commencement of therapy, any complications and PICU length of stay were documented (Schibler et al 2011; McKiernan et al 2010). Patients were categorised as having failed high flow nasal cannula therapy if they required more intensive respiratory support which in all three studies was intubation and mechanical ventilation (Abboud et al 2012; Schibler et al 2011; McKiernan et al 2010). Intubation criteria were based on overall clinical status including respiratory rate and work of breathing (retractions, flaring, grunting) and ability to maintain that respiratory effort. In addition, poor neurological status (lethargy), cyanosis, mottling, poor perfusion, apnoea or inability to maintain adequate oxygen saturations were indications for intubation, as was the clinical decision of the treating medical officer (Abboud et al 2012; McKiernan et al 2010: 635).
In comparison the two prospective, observational studies (Milesi et al 2013; Arora et al 2012), used a more hands on approach inserting a transducer/pressure probe into the nasopharynx to record continuous clinical and manometric data. Both studies also used the Fisher Paykel system to provide the humidified, high flow oxygen therapy. The flow rates in both studies were increased in increments, starting at the lowest flow rate of 0.5 litres/minute to a maximum of 8 litres/minute, the child was allowed a period of time for stabilisation and recording before the flow rate was further increased. Clinical documentation included heart rate, respiratory rate, SpO2 and blood pressure, a pacifier/dummy was used to provide a closed mouth system, to limit the amount of air leak from the mouth (Milesi et al 2013: 1089). Informed consent was obtained from the patients’ parents in both studies. Common themes among the three chart review studies, show promising results for the introduction of high flow nasal cannula oxygen therapy. All three have shown a clinically significant reduction in the intubation rates when a child with bronchiolitis is treated with HFNC therapy, as McKiernan et al (2010) compared two seasons, one without HFNC and one with HFNC, in the season before the introduction 23% of the infants who presented with bronchiolitis required intubation as compared with 9% of the infants who presented the following season when HFNC was available as a treatment option. Thus the availability of HFNC resulted in a 14% absolute risk reduction in the need for intubation (McKiernan et al 2010: 636). Similarly, Abboud et al (2012) had a failure rate to HFNC of only 18.6%, meaning 81.4% responded to HFNC, it was noted that of those who did not respond to HFNC therapy and required intubation, most were clinically more unwell prior to commencing HFNC therapy and 11 out of the 17 patients tested for co-infections, were positive for various bacterial sources of infection. Those who did respond had improved oxygen saturations and decreased respiratory rates (Abboud et al 2012: 346). In keeping with reduced intubation rates, Schibler et al (2013) state the overall intubation rate within the unit dropped from 37% prior to HFNC therapy, to just 7% after its introduction four years later. The median length of stay within the PICU for bronchiolitic infants dropped from 2.42 days anmf.org.au
Clinical update
THE REVIEW OF THE LITERATURE HAS SHOWN THAT THE USE OF HFNC OXYGEN THERAPY IS OF SIGNIFICANT BENEFIT TO THOSE INFANTS AND YOUNG CHILDREN WITH BRONCHIOLITIS REQUIRING OXYGEN SUPPORT. to 2.33 days in this study. In all infants there was a significant reduction in respiratory rate and heart rate after the initiation of HFNC therapy, in this study there was no significant interaction between HFNC therapy and SpO2 or SpO2/FiO2 ratio (Schibler et al 2013: 850). Milesi et al (2013), compliments the results in reduction of intubation rates seen in the case reviews with scientific data. Pharyngeal pressure increased from 0.2cmH2O at 1litre/ minute to 4cmH2O at maximal flow of 8 litres/ minute. However only flows equal to and greater than 6L/min generated an increase in pharyngeal pressure resulting in positive pressure values during both inspiration and expiration. A flow equal to 2L/kg/min was associated with the generation of a mean pharyngeal pressure greater than 4cmH2O (Milesi et al 2013: 1091). Arora et al (2012) recorded similar results, nasopharyngeal pressures increased linearly with increasing flow rate up to 6L/min both in open and closed mouth positions. On average, nasopharyngeal pressure increased by 0.45cmH2O for each 1L/min increase in flow rate, the maximum recording achieved was 5cmH2O, however mean nasopharyngeal pressure for clinical improvement was 3.4cmH2O (Arora et al 2012: 1181). The review of the literature has shown that the use of HFNC oxygen therapy is of significant benefit to those infants and young children with bronchiolitis requiring oxygen support. The chart reviews have shown an overwhelming appreciation in order to reduce the intubation rates, HFNC does in the majority of cases reduce a child’s work of breathing and provides an increase in oxygen saturations, not only does it improve physiological scores but it also allows the child more freedom. The physiological studies have also provided anmf.org.au
promising results, showing that HFNC provides positive pressure within the nasopharyngeal space, as well as providing a washout of carbon dioxide rich gas, this has been shown to be most effective in flow rates of 4L/min and more. The literature chosen for this review paints a promising picture for the future use of high flow nasal cannula oxygen therapy in the treatment of infants and young children with bronchiolitis. It has the potential to significantly decrease the intubation rates, by decreasing the infant’s work of breathing and respiratory distress whilst providing a comfortable and well tolerated means of non-invasive ventilatory support (McKiernan et al 2010: 637). Some of the studies did have a small sample size, so a multi-centre randomised controlled trial comparing HFNC therapy with standard care is needed to assess and prove the efficacy of HFNC therapy (Schibler et al 2011). Objective measures of work of breathing could test the hypothesis that HFNC decreases the rates of intubation in infants and young children with bronchiolitis (McKiernan et al 2010: 637). At this time there is one randomised controlled trial of high flow nasal cannula oxygen therapy compared to standard oxygen therapy in the management of moderate bronchiolitis in infants less than 24 months in progress in Australia (registered with Australia New Zealand Clinical Trials Registry), however no results are available as yet. The safety of HFNC oxygen remains an issue due to the concern for barotrauma. When infants receive conventional nasal CPAP, it is possible to measure and regulate the pressure applied to the pharynx from the circuit, however, in HFNC the pressure delivered to the airway cannot be determined, so this does raise concerns about the possibility of airway and lung trauma, therefore, larger prospective studies are needed to assess the safety and efficacy of HFNC therapy (Arora et al 2012: 1183). The most common reason for non-elective admissions to a PICU in Australia is viral bronchiolitis which imposes a significant financial burden on the hospital (Schibler et al 2011:850). Not only is there a financial burden for the hospital, but also to the family, but more importantly there is also the emotional and physical needs of the sick child and their family to consider. On average the general paediatric ward of Albury Wodonga Health admits 85 infants and
young children with bronchiolitis each year, many of these children require supportive care which often includes oxygen therapy. The use of high flow nasal cannula oxygen therapy has increased in this unit, however at this time children can receive a maximum of 4 litres/min of oxygen/air therapy, if there is no improvement in their condition, they are required to be transferred to the intensive care unit or a tertiary centre. Further research on the efficacy and safety of this treatment will lend itself to improved and evidenced based practice on the care of a child with bronchiolitis receiving high flow nasal cannula oxygen therapy.
References Abboud, P.A., Roth, P.J., Skiles, C.L., Stolfi, A. & Rowin, M.E. 2012. Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy. Pediatric Critical Care Medicine. 13 (6):343-349. Arora, B., Mahajan, P., Zidan, M.A. & Sethuraman, U. 2012. Nasopharyngeal airway pressures in bronchiolitis patients treated with high-flow nasal cannula oxygen therapy. Pediatric Emergency Care. 28 (11): 1179-1184. Beggs, S., Wong, Z.H., Kaul, S., Ogden, K.J. & Walters, J.A. 2014. High-flow nasal cannula therapy for infants with bronchiolitis (Review). The Cochrane Database of Systematic Reviews. 1: 1-24. Cambonie, G., Milesi, C., Jaber, S., Amsallem, F., Barbotte, E., Picaud, J.C. & Matecki, S. 2008. Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis. Intensive Care Medicine. 34: 1865-1872. McKiernan, C., Chua, L.C., Visintainer, P.F. & Allen, H. 2010. High flow nasal cannulae therapy in infants with bronchiolitis. The Journal of Pediatrics. 156 (4): 634-638. Milesi, C., Baleine, J., Matecki, S., Durand, S., Combes, C., Novais, A.R. & Cambonie, G. 2013. Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study. Intensive Care Medicine. 39: 1088-1094. Schibler, A., Pham, T.M., Dunster, K.R., Foster, K., Barlow, A., Gibbons, K. & Hough, J.L. 2011. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Medicine. 37: 847-852. Teshome, G., Gattu, R. & Brown, R. 2013. Acute bronchiolitis. Pediatric Clinic. 60: 1019-1034. Walter, E.C. 2013. High-flow nasal cannula- What is it, how does it work, and do we know if it works? Critical Care Alert. 21 (1): 1-5.
Danielle Hanlon is a Registered Nurse (currently completing her post graduate certificate in Paediatrics) at Albury Wodonga Health- Paediatric Ward in New South Wales. September 2014 Volume 22, No.3 31
Focus – Infection Control Preventing infections through cleaner hospitals project By Michelle Allen, Kate Halton, Lisa Hall, Emily Bailey and Nick Graves While many Australian hospitals have good infection control practices, research about the role cleaning in the hospital environment plays in preventing infections is limited. Numerous cleaning standards and guidelines exist, but translating this information into meaningful and sustained improvements in cleaning practice is challenging. Development of a bundle approach to improving environmental cleaning may provide a solution. A bundle is a small, straightforward set of evidence based practices that when performed collectively and reliably improve patient outcomes (Resar et al 2005). The Preventing Infections Through Cleaner Hospitals (PITCH) project has developed, implemented, and will evaluate, an environmental cleaning bundle to reduce healthcare associated infections (HAI). A structured literature review was used to identify evidence and a multidisciplinary expert panel was used to prioritise practices for inclusion. The five key areas identified were product use, cleaning technique, enhanced auditing, comprehensive training and improved communication. The Promoting Action Research in Health Services (PARIHS) framework (Kitson et al 1998) was utilised for design and implementation and provided an easy to use, yet comprehensive process. Use of the framework during bundle development ensured that all relevant forms of evidence were considered, including clinical and user experience and local data as well as guidelines and scientific literature, and maximised stakeholder engagement. The framework was then used to guide implementation of the bundle into a large Brisbane hospital by mapping the process to the framework through a needs assessment of the hospital context (eg. leadership, systems and processes, culture). This helped to identify specific areas key to successful implementation, such as a need 32 September 2014 Volume 22, No. 3
Christine Welsh and Michelle Allen conducting cleaning audits as part of the PITCH project
for improved nurse-cleaner communication, and better staff access to information and helped guide synthesis of information obtained from staff consultations and patient and staff surveys, to develop training resources. Ongoing monitoring has shown that use of the PARIHS framework enabled us to achieve high levels of stakeholder engagement and avoid delays in implementation. We are also already seeing improvements in cleaning practice. To evaluate the PITCH bundle we will estimate its effectiveness in terms of changes to cleaning knowledge and performance, and infection rates and estimate its cost-effectiveness. Once this trial is complete, a randomised controlled trial called Researching Effective Approaches to Cleaning in Hospitals project (REACH) will be rolled out to 11 hospitals nationally, to demonstrate whether investing in an environmental cleaning program in acute hospitals reduces the risks of HAI and is cost-effective across a variety of settings. Based on our
successes, the larger trial will again use the PARIHS framework to support implementation and evaluation of this complex intervention. References Kitson A, Harvey G, McCormack B., (1998). Enabling the implementation of evidence based practice: a conceptual framework; Quality in Health Care; 7(3):149-158. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T.,(2005). Using a bundle approach to improve ventilator care processes and reduce ventilatorassociated pneumonia. Joint Commission Journal on quality and patient safety/Joint Commission Resources; 31(5):243-248. Disclosure of interest: No conflicts of interest to declare. Ms Allen is supported by a scholarship funded through an NHMRC Centre of Research Excellence grant (1030103). Professor Nicholas Graves is supported by NHMRC Research Fellowship grant (1059565).
Ms Michelle Allen, Dr Kate Halton, Dr Lisa Hall, Ms Emily Bailey and Professor Nick Graves are located at the Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology anmf.org.au
Focus – Infection Control Nurses working to reduce infection and other complications for children with central venous access devices By Claire Rickard and Amanda Ullman Each year in Australia around 500,000 central venous access devices (CVADs) are inserted to provide therapy during acute and chronic illness. Drastically, between 20 and 50% of CVADs fail prior to treatment being complete. The most serious and life-threatening complication is catheter-related bloodstream infections, which occur when bacteria or fungi from the skin or external environment gain entry directly via the CVAD to the patient’s bloodstream. Tricia Kleidon, nurse practitioner at the Royal Children’s Hospital, Brisbane, who is also a research fellow at the NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith Health Institute, manages the care of around 800 children with CVADs each year. After witnessing the suffering of many young children from devastating bloodstream infections, she believes that many of these are completely preventable, with improved nursing care and ongoing research. “CVADs are vital for sick children’s treatment and these healthcare associated infections result in significant harm. They interrupt essential treatment, increase procedural risks associated with reinsertion of new CVADs and each infection greatly prolongs hospital stay, costs and risk of mortality,” said Ms Kleidon. Two key factors in preventing infections and other complications are the securement of CVADs to the skin and dressing of the incision site. But there is a large variety of dressing and securement products available for CVADs, and nurses are forced to choose a product without adequate evidence regarding their effectiveness. Ms Kleidon is working collaboratively with the Alliance for Vascular Access Training and Research (AVATAR) group anmf.org.au
Chief Investigator, Nurse Practitioner and Research Fellow Tricia Kleidon
from Griffith University, including Professor Claire Rickard and PhD candidate Amanda Ullman. Together they are undertaking pilot randomised controlled trials (RCT) to assess the feasibility and the effectiveness of improved dressing and securement methods to prevent CVAD complications. Children will be randomly allocated to receive standard practice or one of three novel products including tissue adhesive (medical-grade superglue).
“OUR RESEARCH WILL HELP IDENTIFY CLINICALLY AND COST-EFFECTIVE SECUREMENT AND DRESSING APPROACHES THAT PREVENT CVAD INFECTIONS FOR OUR MOST VULNERABLE POPULATION”
“Our research will help identify clinically and cost-effective securement and dressing approaches that prevent CVAD infections for our most vulnerable population,” said Ms Kleidon.
Excellence in Nursing, Centre of Health Practice Innovation, Griffith Health Institute
The pilot RCTs are underway at the Royal Children’s Hospital, Brisbane. Claire Rickard is Director, Alliance for Vascular Access Teaching and Research (AVATAR) Group and Professor of Nursing, NHMRC Centre of Research
Amanda Ullman is PhD Candidate & Senior Research Assistant, NHMRC Centre of Research Excellence in Nursing, Centre of Health Practice Innovation & School of Nursing and Midwifery, Griffith University and Honorary Research Fellow: Royal Brisbane and Women’s Hospital September 2014 Volume 22, No.3 33
Focus Surveillance to reduce urinary tract infections: The STRUTI project By Oyebola Fasugba, Anne Gardner, Brett Mitchell, Wendy Beckingham and Noleen Bennett
Professor Anne Gardner (R) and Bola Fasugba (L) School of Nursing, Midwifery and Paramedicine Australian Catholic University
An estimated 65 to 70% of healthcare associated urinary tract infections (HAUTIs) may be prevented using infection control measures (Umscheid et al 2011). Point prevalence surveys (PPS) are a useful cost-effective surveillance method for prevention and control of HAUTIs. The data can help inform policy and nursing practice thereby reducing the risk of HAUTI acquisition (Smiddy & Murphy 2013).
Researchers and infection control experts at Australian Catholic University’s School of Nursing, Midwifery and Paramedicine; Avondale College for Higher Education; Canberra Hospital; and Victorian Healthcare Associated Infection Surveillance Coordinating Centre are working in partnership to develop a national surveillance system for HAUTIs using PPS. This is a three phase project with recent completion of phase I (Gardner et al 2014). Preliminary findings from phase I were used to develop a national protocol which has recently been published (Mitchell et al 2014). Phase II will develop and test a website for online collection of HAUTI surveillance data in Australian acute care hospitals and aged care facilities. This phase is being funded by a 2014 Ian Potter Foundation Grant and an Australian Catholic University Faculty of Health Sciences Research Grant. Utilisation of surveillance findings with the use of care plans will support delivery of a quality and safety-orientated healthcare service (Smiddy & Murphy 2013) consistent with Standard 3.2 of the National Safety and Quality Health Service Standards (ACSQHC, 2011). The researchers, through continued collaboration with hospitals and aged care facilities, will continue to progress work in developing a national surveillance system for HAUTIs. References Australian Commission on Safety and Quality in Health Care (ACSQHC) (2011). National Safety and Quality Health Service Standards. Sydney. Gardner, A., Mitchell, B., Beckingham, W. and Fasugba, O., (2014). A Point Prevalence Cross Sectional Study of Health Care Associated Urinary Tract Infections in Six Australian Hospitals. BMJ Open. (In press, accepted 24 June 2014)
Minimum standard for wound dressing procedure in the home care environment By Terry Swanson
34 September 2014 Volume 22, No. 3
A working party for the Australian Wound Management Association (AWMA) is developing a position paper on the minimum standard for wound dressing procedure in the home care environment. The group consists of nurses from acute, community, general practice and the outpatient setting as well as an infection control consultant, GP and a podiatrist.
Mitchell, B., Gardner, A., Beckingham, W. and Fasugba, O., (2014). Healthcare associated urinary tract infections: a protocol for a national point prevalence study. Healthcare Infection. 19(1):26-31. Smiddy, M.P. and Murphy, O.M., (2013). The use of point prevalence surveys of healthcare-associated infection to identify risk factors and facilitate infection prevention and control planning. Healthcare Infection. 18(4):162-167. Umscheid, C.A., Mitchell, M. D., Doshi, J. A., Rajender A., Kendal W. and Patrick J. B., (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection control and hospital epidemiology. 32(2):101-114.
Oyebola Fasugba is a research associate in the School of Nursing, Midwifery and Paramedicine (Canberra Campus) at Australian Catholic University. Professor Anne Gardner is a professor of nursing in the School of Nursing, Midwifery and Paramedicine (Canberra Campus) at Australian Catholic University. Dr Brett Mitchell is a senior lecturer in the Faculty of Nursing and Health, Avondale College of Higher Education in NSW; and an honorary fellow at Australian Catholic University (School of Nursing, Midwifery and Paramedicine). Ms Wendy Beckingham is a clinical nurse consultant in Infection Control at the Canberra Hospital. Dr Noleen Bennett is a senior infection control consultant at the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre.
This group was formed after a request from the membership seeking clarification and guidance regarding The National Safety and Quality Health Service Standards published by the Australian Commission on Safety and Quality in Healthcare (2011) which includes Standard 3 - Preventing and Controlling Healthcare Associated Infections and Aseptic Technique in relation to the wound dressing procedure that is discussed in the Australian Guidelines for the
anmf.org.au
Focus NSW hand hygiene campaign By Paul Smollen, Iain Crawford and Paul Curtis Hand hygiene is one of the most important measures in reducing the transmission of infectious agents in healthcare settings The Clinical Excellence Commission (CEC) has identified hand hygiene as a high priority for the prevention of healthcare associated infection (HAI) in New South Wales. The National Safety and Quality Health Service Standards view hand hygiene as important element to health facilities achieving accreditation (ACSQHC 2011). The CEC’s Hand Hygiene Program advocates the need to improve and sustain hand hygiene practices of healthcare workers, at the right times, in the right way to help reduce the spread of potentially lifethreatening infections in healthcare facilities. NSW subscribes to the National Hand Hygiene Initiative and the 5 Moments of Hand Hygiene, based on the World Health Organization’s (WHO) program. This is designed to break infection transmission at key points in the care process: specifically when approaching or leaving the patient; and before and after procedures. NSW healthcare staff are audited at regular intervals to give facilities local data that can be compared to state and national benchmarks. This process highlights opportunities for education and re-education with a strong focus on changing culture and championing infection prevention.
Prevention and Control of Infection in Healthcare 2010. This important document aims to provide practical information that risk manages and utilises the concepts from the “wound world” with nomenclature of infection prevention and control. Many nurses have been confused by changes, and will clarify the requirements of the Aseptic Non-Touch Technique (ANTT®) framework by outlining a set of
anmf.org.au
NSW Compliance Rate by Moment, March 2014 Real improvements have been made across NSW in practising hand hygiene since the beginning of the Hand Hygiene program in 2009. However clinicians can still be uncertain of when to clean their hands and may do this at inappropriate times. One of the CEC’s most recent initiatives encourages the clinician to break the cycle of transmission by adapting a culture of “Clean in, Clean out”. Historically clinicians are very good at protecting themselves from exposure to body fluids; with strong compliance with Moment 3 across all the data, yet when it comes to protecting the patient from introduced HAIs at Moment 1, clinicians often miss important opportunities. The ‘Clean In, Clean Out’ campaign is designed to complement the 5 Moments program to raise awareness of the importance of performing hand hygiene before patient contact (Moment 1, which currently rates at 77% compliance) and after patient contact Moment 4 and 5.
This campaign is directed to all clinicians to remind them to build hand hygiene into their routine practice. It is hoped the new tagline ‘Clean In, Clean Out’ becomes more of a mantra to staff and helps ingrain a ritualistic practice among staff.
References Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report, 2002;51 Commonwealth Government, Australian Commission for Safety and Quality in Healthcare, September 2011. National Safety and Quality Health Service Standards, Sydney. Financial disclosure: The authors have no conflicts of interest to disclose. The work described in this article has been funded wholly by the Clinical Excellence Commission.
Paul Smollen is HAI Program Manager, Iain Crawford, Hand Hygiene project officer and Paul Curtis is Director Clinical Governance all at the Clinical Excellence Commission in NSW
Compliance Rate by Movement – New South Wales (March 2014) 1
Before Touching a Patient
2
Before Procedure
3
After a Procedure or Body Fluid Exposure Risk
4
After Touching a Patient
5
After Touching A Patient’s Surroundings
0
20
40
60
80
100
Compliance Rate
principles for aseptic practice to be implemented in individual circumstances. It is anticipated that this document will be endorsed by AWMA in 2014. Members will then be able to access it via the AWMA website: www.awma.com.au References Australian Commission on Safety and Quality in Healthcare (ACSQH) (2011) National Safety and Quality Health Service Standards, ACSQHC, Sydney
National Health and Medical Research Council (NHMRC) (2010) Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia
Terry Swanson is the nursing representative (on behalf of the AWMA AT Working Party), nurse practitioner wound management at South West Healthcare in Victoria and chair AWMA Aseptic Technique Working Party
September 2014 Volume 22, No.3 35
Focus Reducing catheter associated urinary tract infections By Jan Gralton, Paul Smollen and Paul Curtis catheterisation, catheter care and bladder scanning and will be supported through the delivery of multi-modal education. Financial disclosure: The authors have no conflicts of interest to disclose. The work described in this article has been funded wholly by the Clinical Excellence Commission, NSW. References Bradbury, R.S., L.P. French, and L. Blizzard., (2014). Prevalence of Acanthamoeba spp. in Tasmanian intensive care clinical specimens. Journal of Hospital Infection no. 86 (3):178-81. Chen, S.C., Z.S. Tong, O.C. Lee, C. Halliday, E.G. Playford, F. Widmer, F.R. Kong, C. Wu, and T.C. Sorrell.,(2008). Clinician response to Candida organisms in the urine of patients attending hospital. European Journal of Clinical Microbiology and Infectious Diseases no. 27 (3):201-8. Dobson, C., S. Naidu, and M. Johnson.,(1996). Nurses’ perception of urinary catheter selection and management. Urology nursing no. 16 (4):140-5.
Catheter-associated urinary tract infections (CAUTIs) are the most common type of healthcare associated infection (HAI).
health services. In its first phase, the project will prompt for quality checks at key moments before, during and after urinary catheter insertion in acute care settings.
Locally, the etiology of CAUTIs has been attributed to common HAI pathogens, such as Escherichia coli and Klebsiella pneumonia (Kennedy, Roberts, and Collignon 2008; Jenney et al. 2006), as well as less prevalent pathogens such as Candida albicans and Acanthamoeba spp. (Chen et al. 2008; Bradbury, French, and Blizzard 2014). In Australia, a CAUTI may result in lengthened hospitalisation for the patient and lost bed days for the health service (Graves, Halton, and Robertus 2008). The two main risk factors for CAUTIs are catheterising inappropriately (eg. for convenience) and leaving an indwelling urinary catheter (IUC) in situ for an unnecessarily prolonged period (Lo et al. 2014). The evidence suggests clinicians lack knowledge about the appropriate indications for IUCs and are often not aware of the presence of an IUC and its dwell time (Dobson, Naidu, and Johnson 1996; Harley et al. 2011) resulting in higher rates of CAUTIs.
Previous research has reported the risk of CAUTIs is lessened when alternative to IUCs are used (Patel, Watts, and Grant 2001). To encourage consideration of catheterisation appropriateness and alternatives to IUCs, the first project resource to be produced is a catheterisation decision support tool for clinicians working in acute care settings, particularly emergency, critical care, surgical, aged care, stroke and maternity units. The decision support tool also provides the basis for a criteria-led catheter removal protocol. Combined with a daily catheter management checklist, a criterialed catheter removal protocol enables frequent monitoring of catheter need and timely removal when need has resolved. The protocol will be particularly useful for units that are currently dependant on documented IUC removal orders.
Therefore, the Clinical Excellence Commission has commenced a quality improvement project targeting urinary catheter use and CAUTIs in NSW public 36 September 2014 Volume 22, No. 3
Other project tools will focus on including of IUCs into patient handover and daily patient rounding, implementing an IUC insertion checklist that addresses aseptic technique and auditing the appropriateness of catheter specimen urine collection. This project will be underpinned by new state-wide guidelines on acute urinary
Graves, N., K. Halton, and L. Robertus., (2008). Costs of health care associated infection. In Reducing Harm to Patients from Health Care Associated Infection: the Role of Surveillance, edited by M. Cruikshank and J. Ferguson. Canberra: Australian Commission on Safety and Quality in Health Care. Harley, G., A.L. Yeo, R.L. Stuart, and C. Dendle.(2011). A real-life snapshort of the use and abuse of urinary catheters on general medical wards. Infection Control and Hospital Epidemiology no. 32 (12):1216-8. Jenney, A.W., A. Clements, J.L. Farn, O.L. Wijburg, A. McGlinchey, D.W. Spelman, T.L. Pitt, M.E. Kaufmann, L. Liolios, M.B. Moloney, S.L. Wesselingh, and R.A. Strugnell.,(2006). Seroepidemiology of Klebsiella pneumoniae in an Australian tertiary hospital and its implications for vaccine development. Journal of Clinical Microbiology no. 44 (1):102-107. Kennedy, K.J., J.L. Roberts, and P.J. Collignon.,(2008). Escherichia coli bacteraemia in Canberra: incidence and clinical features. Medical Journal of Australia no. 188 (4):209-13. Lo, Evelyn M. D., Lindsay E. M. D. Nicolle, Susan E. M. D. M. P. H. Coffin, Carolyn M. D. M. S. Gould, Lisa L. M. D. M. P. H. Maragakis, Jennifer M. D. MSc Meddings, David A. M. D. Pegues, Ann Marie R. N. B. S. N. C. I. C. Pettis, Sanjay M. D. M. P. H. Saint, and Deborah S. M. D. M. P. H. Yokoe., (2014). Strategies to Prevent CatheterAssociated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology no. 35 (5):464-479. doi: 10.1086/675718. Patel, M. I., W. Watts, and A. Grant., (2001). The optimal form of urinary drainage after acute retention of urine. BJU International no. 88 (1):26-29. doi: 10.1046/j.1464-410x.2001.02253.x.
Jan Gralton is HAI Project Officer, Paul Smollen is HAI Program Manager and Paul Curtis is Director Clinical Governance all at the Clinical Excellence Commission in NSW anmf.org.au
Focus Preventing infections following caesarean section By Elizabeth Martin Surgical site infections following caesarean section are a serious and costly adverse event for Australian hospitals. In the United Kingdom, 9% of women are diagnosed with a surgical site infection following caesarean section either in hospital or post-discharge (Wloch et al 2012, Ward et al 2008). Additional staff time, pharmaceuticals and health supplies, and increased length of stay or readmission to hospital are often required (Henman et al 2012). Part of my PhD investigated the economics of preventing post-caesarean infection. This paper summarises a review of relevant infection prevention strategies. Administering antibiotic prophylaxis 15 to 60 minutes pre-incision, rather than post cordclamping, is probably the most important infection prevention strategy for caesarean section (Smaill and Gyte 2010, Liu et al 2013, Dahlke et al 2013). However the timing of antibiotic administration is reportedly inconsistent in Australian hospitals. Clinicians may be taking advice from the influential, but out-dated RANZCOG and United States Centers for Disease Control and Prevention guidelines (Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2011, Mangram et al 1999). A number of other important international clinical guidelines, including Australia’s NHMRC guidelines, recommend universal prophylactic antibiotics pre-incision for caesarean section (National Health and Medical Research Council 2010, National Collaborating Centre for Women’s and Children’s Health 2008, Anderson et al 2008, National Collaborating Centre for Women’s and Children’s Health 2011, Bratzler et al 2013, American College of Obstetricians and Gynecologists 2011a, Antibiotic Expert Group 2010). We need to ensure women receive preincision antibiotic prophylaxis, particularly as nurses and midwives play a significant role in managing an infection that may result from sub-optimal practice. It is acknowledged more explicitly now that nurses and midwives can influence prescribing and administration of antibiotics through informal approaches (Edwards et anmf.org.au
al 2011). Methods such as surgical safety checklists are a more formal way for nurses and midwives to ensure that antibiotics are administered pre-incision (American College of Obstetricians and Gynecologists 2011b). Nurses and midwives can also be directly responsible for other infection prevention strategies such as instructing women to not remove pubic hair in the month before the expected date of delivery and wound management education (Ng et al 2013). Potentially more costly but effective strategies include using a Chlorhexidine-gluconate (CHG) sponge preoperatively (in addition to the usual operating room skin preparation) and vaginal cleansing with a povidone-iodine solution (Riley et al 2012, Rauk 2010, Haas, Morgan, and Contreras 2013). References American College of Obstetricians and Gynecologists., (2011a). Use of Prophylactic Antibiotics in Labor and Delivery. Obstetrics and Gynecology no. 117 (6):1472-1483. American College of Obstetricians and Gynecologists., (2011b). Patient Safety Checklist no. 4: preoperative planned cesarean delivery. Obstetrics and Gynecology no. 118 (6):1471-2. doi: 10.1097/ AOG.0b013e31823ed223. Anderson, D. J., K. S. Kaye, D. Classen, K. M. Arias, K. Podgorny, H. Burstin, D. P. Calfee, S. E. Coffin, E. R. Dubberke, V. Fraser, D. N. Gerding, F. A. Griffin, P. Gross, M. Klompas, E. Lo, J. Marschall, L. A. Mermel, L. Nicolle, D. A. Pegues, T. M. Perl, S. Saint, C. D. Salgado, R. A. Weinstein, R. Wise, and D. S. Yokoe., (2008). Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology no. 29 (S1):S51-S61. doi: 10.1086/591064. Antibiotic Expert Group., (2010). Therapeutic guidelines: antibiotic. Melbourne: Therapeutic Guidelines Limited. Bratzler, D. W., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. Bolon, D. N. Fish, L. M. Napolitano, R. G. Sawyer, D. Slain, J. P. Steinberg, R. A. Weinstein, Pharmacists American Society of Health-System, America Infectious Disease Society of, Society Surgical Infection, and America Society for Healthcare Epidemiology of., (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy no. 70 (3):195-283. doi: 10.2146/ajhp120568. Dahlke, Joshua D., Hector Mendez-Figueroa, Dwight J. Rouse, Vincenzo Berghella, Jason K. Baxter, and Suneet P. Chauhan., (2013). Evidence-based surgery for cesarean delivery: an updated systematic review. American Journal of Obstetrics and Gynecology no. 209 (4):294-306. doi: http://dx.doi.org/10.1016/j.ajog.2013.02.043. Edwards, R., L. Drumright, M. Kiernan, and A. Holmes.,(2011). Covering more Territory to Fight Resistance: Considering Nurses’ Role in Antimicrobial Stewardship. J Infect Prev no. 12 (1):6-10. doi: 10.1177/1757177410389627. Haas, D. M., S. Morgan, and K. Contreras., (2013). Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Systematic Reviews no. 1:CD007892. doi: 10.1002/14651858.CD007892.pub3. Henman, K., C. L. Gordon, T. Gardiner, J. Thorn, B. Spain, J. Davies, and R. Baird., (2012). Surgical site infections
following caesarean section at Royal Darwin Hospital, Northern Territory. Healthcare Infection no. 17 (2):47-51. Liu, J., J. Sun, M. Ding, J. Liu, Y. Li, X. Sun, T. Liu, and Y. Chen., (2013). Prophylactic administration of cefazolin prior to skin incision versus antibiotics at cord clamping in preventing postcesarean infectious morbidity: A systematic review and meta-analysis of randomized controlled trials. Gynecologic and Obstetric Investigation no. 75 (3):175-178. Mangram, A. J., T. C. Horan, M. L. Pearson, L. C. Silver, and W. R. Jarvis., (1999). Guideline for Prevention of Surgical Site Infection, 1999. American Journal of Infection Control no. 27 (2):97-134. doi: http://dx.doi. org/10.1016/S0196-6553(99)70088-X. National Collaborating Centre for Women’s and Children’s Health., (2008). Surgical site infection: Prevention and treatment of surgical site infection. London: National Institute for Health and Clinical Excellence. National Collaborating Centre for Women’s and Children’s Health., (2011). NICE clinical guidelines - Caesarean section. London: Royal College of Obstetricians and Gynaecologists. National Health and Medical Research Council., (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. Ng, W., D. Alexander, B. Kerr, M. F. Ho, M. Amato, and K. Katz., (2013). A hairy tale: successful patient education strategies to reduce prehospital hair removal by patients undergoing elective caesarean section. Journal of Hospital Infection no. 83 (1):64-67. doi: http:// dx.doi.org/10.1016/j.jhin.2012.09.013. Rauk, P. N., (2010). Educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections. American Journal of Infection Control no. 38 (4):319-323. doi: 10.1016/j. ajic.2009.10.004. Riley, M. M., D. Suda, K. Tabsh, A. Flood, and D. A. Pegues., (2012). Reduction of surgical site infections in low transverse cesarean section at a university hospital. American Journal of Infection Control no. 40 (9):820825. doi: http://dx.doi.org/10.1016/j.ajic.2011.12.011. Royal Australian and New Zealand College of Obstetricians and Gynaecologists., (2011). C-Gen 17: Prophylactic antibiotics in Obstetrics and Gynaecology. Melbourne: Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Smaill, F. M., and G. M. L. Gyte. 2010. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database of Systematic Reviews (1), http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD007482.pub2/abstract. Ward, V. P., A. Charlett, J. Fagan, and S. C. Crawshaw., (2008). Enhanced surgical site infection surveillance following caesarean section: experience of a multicentre collaborative post-discharge system. Journal of Hospital Infection no. 70 (2):166-173. Wloch, C., J. Wilson, T. Lamagni, P. Harrington, A. Charlett, and E. Sheridan., (2012). Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. British Journal of Obstetrics and Gynaecology no. 119 (11):1324-1333. doi: 10.1111/j.14710528.2012.03452.x.
Elizabeth Martin is a PhD candidate at the Queensland University of Technology September 2014 Volume 22, No.3 37
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Focus
Clinical waste in home healthcare: navigating the swamp By Raylee A Pandur Clinical waste disposal pertaining to non-sharps is the only component of infection prevention and control that is not governed by clear evidence based guidelines. This is due to a dearth of information about the real risks of developing an infection from accidentally interacting with ill-disposed non sharps clinical waste. Instead, recommendations are based on perceptions and particularly those related to aesthetics and public offence. Healthcare workers have to navigate blindly through a minefield of regulations and guidelines that are contradictory, illogical and impractical in the hope of complying with national, state and organisational requirements. This is particularly evident in home healthcare where the financial and practical impact of full compliance with state regulations can be untenable and crippling. The risks associated with sharps injuries are well recognised and quantified (CDC 2013). However the same cannot be said about individuals acquiring a significant infection from contact with non-sharps clinical waste. In fact, existing research has shown that hospital clinical waste is no more infective than general household waste (Collins & Kennedy 1992; Phillips 1999). In Australia, the states and territories cannot agree on what actually comprises clinical waste. The divergent definitions vary anmf.org.au
from ‘free flowing or expressible blood and body fluids’ (NT Government 2009) to ‘bandages and dressings soiled with blood or body fluids’ (EPA 2009). In order to have a consistent, practical, financially viable and publically acceptable waste disposal policy, there must be congruence in the definition of clinical waste, and it must be based on risk. The clinical waste category should not be applied in the home care setting. The Queensland Government Department of Environment and Heritage Production definition specifically releases healthcare workers in the home environment from the confines of the clinical waste classification other than sharps or devices used to penetrate the skin. Furthermore, they specify the exclusion of dried blood and items slightly contaminated with blood (Queensland Government 2013). This waste classification should be adopted nationally. If home healthcare providers were forced to dispose of all wound dressings in the clinical waste stream irrespective of the amount of blood or body fluids contained within the dressing, the burden of waste management in this setting would be unsustainable and still have no proven environmental benefit. Nurses apply risk assessment principles to evidence based frameworks whilst operating on a common sense paradigm. If we are told to do something that affronts our logic, and for which there is no evidence, we naturally push back.
We need environmental authorities and regulatory bodies to come together and solve the conundrum, particularly for community based health organisations. Either establish irrevocably that a wound dressing stained with blood poses an unacceptable risk to public health or accept that the risk is so low as to be unquantifiable and allow common sense to prevail, thereby enabling disposal in the client’s domestic waste. References Collins CH and Kennedy DA. The microbiological hazards of municipal and clinical wastes. Journal of Applied Bacteriology 1992; 73: 1-6. EPA Victoria Clinical and Related Waste – Operational Guidance, 2009. Available from: www.epa.vic.gov. au/ourwork/publications/publication/2009/september/ iwrg612-1 Accessed 7 July 2014. Northern Territory Government Department of Health and Families, 2009. Waste Management. Available from: remotehealthatlas.nt.gov.au/waste_management. pdf. Accessed 7 July 2014. Phillips G. Microbiological aspects of clinical waste, (1999). Journal of Hospital Infection; 41: Issue 1:1-6. Queensland Government Department of Environment and Heritage Protection, (2013). Information sheet: Defining clinical waste (EM1250 V2). Available from: www.ehp.qld.gov.au/licences-permits/business-industry/ waste-management/pdf/info-define-clinical-wasteem1250.pdf. Accessed 7 July 2014. US Centers for Disease Control (CDC). Stop Sticks, (2013). Available from: www.cdc.gov/niosh/stopsticks/ sharpsinjuries.html. Accessed 18 July 2014.
Raylee A Pandur is an infection prevention clinical nurse consultant at the Royal District Nursing Service Limited (Victoria) September 2014 Volume 22, No.3 39
Focus The challenges faced in infection prevention and control practices By Allison Roderick As I pen this article, the number of cases of Ebola Haemorrhagic Fever (HF) totals 964, with 603 deaths in Africa (WHO 2014). It has been described as an epidemic. As midwives and nurses across this great land, what would our response be if one day we walked into work and were informed, that one of these emergent diseases was on our unit? Would we feel equipped and ready? Would our practice change? To be honest, I know little about Ebola HF. I’ve never seen it and the thought of an acute viral illness with the typical fever and muscle aches and pains then evolving into my organs exploding (internal and external bleeding), is more reminiscent of a Hollywood blockbuster than everyday practice. But every day we do look after deadly microorganism staphylococcus aureus, pseudomonas and
enterococcus. They might not be devastating like Ebola HF but they are ever present in our healthcare units and continuously evolving. The result of these microorganisms is increased pain, suffering, prolonged hospitalisation and increased hospital costs. Infection prevention and control practices are challenging for two reasons: knowledge and practice. Firstly, as clinicians how do we keep up to date with emerging conditions and diseases. Many conditions such as MERS we are still learning about. What do we need to know? How do we keep abreast of all of this knowledge and these changes? Secondly, as clinicians what is in our arsenal of defence? Part of the solution is preventative practice through the use of precautions: standard and transmission based precautions. My challenge to you is to look at your own context of practice. What knowledge is needed about infection prevention and control and how do we inform our practice that meets our needs both actual and those that potentially wait around the corner? Our challenge is to keep up in an information savvy and globalised age. Is the answer
Allison Roderick
through mobile devices, online learning packages or hands on training? But equally challenging is how to do this while providing quality care and being fiscally responsible. If you would like to know more please contact Allison Roderick at allison.roderick@flinders.edu.au Reference World Health Organization (WHO).,(2014), Ebola virus disease, West Africa update, viewed 17 July 2014, www.who.int/csr/don/2014_07_15_ebola/en/>.
Allison Roderick is Lecturer in Nursing at Flinders University School of Nursing and Midwifery in South Australia
TRANSFUSION NURSE SPECIALIST • Auckland, New Zealand • 12 month fixed-term (early – mid 2015) • Full-time Are you ready for something a little different? Due to a staff member heading away on her own 12 month break, we have a fantastic opportunity for someone with the right experience looking for a bit of a change. So, whether you are a thrill seeker, love the outdoors or just enjoy a relaxing lifestyle – why not consider looking at New Zealand as a destination for a year! As a Transfusion Nurse Specialist with the NZ Blood Service, you will work with the Transfusion Medicine Specialist to assist in the delivery of specialist knowledge, quality activities and staff education, focusing on promoting excellence in the practice of blood transfusion. Key priorities for the role will involve clinical audit of blood product use, Haemovigilance, change management and education of the District Health Board staff in the appropriate use of blood and its components. You will be the knowledgeable and helpful face of NZBS who will assist the clinical staff to identify specific transfusion learning needs and develop strategies to address them as well as regularly auditing hospital transfusion practices, preparing reports and presenting findings to staff at relevant clinical and Hospital Transfusion Committee meetings. Although working primarily in one large DHB, you will need the flexibility to be able to assist other hospitals within the Auckland area as the need arises. We are looking for a self-starter who shows initiative, motivation, good interpersonal skills, flexibility and an ability to work on their own. To be successful in this role, you will be a Registered Nurse (eligible for Registration in New Zealand) with a background in a similar role or in haematology. For further information and to apply for this role, please visit our careers site at www.careers.nzblood.co.nz Applications Close: Friday, 17 October 2014. All applications will be treated in the strictest confidence. NZBS is an Equal Opportunity Employer
careers.nzblood.co.nz
Focus
The circle of life – the infection prevention and control program By Marija Juraja Infection prevention and control programs are similar to the ‘circle of life’. Each part of that circle is important, as it is the essence that holds everything together. When we think of the circle, we think of unity, strength and family. When we lose a part of the circle or break it, there is a ripple effect that can lead to minor or major ramifications for everyone or anything connected to the circle. The ‘circle of life’ is the essence that holds everything together and for the infection control practitioner/professional this is the ‘infection prevention and control program’. This program covers every area of National Standard 3 from the Australian Commission for Safety and Quality in Healthcare (ACSQHC). It ensures that each healthcare facility across the patient continuum provides a safe system of care, with quality initiatives such as consumer education, aseptic technique and bloodstream prevention strategies that prevent infections and save lives. What is the ripple effect in the area of infection prevention and control? The first ripple area is the area of patient safety, such as increased healthcare infections, increased length of stay, reduced personal income to the patient and the healthcare facility, loss of reputation (personal anmf.org.au
as well as professional), and lastly adverse outcomes which can lead to patient mortality. The second ripple area is worker health with increased avoidable exposure through non-compliance with personal protective equipment, poor risk assessment leading to personal injuries (such as needlestick, blood and body fluid splashes) decreased safety (personal and patient) and also legal liability implications. The last ripple area is the patient or consumer who now has a healthcare acquired infection (HAI), increased pressure on their already existing co-morbidities, loss of income, personal stigma because of the HAI (MRSA, VRE etc.), potential loss of employment, personal emotional trauma/ body image issues and a loss of faith in the healthcare system. As healthcare workers we are told to “do no harm”, yet in our busy working life we might take short cuts like not stopping to wash our hands before touching a patient or undertaking an aseptic procedure. We are asked to be advocates for our patients yet when we take liberties that break this circle even with knowing there are consequences to our actions, we fail them. For over 30 years, now as the Australasian College for Infection Prevention and Control (ACIPC), college members have worked with key stakeholders, including
our own membership to ensure we offer robust education programs, timely responses to national and international events, provide advice and support to external stakeholders through committee representation on ACSQHC, Coalition of National Nursing Organisations and that we are acknowledged as the experts through our credentialling program in infection prevention and control In Australasia. The consumer is an important focus for the college and we acknowledge this with the launch of our first consumer website focusing on empowering them in preventing HAIs. Preventing and controlling infections, the program, is all part of the ‘circle of life’ and every person/team member in healthcare holds a part to play in ensuring that it has a multidisciplinary approach, supported at the highest level of governance and at our best ensuring through our program that we are delivering the safest care possible to every single consumer. References Australian Commission on Safety and Quality in Health Care (ACSQHC), (2011). National Safety and Quality Health Service Standards. ACSQHC Sydney NHMRC, (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia.
Marija Juraja is Australasian College for Infection Prevention and Control (ACIPC) past president, CICP September 2014 Volume 22, No.3 41
Focus Intern credentialing training at the Princess Alexandra Hospital By Reto Federi and Fiona Fullerton The insertion of IV cannulas is one of the most performed invasive procedures in Australia and yet education and training is not regulated consistently. Nursing staff are required to undergo specific workshop based training to become IV cannulation competent at the Princess Alexandra Hospital (PAH), Brisbane. The training includes a range of topics that provides the nurses with the skills needed to safely perform the procedure while following hospital guidelines. However, there is no formal process for medical staff that ensures the same level of quality. Whilst medical students are provided with some cannulation training in a simulated environment at university, there is a lack of support when getting to the stage of cannulating a patient during
their clinical rotations. We still see the ‘see one, do one’ culture which should be of the past. Medical Interns with often little cannulation experience are called to perform difficult cannula insertions and due to the lack of previous support and feedback are put under a lot of pressure. This is not only distressing for the medical officer, it can lead to poor compliance with aseptic and non-touch technique (ANTT) and can potentially cause discomfort or harm to the patient.
Cannulation Workbook and the Hand Hygiene Australia Medical Officer online learning module. In addition, a workshop was provided where interns were assessed for IV cannulation, phlebotomy, applying and removing PPE and hand hygiene. Further sessions were delivered for interns who required additional training and support. Once in their clinical environment, the interns were further supported and practically assessed while cannulating a patient.
For the first time this year, the Vascular Access Surveillance Team (VAST) with the support of Infection Control, the Nursing Practice Development Unit and Medical Education, have delivered an intern credentialing program as part of intern orientation in January. The mandatory program involved the completion of the Hospital Cannulation Policy, the PAH
The intern credentialed process has been welcomed by medical officers and by the hospital executive. Ninety-five interns have been credentialed in IV cannulation and phlebotomy and are able to follow ANTT principles. Our next focus will be to support medical students with a similar process before they are able to cannulate patients unsupervised.
POSTGRADUATE DEGREES INFORMATION SESSION Deakin University School of Nursing and Midwifery invites you to an information session to hear about our innovative postgraduate degrees: • • • • •
Diabetes education Midwifery Perioperative care Intensive care Cardiac care
• • • • •
Interventional cardiac nursing Emergency care Nursing Practice Nurse Practitioner Research degrees
Melbourne Burwood Campus, 221 Burwood Highway Burwood. Building BC, Level 2. Tuesday 9 September, 5.00–6.30 pm. A short presentation will begin at 5.15 pm after light refreshments. There will be an opportunity to move to breakout rooms with course leaders to discuss specific courses and answer your questions. To register your attendance at the information session please email nursinfo@deakin.edu.au. For more information call 9244 6102, deakin.edu.au/nursing DEA0079 Deakin University CRICOS Provider Code: 00113B
Focus FOR THE FIRST TIME THIS YEAR, THE VASCULAR ACCESS SURVEILLANCE TEAM (VAST) WITH THE SUPPORT OF INFECTION CONTROL, THE NURSING PRACTICE DEVELOPMENT UNIT AND MEDICAL EDUCATION, HAVE DELIVERED AN INTERN CREDENTIALING PROGRAM AS PART OF INTERN ORIENTATION IN JANUARY. Reto Federi is a clinical nurse and Fiona Fullerton is a clinical nurse consultant with the Vascular Access Surveillance Team in Infection Management Services at Princess Alexandra Hospital, Metro South Health in Queensland
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Education BiPAP/CPAP The ANMF has launched a new online education training room called the ‘Body Systems Training Room’. Here you will find low cost subscription access to courses in a number of therapeutic areas including basic and advanced learning programs covering anatomy, physiology, diseases and medical procedures. We are offering all members an inaugural discount for our first month, so visit our education page to access this fantastic new training room. http://anmf.org.au/pages/online-education-programs You will find two new tutorials on the ANMF CPE website, Mental Health Liaison in General Hospitals, Part 1 (four in total) and BiPAP/CPAP. The Mental Health Liaison in General Hospitals tutorial is directed at healthcare professionals in generalist settings to assist them to increase their understanding, awareness and confidence in providing mental healthcare in areas such as – the care of suicidal patients, delirium and its associated features, aggression management, difficult behaviours, capacity assessment and consent to treatment related issues. Part 1 discusses delirium and its associated features as well as management of aggression. Our new BiPAP/CPAP tutorial is a much anticipated addition to our collection of critical care topics. Authored by Beth Horner, (B.N, M.H.Sc, R.N) a nurse educator with a clinical background in coronary care, high dependency and medical-surgical nursing, this tutorial explains the purpose and benefits of BiPAP and CPAP therapies. Below is an excerpt from this informative tutorial. Broadly speaking, CPAP and BiPAP improve the ability of the lungs to absorb oxygen, expel carbon dioxide and reduce the work of breathing without the need for intubation. They have become increasingly popular over recent decades due to their ability to avoid invasive ventilation via an endotracheal tube (ETT) and sedation. Previously these two therapies were only offered in critical care areas; their use has now extended to the general wards and community. Whilst BiPAP and CPAP have differing uses and indications, 44 September 2014 Volume 22, No. 3
many similarities exist. The nursing care and management can be considered interchangeable. The role of the nurse is critical in the implementation of BiPAP/CPAP therapy. Once prescribed, it is generally nurses that initiate/monitor and care for patients receiving Non-Invasive Ventilation (NIV). Optimal nursing care is vital to patient comfort, safety, compliance and ultimately the effectiveness of the therapy. CPAP utilises only one level of pressure. The level of pressure is applied constantly, throughout both inspiration and expiration. CPAP can be delivered by attaching a PEEP (positive end expiratory pressure) valve to the exhalation port or the valve may be managed internally by the ventilator. CPAP is also known as PEEP when used on a traditional ventilator and is the same as EPAP when applied in the BiPAP mode. CPAP improves arterial oxygen levels (PaO2) and reduces the work of breathing by: • Increasing mean airway pressure and preventing airway closure; • Promoting gaseous exchange by recruiting and maintaining the alveoli as open throughout the entire respiratory cycle; • Increases the surface area available for gas exchange and subsequently the functional residual capacity (the volume of gas contained within the lungs at the end of normal expiration); • Forces interstitial fluid back into the pulmonary circulation. Due to the lack of inspiratory support offered by CPAP, it is not able to facilitate the removal of carbon dioxide and as such,
it is generally not considered appropriate to use this modality in hypercapnic patients. BiPAP or Bi-level positive airway pressure utilises two separate pressure levels that cycle between inspiration and expiration. These are known as: IPAP - Inspiratory Positive Airway Pressure and EPAP Expiratory Positive Airway Pressure. The difference between IPAP and EPAP is the Pressure support. IPAP is applied during the inspiratory phase of breathing. A pre-set level of positive pressure is delivered to the patient, set higher than EPAP/PEEP. It provides breathing assistance in the form of pressure support and increases tidal volume and minute ventilation to achieve a proportional increase in alveolar ventilation and a reduction in carbon dioxide levels. It reduces the work of breathing to relieve dyspnoea. At the start of the expiratory phase pressure support generated by IPAP ends and the machine cycles to the pre-set EPAP. EPAP is set lower than IPAP. EPAP is the level that maintains a continuous positive pressure in the airways throughout respiration, generating the same effect as CPAP. Benefits of NIV versus Traditional Mechanical Ventilation (via ETT) include avoidance of complications associated with ventilation via ETT eg. ventilator acquired pneumonia, dental damage, vocal cord injury. There is no need for endotracheal intubation and sedation. The patient maintains spontaneous respiration and is able to maintain coughing mechanisms, oral intake, ability to communicate and potentially, mobilise. Therapy can be anmf.org.au
Education
delivered by trained nurses in general wards, decreasing the demand for critical care beds. Patterns of use vary and depend upon the needs of the patient. Single use, intermittent, continuous or nocturnal use patterns in acute, chronic and palliative scenarios for both adult and paediatric patients. Acute use of CPAP and BiPAP is generally delivered in the hospital setting in critical care areas, wards and emergency departments. Chronic and palliative use of CPAP/BiPAP is more commonly seen in the community. However, chronic and palliative NIV users can be admitted for acute care across any discipline presenting a need for nursing staff on general wards and emergency departments to be trained in NIV. However, it is important to note that the experience of staff is a crucial factor in the success or failure of NIV regardless of the location of care. anmf.org.au
Earn hours of CPD By reading this article you have gained half an hour of learning that can be added to your CPD portfolio. By accessing this tutorial in its entirety you will learn more about the indications, contraindications and mechanisms of delivery of BiPAP and CPAP and earn three hours of CPD. Go to the CPE website www.onwebfast.com/anf/login_member.php to complete this online activity. The online article this month costs $7.70 for ANMF, NSWNMA and QNU members and $30 for non-members. For further enquiries please contact Jodie or Rebecca on Ph: (02) 6232 6533 or education@anmf.org.au
September 2014 Volume 22, No.3 45
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The ANMF online Body System Training Room (BSTR), offers the most comprehensive collection of health education programs providing nurses and midwives with the opportunity to remotely meet their CPD requirements for registration. The BSTR currently offers 32 courses and we are adding new courses all the time. Courses can be purchased as individual courses, as part of tailored packs or as a complete library. Courses are available for 12 months from the date of purchase. Member and non-member prices available Individual courses start at just $23.99 excl GST Tailored packs start from just $44.99 excl GST ANMF Federal Office T 02 6232 6533 E education@anmf.org.au
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Calendar SEPTEMBER
OCTOBER
NOVEMBER
JANUARY
Lung Health Promotion Centre at The Alfred 3-5 September / 15-16 October Respiratory Course 3-5 September Respiratory Course (Module A) Lung Health Promotion Centre at The Alfred P: (03) 9076 2382 E: lunghealth@alfred.org.au
Australasian Association of Bioethics and Health Law Conference How should we decide 2-4 October University of Western Australia, Perth WA. www.conferencedesign.com.au/ aabhl2014/
Australian College of Nursing National Nursing Forum 2-4 November, Adelaide www.acn.edu.au/forum
Winter Global Nursing Symposium Nursing Practice, Nursing Education, Nursing Management, and Disaster Management 9-10 January 2015 Los Angeles, CA, United States of America. www.uofriverside.com/ conferences/global-nursingsymposium/2015-winterglobal-nursing-symposium/
18th International Conference on Cancer Nursing 7-11 September Hilton Panama Panama City www.isncc.org/?page=18th_ICCN 3rd World Congress of Clinical Safety (3WCCS) Clinical Risk Management 10-12 September Ayre Gran Hotel Colon Madrid, Spain www.iarmm.org/3WCCS/ New Zealand Nurses Organisation (NZNO) Conference Nurses – champions for change 18 September 2014 Michel Fowler Centre, Wellington, New Zealand. www.nzno.org.nz/2014conference Nurses for Nurses Network 2014 Annual Conference Practice Innovation in a Contemporary Nursing Landscape 20-27 September Norwegian Jade, Departing Venice, Italy CPD Educational Cruises and Nurses for Nurses Network are proud to host the Nurses For Nurses Network 2014 Annual Conference onboard the luxurious Norwegian Jade cruising the Greek Islands. Join nursing colleges from around Australia participating in some of the most innovative clinically focused nursing education available. Earn up to 25 hours continued professional development towards your CPD portfolio. http://cpdcruises.com.au/conferences/ Nurses-for-Nurses-2014-AnnualConference/ CATSINaM 16th National Conference & AGM Embrace the difference within our people 23 September, Student Day, Registrations and AGM 24-25 September, Conference Rendezvous Hotel, Scarborough Beach, Perth WA. www.catsinam.org.au anmf.org.au
International Tracheostomy Symposium 2014 and combined Australasian kickoff of the Global Tracheostomy Collaborative 8 October An exciting multidisciplinary event including international speakers presenting on excellence in Tracheostomy care. Register via: www.tracheostomyteam.org National Indigenous Mens Conference 13-15 October Pullman Cairns International Hotel, Cairns, Qld. www. indigenousconferences.com Greening the Healthcare Sector 2014 Hosted by Australian Healthcare and Hospitals Association (AHHA) and Climate and Health Alliance (CAHA) The Health Sector as a Leader in Low Carbon Transformation 14 October Mater Hospital, South Brisbane. To register your interest in attending, please email convenor@caha.org.au or sign up to the mailing list for updates at www.caha.org.au Lung Health Promotion Centre at The Alfred 15–16 October Respiratory Course (Module B) 23-24 October Managing COPD 27-28 October Spirometry Principles & Practice Lung Health Promotion Centre at The Alfred P: (03) 9076 2382 E: lunghealth@alfred.org.au 25th PANDDA Conference and AGM Through the looking glass… wisdom, reflection, experience 15-16 October www.pandda.net/PANDDA/ Conference_2014.html
The National Primary Health Care (NPHC) Conference 5-7 November, National Convention Centre Canberra. http://amlalliance.com.au/events/ national-primary-health-careconference-2014
MARCH
Lung Health Promotion Centre at The Alfred 11 November, Educating & Presenting With Confidence 12-14 November Asthma Educator’s Course 20-21 November, Smoking Cessation Facilitator’s Course Lung Health Promotion Centre at The Alfred P: (03) 9076 2382 E: lunghealth@alfred.org.au
International Women’s Day 8 March 2015 www.unwomen.org/ Florence Nightingale Foundation Annual Conference 12-13 March 2015 Queen Elizabeth II Conference Centre, London. www.fnfalumni.org/event-1717850
6th Australian Rural and Remote Mental Health Symposium The Practitioner’s Voice 12-14 November Commercial Club, Albury, NSW. http://anzmh.asn.au/rrmh/ 2nd International Conference on Nursing & Healthcare Exploring the Possibilities towards Better Healthcare 17-19 November Chicago, USA. http://nursing2014. conferenceseries.net/ 17th South Pacific Nurses Forum Nurses collaboratively rowing (leading) the way Showcasing innovative ways for promoting Pasifika healthy lifestyles 18-21 November, Tonga. www.spnf.org.au/ Australasian College for Infection Prevention and Control Conference 23-26 November Adelaide Convention Centre, Adelaide, SA. www.acipcconference.com.au/ The Emerging Face of Midwifery Education & Research Conference 28 November, Charles Darwin University, Northern Territory. This one day midwifery conference provides an opportunity to explore current research and perinatal trends in the Northern Territory. www.midwiferynt.com.au
NETWORK John Fawkner Private Hospital/Sacred Heart Hospital celebrates its 75th anniversary 25 October Gala Dinner Melbourne Museum. Tickets and information available from Chris Papas, Executive Secretary at chris. papas@healthscope.com.au or P: (03) 9385 2501 Alfred Hospital Nurses League 96th AGM and Lunch 25 October at 12md Mt.Erica Hotel, Prahran. For further information and bookings, contact Hon Sec Dorothy Owen E: dorothy@e-owen.com Royal Adelaide Hospital Nurses Training, Group 895, 25-year reunion 29 November Adelaide. Contact Julia Curley E: juliacurley@hotmail.com
Email cathy@anmf.org.au if you would like to place a reunion notice
September 2014 Volume 22, No.3 47
Mail Flawed recruitment and retention If recruitment and retention is always an issue in any healthcare department’s strategic planning why then is the interview process such a flawed one. I have witnessed over the years many colleagues in temporary positions praised for their performance and devotion to their role only to be shown the door when not able to answer a few questions in 20 minutes to an interview panel. Surely if that person’s work performance was below standard then a performance management plan would have been put in place whilst undertaking that role. This however is not the case and the person is left feeling devalued and is more likely to
leave current employment which then costs the establishment more funds. One would agree that an interview must be a fair and equitable process but 20 minutes does not give a comprehensive picture of what that person’s performance will be like in the workplace but rather gives an indication of how well they can answer a few questions under pressure. If we are to value our staff, retain those with excellent work performance then a different recruiting process should be devised. One that takes into consideration the performance of those in the temporary position and not just an interview process. Anonymous RN, South Australia
Stand up for aged care As a nurse with 25 years’ experience working in aged care, I was initially angered by the article “The Shocking Abuse in our Nursing Homes” (Australian Women’s Weekly, (AWW) August 2014). As I read the anger did not go away but I felt increasingly saddened by the reports of the terrible things happening in some of the aged care facilities in our country. Yes, terrible things have occurred, people have died who should not have died at that time, people have been injured, maybe there has been cover ups, whether to protect the staff, the reputation of the facility or even the emotions of families of residents involved. Yes, these things should not happen, there is no excuse for the failings, generally of individuals in positions of authority. As I continued to read I remained angry but a sense of sadness almost overshadowed the anger. Aged care is very highly regulated, ‘support visits’ or ‘spot checks’ by the accreditation agency can occur without warning as well as the regular reviews through accreditation. When these reviews occur, particular areas are targeted and the investigation is extremely thorough. Residents of aged care facilities are increasingly frail, have multiple medical problems and require increased care. Many are at high risk of falls, of pressure related 48 September 2014 Volume 22, No. 3
injury (bed sores) and infection. There are also challenges around ensuring adequate food and fluid intake and dementia adds more challenges with increased potential for aggression. Aged care has no mandatory staffing ratios, unlike hospital staffing and childcare centres. There are also no minimum qualifications required for carers, and pay rates are low. The Australian Nursing & Midwifery Federation focus over the last few years has attempted to draw attention to these issues, including the registered and enrolled nurses salaries being up to $300 a week lower than acute care nurses. Aged care nurses face many challenges, not least the reducing number of GPs who are willing to visit nursing homes, the difficulty of obtaining the support of allied health such as physiotherapists, dieticians, speech pathologists, dental care, and the higher expectations from people entering aged care and their families. Staff attrition rates are also high, many care staff are working to pay their way through university (and not always in nursing or health related fields) and a high number of workers from overseas, some of whom do not have adequate English language skills. All these things make our job difficult, and then, unfortunately, the negative press which healthcare in general generates, really causes society to have a very negative view of aged care. Comments such as, “looking after the elderly is boring and burdensome” does nothing for the esteem of staff who love their jobs, love
Nursing passion (Letter of the month)
Sometimes I question if I am the right person to be a nurse, as the years pass I have become very cynical. This question was answered on a recent night shift. Along with my fellow nursing buddies we were united in the protection of a patient’s right to dignity and comfort during her final hours. The passion expressed by all nurses involved has filled me with great pride to be part of a team with such a commitment. I may not be the most patient but my commitment as the patient advocate holds firm. Rosemary Boyd RN Victoria 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
the people they care for and relate well to residents family members who are a part of our team. Anyone who thinks like this should not be working in this industry. We need staff who want to be there, are willing to meet the needs of our residents and their families, to strive to meet the standards that are legislated. Instead of complaining about the problems, instead of putting all aged care facilities and organisations into the same box, instead of putting down the staff who are trying to do a great job under very difficult circumstances, instead of saying “someone should change things”. Let’s all stand together, lobby the government for better conditions which will attract better staff, to encourage nurses, doctors and allied health staff to see the benefits of aged care work. Jenny Bolin, RN ACT Editor’s note: The ANMF has responded to AWW about the article, outlining some important facts about aged care and the ANMF’s position on staff numbers, skill mix and adequate pay. anmf.org.au
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