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OUR ENVIRONMENTAL WARRIORS

EDUCATION

Crystal Methamphetamine – ICE One of our newest topic additions to the CPE website is Crystal Methamphetamine – ICE, a tutorial for nurses and frontline workers. This topic was written in collaboration with Marie Coughlan, CNC Co-morbidity, Hospital Consultation Liaison SESLHD D&A Services; Jodie Davis, ANMF Federal Education Officer and Peer reviewed by the NSWNMA Drug and Alcohol Reference Group.

CPD

HOURS

Statistics show that it is highly likely, as nurses and frontline workers, that in the course of your work, you will, in some form or another, encounter the issue of methamphetamine use – also commonly called ICE or meth for short.

According to the 2013 National Drug Strategy Household Survey (NDSHS), (Latest national data available); 7% of the Australian population aged 14 years or older reported using amphetamine or methamphetamine at least once in their lifetime. In the same survey, 2.1% reported recent amphetamine or methamphetamine use. Of these people, 50.4% report Crystal or ICE as the main form of the drug used. The last United Nations World Drug Report

37 June 2017 Volume 24, No. 11

(2014) confirmed that Australia leads the world in ecstasy and cannabis use, was third for methamphetamines and fourth for cocaine.

Methamphetamine is not a new drug, although it has become more powerful in recent years as techniques for its manufacture have evolved.

It is the chemical 2-methylamino-1phenylpropane hydrochloride, also known as methylamphetamine or desoxyephedrine. When it is in its crystalline form, the drug is called Crystal Meth or ICE. Methamphetamine is a highly addictive stimulant.

Estimates suggest that there have been substantial increases over the past

five years in the numbers of regular and dependent methamphetamine users in Australia. While the crystalline appearance of ICE makes it look pure, its side-effects are worse than for other forms of methamphetamine.

The short-term effects include euphoria, alertness and increased confidence, and may also be accompanied by a decrease in appetite.

Methamphetamine is a strong psychomotor stimulant that mimics the actions of certain neurotransmitters that affect mood and movement. It causes a release of dopamine and serotonin, producing an intense rush. After the initial rush subsides, the brain remains

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in an alert state. After the effects have worn off, the brain is depleted of its dopamine, sometimes resulting in depressed mood and fatigue.

It imitates the brain’s reward chemical, dopamine, and its alertness chemical, noradrenaline, which causes the brain’s neurons to release more of those, while also causing neuro adaptation creating a demand for the drug in the brain. Long term use can result in chronic depletion of brain serotonin levels and endorphin production.

ICE also stimulates locomotor activity (ie. reflexes, basic physical movements) and can produce ‘stereotypic behaviours’ random, repetitive, compulsive movements and actions such as twitching or picking at the skin - as a side effect. ICE users experience bursts of energy, talkativeness, and excitement. People who use ICE may go without sleep or food as a result of this intense energy. High doses or chronic use have been associated with increased nervousness, irritability, paranoia, and occasionally violent behaviour, while withdrawal from high doses can lead to low mood, anxiety, agitation, irritability and feeling down. Use of ICE, as with other drugs can exacerbate existing mental health problems such as anxiety and depression.

After using ICE a person may experience a comedown which can cause fatigue or sometimes a crash, which may leave them dehydrated and exhausted physically, mentally and emotionally. This stage can last from two to five days depending on how much the person has used. Withdrawal from ICE will usually start within the first few days of ceasing use. For some people they can experience a low mood, loss of energy and the inability to experience normal pleasures that they previously experienced. As with other drugs people are likely to experience cravings and again, as with other drugs, cravings can continue for weeks, months or years and may be a significant contributor to relapse of use.

One of the side effects of regular crystal meth addiction is formication (latin for ‘creep like an ant). Heavy stimulant use causes a rise in body temperature and increased blood flow to the skin to counteract it. The produced sweat contains an enzyme that increases blood flow to the skin even more. When the sweat evaporates, it removes the protective sebaceous oil which coats the skin. The combined effects of dehydration, sweating and removal of the sebaceous oil on the skin create a sensation on the nerve endings of the skin and cause the addict feelings of something irritating or ‘crawling’ on or under the skin (Delusional Parasitosis).

Meth also reduces the amount of protective saliva. Saliva is needed to neutralise harsh acids and reduce bacteria in the mouth.

Meth dries up the salivary glands, letting the acids and bacteria build up and rot teeth anmf.org.au

and gums. Meth causes blood vessels to shrink reducing the supply of blood to the teeth and gums. This can lead to infections and gum disease. Users often clench and grind their teeth causing cracked teeth and sores in the mouth. Oral hygiene may also be neglected.

Short-term effects include:

• brief rush, euphoria, surge of energy; • increased physical activity; • increased blood pressure and breathing • • • • • • • • • • • • •

rate; dangerously elevated body temperature; loss of appetite; sleeplessness; paranoia, irritability; unpredictable behaviour; performing repetitive, meaningless tasks; dilated pupils, heavy sweating; nausea, vomiting, diarrhoea; tremors; dry mouth, bad breath; headache; uncontrollable jaw clenching; seizures, sudden death.

Soon after taking ICE, the receptors in the brain start to turn off the natural production of dopamine. Unlike other stimulants that allow brain cells to re-capture and package dopamine, ICE does not. When taken repeatedly over time, methamphetamine can produce lasting damage in the nerve cells located in the brain’s pleasure centre, as well as nerve cells in other locations. For a detailed list of long term effects of ICE use, please refer to the tutorial.

A collaborative approach between police, ambulance and emergency departments is essential to ensure prompt and timely management of individuals who are experiencing, or suspected of experiencing, psychostimulant toxicity.

A thorough assessment should be undertaken which includes drug use history and presence of psychostimulant toxicity. Calming communication to deescalate potentially dangerous situations is recommended. Security or the police should always be called to any high-risk situation.

The aim of initial management is to firstly identify patients who present with suspected psychostimulant toxicity; rapidly and safely manage suspected or confirmed psychostimulant toxicity utilising a standardised sedation protocol; and recognise and safely manage medical complications.

Medical complications are often serious and include hyperthermia, cerebrovascular accidents, seizures, myocardial ischaemia and infarction, serotonin toxicity, rhabdomyolysis, hypoglycaemia, hyponatremia, hyperkalemia and others.

Some peculiarities of medical management are specific to psychostimulant use being identified.

EARN UP TO TWO HOURS OF CPD By accessing the complete topic, reading about management guidelines and treatment this article in its entirety and doing the associated learning activity online you can receive two hours of continuing professional development (CPD). For more information go to http://anmf. cliniciansmatrix.com If you have any questions please contact us via education@anmf.org.au

Individuals suffering from psychostimulant toxicity can become extremely agitated, irrational, impulsive, paranoid and psychotic, which may lead the person to behave in an uncontrolled, aggressive and/or violent manner. The number of ambulance attendances to patients presenting with putative psychostimulant intoxication or toxicity has risen in some Australian locations, and paramedics and emergency department staff are increasingly required to manage the acute behavioural disturbances associated with psychostimulant misuse.

The primary aim of management of behavioural disturbance is to reduce the risk of harm to the patient, emergency department staff and other people. It is necessary to utilise the established hospital protocols for the management of behavioural disturbances in the event of such an incident. Hospital security or police presence is mandatory until behaviour is controlled.

In emergency situations it is often difficult to differentiate between a severe behavioural disturbance secondary to acute drug intoxication, drug-induced psychosis, or an exacerbation of a pre-existing psychotic disorder. Suspected drug-induced psychosis (or exacerbation of existing psychotic disorder) should not be considered a contraindication to urgent sedation.

Rather, a period of sedation and behavioural control will allow clinicians to re-assess the patient after the acute effects of the drug have worn off, allowing for a more accurate differential diagnosis. In general, treatment of patients with psychostimulant-induced psychosis is similar to treatment of acute mania or schizophrenia and establishing a ‘safe’ environment should be the first priority.

June 2017 Volume 24, No. 11 38

WORLD

NEW ZEALAND

GLOBAL

Workforce strategy needed to attract and retain Mãori nurses

Hepatitis is fast becoming a growing concern

Without a Māori Nursing workforce strategy, the aim to attract and retain thousands more Māori nurses into nursing would never be realised according to New Zealand Nurses Organisation (NZNO) Kaiwhakahaere Kerri Nuku

New data from the World Health Organization (WHO) has revealed that an estimated 325 million people worldwide are living with chronic hepatitis B virus (HBV) or hepatitis C (HCV) infection.

Ms Nuku made the statement at the United Nations forum of the United Nations Declaration on the Rights of Indigenous People (UNDRIP) in New York recently.

“It is unacceptable that nothing has been done to attract more Māori into nursing in Aotearoa New Zealand since I last addressed the UNDRIP forum two years ago,” she said.

“It is clear that matching the demographics of the workforce to population, ethnic makeup improves health outcomes.

Culturally appropriate health services are economically sensible and the right thing to do for our Indigenous people.

“Māori nurses offer a whanau and holistic approach to health and wellbeing and this is proving effective for Māori, particularly in deprived areas. I don’t see a decent commitment to rolling out this approach where needed, or the funding commitment to pay Māori nurses working with Māori health employers on a par with other health providers.

“Clearly the government is not fulfilling its obligations under Article 20, Convention 169 of International Labour Organisation agreement to do everything possible to prevent discrimination between workers, and achieve equal remuneration for equal value.”

Māori nurses make up 7% of the nursing workforce yet the Māori population is around 15%.

39 June 2017 Volume 24, No. 11

According to WHO the large majority of these people lack access to life-saving testing and treatment. As a result millions of people are at risk of a slow progression to chronic liver disease, cancer and death.

Viral hepatitis caused 1.34 million deaths in 2015, a number comparable to deaths caused by tuberculosis and HIV. But while mortality from tuberculosis and HIV have been declining, deaths from hepatitis are on the increase.

While Hepatitis B levels vary across the world, the African Region and Western Pacific Region share the biggest burden.

“Viral hepatitis is now recognised as a major public health challenge that requires an urgent response,” said Dr Margaret Chan, WHO Director General.

There is currently no vaccine against HCV, and access to treatment for HBV and HCV is still low.

WHO’s Global Health Sector Strategy on viral hepatitis aims to test 90% and treat 80% of people with HBV and HCV by 2030.

“We are still at the early stage of the viral hepatitis response, but the way forward looks promising,“ said Dr Gottfried Hirnschall, Director of WHO’s Department of HIV and the Global Hepatitis Programme. “More countries are making hepatitis services available for people in need. But the data clearly highlights the urgency with which we must address the remaining gaps in testing and treatment.”

IRELAND

Irish nursing and midwifery graduates plan to leave the country Over 78% of nursing and midwifery students studying in Ireland plan to emigrate upon qualification according to a survey conducted by the Irish Nurses and Midwives Organisation (INMO).

However, nearly the same number of respondents said they would consider staying in the Irish public health service for at least a year upon qualifying if offered guaranteed permanent contracts.

The survey results suggested that 70.2% of respondents had been approached by overseas recruitment agencies, while only 29.8% had been offered permanent or part time positions in the Irish public health service.

“The results of this survey have clearly put into perspective the ongoing crisis in the recruitment and retention of nurses and midwives in the country. It highlights the significant need to improve the current incentives being offered in the public health service and the need to offer full-time permanent posts to current interns much earlier in their 4th year. This trend must be halted given the current crisis in the public health service, Ireland’s ageing population and increasing demands on the public health system.”

“The number of nurses and midwives working in the Irish public health service has reduced from 39,006 in 2007 to 35,835 in 2016. The actual number is less given that 2% are on maternity leave at any given time and there is very little replacement,” said Phil Ni Sheaghdha INMO Director of Industrial relations. “Our new graduates continue to be lured abroad and into private hospitals in Ireland by high cost area supplements access to ongoing education, signing on bonus, accommodation allowances etc.”

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PROFESSIONAL

SAFETY AND SECURITY IS EVERYONE’S BUSINESS Workplace safety and security should be a given but as we all know this is not always the case.

Julianne Bryce

Elizabeth Foley

Julie Reeves ANMF Federal Professional Officers

All nurses and midwives have the right to work in a safe and healthy workplace environment and to perform their work without risks to their physical and psychological health and safety (ANMF policy statement 2015). None of us should have to work in fear for our personal safety.

In South Australia earlier last year, remote area nurse Gayle Woodford, was tragically killed while working.

With continuing reports of assaults on nurses in the months that followed, the ANMF accepted the invitation from CRANAplus to participate on the Expert Advisory Group for their Remote Area Workforce Safety and Security Project.

Given the ongoing concerns about safety and security for those working in remote areas the ANMF is committed to ensuring safer workplaces for all those in isolated practice.

The 12 month project, led by CRANAplus, is a Commonwealth Department of Health funded initiative, which commenced last June.

Work on the project commenced with a literature review on the safety and security of the remote health workforce, and engagement in a national conversation using forums, interviews and a survey, on the issues facing our colleagues working in remote.

Consequently, resources to be developed during the year-long project include: practical national safety and security guidelines for remote health, an industry handbook on ‘working safe in remote health’, an easy to use safety and security self-assessment tool, and a free online learning module on working safe in remote practice. This information will be included on the CRANAplus remote health smart device App that is currently under development.

We are now more than half way through the project, with some of the first deliverables to be released early in the New Year.

Reference The Australian Nursing and Midwifery Federation, 2015.

ANMF policy Statement: Occupational Health and Safety

Although workplace safety is always high on our agenda, and the issue of violence against remote health workers is not new, the tragic event of Gayle’s death has certainly placed a spotlight on safety and security, prompting more action in this space.

The Northern Territory has taken the lead, producing two reports in the

40 February 2017 Volume 24, No. 7

latter part of 2016.

ANMF Northern Territory (NT Branch) conducted a Remote Area Nurse (RAN) safety survey in May 2016, available at: www.anmfnt.org.au. The Branch believed it was important to get their RAN members’ perspective on how safe they felt working in remote communities and what they believed was needed to address the lack of safety, where it occurred. With 103 respondents (61.68% response rate), the survey asked questions about call out, accommodation, the work environment, fatigue management, and violence – both physical and verbal.

Respondents provided suggestions on how they could feel safer when on call and how to make their experience in remote areas safer.

The extensive list of suggestions included: • reliable communication technology; • duress alarms; • accompaniment by a second responder; • local community drivers; • support from management; • functioning equipment; • electronic monitoring/tracking; • security staff and • better lighting and further education for all, just to name a few.

A major theme from the responses was the importance of whole of system support for a culture of safety.

Many respondents felt unsupported and that their concerns went unheard.

Following this survey in early December, the NT Department of Health released their report on

Remote Area Nurse Safety: www. health.nt.gov.au/nursing_and_ midwifery/ The Review, examined the policies, practices and procedures relating to remote staff safety in the NT. Four incidents of violence towards remote health staff occurred during the review, further highlighting the pressing need to make safety and security a priority. The NT government has committed to implementing all 14 recommendations outlined in the report, with some recommendations already in train. Future work will include focussing on consistency and standardisation of policy and practice across the NT health system.

This is a great outcome for the NT but there’s still much to do for safe practice, both in the territory, and in all areas of remote and isolated practice across the country.

The ANMF continues to work with CRANAplus and other key stakeholders on the Australian Government funded Safety and Security Project, to develop the planned resources to assist all those in remote practice. We’ll keep you posted on progress and let you know when and how you can provide feedback.

In any environment the first thing we should all consider, before we provide care, is risk to ourselves. We can’t help others if we are placing ourselves in danger. It’s a basic premise of all that we do. Clinicians and their managers must work together to identify and manage risks to safety and security for a safer environment for us all.

It’s for everyone’s benefit so it’s everyone’s business. anmf.org.au

INGRID COTHER, PHOTO: JAMES ELSBY

FEATURE

LEAN ON ME THE CHALLENGES AND OPPORTUNITIES FACING MENTAL HEALTH NURSING

As reform continues to shape Australia’s mental health system, greater access to mental health nurses across all levels of healthcare is crucial. When allowed to work to their full scope, mental health nurses possess the ability to engage and connect with people while helping them drive their own recovery journeys. Robert Fedele reports.

S

everal decades ago it was considered normal for a person experiencing mental illness to be shipped off to an asylum to live out their days. Such was the thinking that the concept of recovery was off the radar and largely regarded as unattainable.

Ideas started to change when Australia’s asylums were shut down in the 90s and mental health services shifted into general hospitals, GP clinics and the community.

The move into mainstream settings occurred alongside the growing philosophy that people experiencing mental illness had the capacity to shape their own recovery journeys.

Ingrid Cother, a mental health nurse at Eastern Community Mental Health Services in Adelaide, engages with clients across the care continuum as part of an integrated community team.

The role includes assessments, building care and treatment plans and linking clients with other programs and services. Clients range in age from 16-64 and experience everything from anxiety and affective disorders to psychotic disorders.

“My focus is across the whole care continuum,” Ingrid says. “It could start with assessment and crisis intervention and treating people when they’re acutely unwell, but also moving through to providing longer term care coordination, which tends to be goal focused. You’re looking at what people want to achieve with their treatment and trying to link them in with services that can help.”

Ingrid’s objective reflects the sector’s gradual shift from the hospital into the community and recovery oriented services. In that time, important programs such as Better Access were introduced, the federally funded initiative increasing community access to mental health professionals such as psychiatrists and psychologists.

“It’s a fundamental shift because it’s actually about people with mental illness being able to live in the community just like anyone else and there’s a fundamental principle underlying that which is essentially human rights – the right for people to choose how they live their life and supporting people with their personal recovery to live the best life possible with or without their symptoms.”

Despite inroads, Ingrid says mental health nursing remains underutilised.

She maintains there’s greater scope for advanced practice roles that enable earlier initiation of pharmacological treatment, which may prevent hospitalisations and improve health outcomes.

Currently, Ingrid could assess a client and identify their mental health diagnosis, yet the person would likely need to wait to see a doctor to receive pharmacological treatment.

It leaves her having to weigh up whether to take a person to hospital so they can access care promptly or hold off. It’s merely one example of how mental health nurses could be better utilised to benefit consumers, Ingrid says.

FEATURE

FEATURE

Extreme weather patterns, global warming and air pollution are increasingly becoming the norm, the consequences of which are being felt across the world. Climate change is being touted responsible, compelling a commitment from world leaders to reduce emissions in an attempt to curtail the impact. Yet to ensure environmental sustainability everyone must play a role including nurses, midwives and healthcare facilities. Natalie Dragon investigates the progress healthcare has made to this end.

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arden development and spaces don’t just happen”, says Melbourne Clinical Nurse Specialist and Horticulturalist Steven Wells.

“And they have to be sustainable with low water use requirement; they have to survive on rainfall.”

Steven is Australia’s first Gardens and Grounds Project Officer at Austin Health, in Melbourne’s north.

A “collection of pots and some nursing time” to support patients with acquired brain injury started in 2003. Steven now creates gardens for respite, recovery and restoration.

“The use of plants and garden-related activities assist with achieving patient goals and promote physical and emotional wellbeing needs.

“While tinkering and chatting we are making a difference to our patients. It’s a moment of normality.

Patients are not sitting in a hospital bed but reconnecting with their world, the natural world.”

Austin Health’s master plan was to develop gardens to patient areas for their health benefits and also for staff.

Since 2011, $754,000 has been spent, largely philanthropic, on garden projects. Some 23 diverse projects include 6,700 plants in garden spaces in acute care, mental health, rehab, child care, and various courtyards over Austin Health’s three campuses.

An impressive 19 metre wide Jessie Mary Vasey Labyrinth at the Heidelberg Repatriation Hospital is a tool for personal, psychological and spiritual transformation. The ‘Sensory Gardens’, a green refuge includes areas of privacy.

“It’s a place to chat with families who are going through tumultuous times of uncertainty and anxiety in whether a loved one can walk again, talk again - essentially recover.”

Steven says there’s a strong link between environmental sustainability and embracing nature to improve health outcomes for patients.

“For everyone, it’s how we can make a difference to the core business of patient care and duty of care. Dream big, start small. Keep creeping and creeping,” he says.

Duty of care

Crowds marched in more than 600 cities worldwide for Earth Day in April amid growing concerns of US President Donald Trump’s stance on climate change and cuts to research funding.

Think globally, act locally, Australian of the Year and prominent scientist Professor Peter Doherty urged delegates at the ANMF Victorian Branch Health and Environmental Sustainability Conference in Melbourne.

“Duty of Care is at the heart of what you do. That must be extended to the natural systems that sustain us and to the other complex life forms.

Climate change is the most serious human health problem of today, says Professor Doherty. “Greenhouse gas levels are at the highest they have ever been for 500 million years. We are on an inexorable path to two degree warming.

We will have warming by three to five degrees by 2100. It’s really dangerous yet we are doing relatively nothing.”

The UN’s Sustainable Development Goals will be extraordinary difficult to meet, he says. “However we need aspirations to work towards and we have got to move forward to have pragmatic solutions. We have to tackle climate change with the best science we have got.

“This is an extraordinary time. We need to act – there is no place for despair. We must change our ways of doing things if future generations are to enjoy a green, clean and liveable world. It’s up to us.”

2015 Paris Agreement

At the 21st United Nations Conference of the Parties meeting in December 2015, countries agreed to increase their level of commitment to limit climate change.

Australia ratified its commitment last year to reduce its emissions to 26-28% on 2005 levels by 2030.

“Paris was great but it’s not enough – it’s not compatible with life,” Climate and Health Alliance (CAHA) President Dr Liz Hanna says.

FEATURE

ANDREW DENTON PHOTOGRAPHER: BEN SEARCY

FEATURE

WHY VOLUNTARY EUTHANASIA IS A QUESTION OF CHOICE The prospect of voluntary euthanasia has created strong debate for decades and provoked passionate opinions from both sides of the fence. While not legal in Australia, a recent revived push for national voluntary euthanasia legislation has once again opened up the conversation and nurses have been encouraged to join the debate.

Robert Fedele investigates the latest thinking and why more people are supporting voluntary euthanasia and the right to die with dignity.

I

t was a moment both poignant and defining and one which Andrew Denton will never forget.

Earlier this year, the media player known for everything from telling jokes to hosting talk shows, travelled to the coastal town of Port Pirie, South Australia, to meet 35-year-old cancer sufferer Kylie Monaghan.

Kylie had been battling cancer for several years and the dreaded disease had now spread to her liver and bones. In the face of a bleak outlook Kylie pledged her support to a national voluntary euthanasia campaign pushing for legislation formed by Denton’s advocacy group Go Gentle Australia and the Australian Nursing and Midwifery Federation (ANMF).

More precisely, Kylie had agreed to become ‘the face’ of the campaign, sharing her story so that people with similar incurable illnesses could be spared unnecessary suffering.

Denton recalls sitting across from Kylie in her family home and having an indescribable conversation about her inevitable death. At the time her health was declining so rapidly that doctors said there was no more meaningful treatment left to give. At one point Denton turned to Kylie and whispered that if she wanted to walk away then and there all she had to do was say the word.

Kylie cast aside the suggestion, instead reaffirming her wish to help others, no doubt fully anmf.org.au

understanding that any new laws would arrive far too late to assist her.

Sadly, Kylie lost her fight and died in October.

In a bittersweet by-product, her strength, resolve, and courage in supporting voluntary euthanasia leaves behind a powerful legacy that typifies why dying with dignity is considered fundamental.

“Once you understand it on a human level it’s hard to then not think of it that way again,” Denton explains. “It ceases to be a dry piece of legislation.

You think about that human being.”

Denton’s personal experience with death, and the catalyst behind his drive to introduce voluntary euthanasia laws across Australia, traces back to the passing of his father Kit almost two decades ago.

Denton was rocked by the traumatic event, calling it the most profoundly shocking experience of his life, and crediting its enduring impact with leading him to search for a better way to die.

“ONCE YOU UNDERSTAND IT ON A HUMAN LEVEL IT’S HARD TO THEN NOT THINK OF IT THAT WAY AGAIN. IT CEASES TO BE A DRY PIECE OF LEGISLATION. YOU THINK ABOUT THAT HUMAN BEING.” GO GENTLE AUSTRALIA DIRECTOR ANDREW DENTON

Presently, Australia is in the middle of a revived effort to implement laws to allow voluntary euthanasia. In South Australia, its Death with Dignity Bill, the 15th time such a piece of legislation has been put forward, was narrowly defeated by one vote last month after painstaking consideration by state politicians.

Similarly, Victoria appears poised for change on December 2016 / January 2017 Volume 24, No. 6 19

QUEENSLAND NP CANDIDATE GEORGIE WAUGH PHOTO: BRIDGETTE NICOL @LITTLERIVERCOLLECTIONS

NURSE PRACTITIONERS THE ROAD LESS TRAVELLED

With the Australian healthcare system struggling to keep up with surging demand, nurse practitioners are ideally placed and suited to fulfil the role for which they were envisioned. Natalie Dragon looks at the challenges to realise the NP potential.

“W

hile I was working as an acute clinical nurse in a community health position doing Pap smears I realised there was a different world out there,” says Nurse Practitioner (NP) candidate Georgie Waugh of her move into primary healthcare.

Georgie works on the south-west Queensland side of the state border with NSW in Mungindi, population 800, more than 300 Indigenous. She juggles her work at the Mungindi Medical Practice and as the community health nurse.

“I could be in at 8am doing all the bloods, in the practice for four hours, then four hours in the community, and then get pulled back into the acute sector ED. I do the primary healthcare for our 15-bed hospital.”

Georgie started her position in Mungindi and her NP studies at the University of Queensland in January 2015. “I can be in the clinic performing chronic disease management, assisting the MO in emergency and then back performing Pap smears.

“In the community, I am brokering a deal for a client with NGOs; setting up a care plan for a client in the community; and organising a case conference through videoconference with a specialist and a multidisciplinary team – truly embracing the collaborative approach.

“Healthcare out west is changing in a big way - all healthcare is changing, with

a primary healthcare focus instead of an acute focus we want to be proactive in treatment.”

RN Frances Barraclough says she could see the potential and struggle of NPs early on.

Becoming a nurse practitioner is a commitment that will change your life, Georgie says. “When they tell you in the first week of uni that your life is going to change and you will have no spare time and things are going to get tough. It’s that and worse. I finish eight to 10 hour days, have dinner and then come back to my case studies and do research.”

As Senior Manager with New England Area Health Service, Ms Barraclough organised meetings with key stakeholders including doctors with NP pioneers. She says there were ‘no shows’. “The NP movement has been fairly major. Initially for some NPs there was no place for them to work, they weren’t given a computer and there was no admin support.”

However that’s the beauty and trap of being a NP, says Georgie. “The more information you get, the more you want.

“Your life will change – you do not switch off. I am reading Medical Observer on my weekend and am constantly up to date in my practice – the minute you stop you are left behind.”

Her advice to others wanting to travel this road is “make sure you have stable grounding and really want to do it.”

Resistance

Figures released at the recent Australian College of Nurse Practitioners’ (ACNP) conference show there are now over 1,380 endorsed NPs. Despite their introduction around the world more than 50-60 years ago, the NP role has evolved more slowly in Australia since the 1990s.

University Centre for Rural Health Program Manager in Clinical Education,

Guest speaker at the ACNP conference held in Alice Springs in August, Canadian NP Dr Tammy O’Rourke says “it is the constipation of the system of why we cannot move forward.”

There have been political barriers and resistance, University of Sydney’s Emeritus Professor Lesley Barclay says.

“I do think it’s such a pity it’s taken too long to value NPs. But their value is being realised. I think medicine is less nervous now. I think there is more wisdom and more sense now; that there can be roles across the health team to fill the need. There are a whole range of areas in rural and remote communities that do not have access to expert health or medical care.”

ACNP President and one of the first emergency NPs in Victoria, Grainne Lowe agrees it’s been slow progress. The first NPs in Australia were endorsed in NSW in 2000. “In NSW in the early

FEATURE

ALL HANDS ON TECH HOW DIGITAL TECHNOLOGY IS REDEFINING HEALTHCARE Digital technology is on the cusp of transforming healthcare. The number of health apps at the fingertips of consumers has surpassed 165,000, giving people around the world more access to information than ever and the tools to take care of themselves.

Similarly, the adoption of digital medical records across clinical settings is another catalyst shaping the new landscape. Robert Fedele explores the digital health movement amid its upward spiral.

PHOTO: ROHAN THOMSON

14 September 2016 Volume 24, No. 3

anmf.org.au

FEATURE Leigh Dicker was in his early 40s when his first heart attack hit.

He describes the episode as a “complete shock” when considering he exercised regularly, wasn’t overweight, and didn’t smoke or drink. “When I went into hospital most of the guys around me were in their 70s plus. It certainly felt very strange,” he recalls.

“It happened at work. Just in the spur of the moment. I have a fairly stressful job. I just thought it was the usual stress coming on and in the end I realised things were fairly serious.”

The heart attack triggered early onset diabetes and helped uncover unknown hereditary cholesterol problems.

Feeling bulletproof, Leigh brushed off the heart attack as a minor glitch and had returned to work six weeks later as though nothing had changed. It would be his second heart attack, just two years later, that delivered the ‘wakeup call’ he needed.

For Leigh, now 60, change meant fine-tuning his diet, reducing stress, and importantly, taking medications regularly.

Over the years he endured a massive regime of trial and error in a bid to juggle his copious amount of medications before stumbling across health app MedAdvisor two years ago. MedAdvisor aims to improve the lives of people taking multiple medications by reminding them how much to take and when.

It’s linked to participating pharmacies across Australia and once a patient signs up, the app keeps track of all medications dispensed, reminds patients when they need to take them, how long their supply will last, and also when it’s time to collect a refill or repeat script from their GP.

Health apps, in part, are viewed as an area which can help reduce the burden on the nation’s health system by enhancing self-care and keeping people out of hospitals.

Adelaide’s Flinders University has just launched its Digital Health Research Centre, with the research and innovation hub being led by Australian digital health experts Professor Anthony Maeder and Professor Trish Williams.

The centre will initially focus on developing smart and interactive technologies to monitor the health of the aged at home and target conditions like diabetes and cardiovascular disease.

“We’re trying to set the centre up to see what contributions digital health can make to what you might call health smart living,” Professor Maeder says, explaining the priority will be on home-based self-care.

Professor Maeder says technology exists to monitor health in various ways at home, such as being able to take one’s blood pressure or heart rate, but interoperability

“I THINK THERE’S A HUGE ROLE TO USE HEALTH APPS FOR PATIENT EDUCATION. IT ACTUALLY FACILITATES INFORMATION EXCHANGE AND CREATES MORE CONSISTENCY IN THE MESSAGE BEING DELIVERED.” Nurse Practitioner Chris Helms

The app, which has more than 120,000 active users, also links with GPs and allows them to track whether a patient is sticking to their medication program.

Leigh, a busy architect who employs numerous people across multiple offices, uses the smartphone app to manage a cocktail of pills which he takes in different quantities and at different times of the day.

“Its basically looking over my shoulder electronically and keeping it all in order,” he says. “It made it consistently easier.

It means I’m taking my medications more regularly, which means better health outcomes.”

issues across systems is what’s affecting data integration.“For example, taking data from a home monitoring system, routing it back to the My Health Record, this is pretty much impossible at the moment.

Digital health research

Colleague Professor Trish Williams says. “We’ve got lots of things from the technology point of view, we can just monitor things, or we can collect it. But it’s actually making that data useful and delivering it in a way that is useful to the clinicians and the patients that is the key.”

In today’s new age of patient empowerment a person can use their smartphone to help them manage a myriad of conditions.

There are apps which tackle obesity by motivating people to undertake exercise, apps that manage mental health by tracking mood and pinpointing the danger signs of depression and anxiety, or apps that prepare a patient before and after surgery and offer step-by-step rehab procedures. anmf.org.au

“The reason isn’t because it’s technically difficult. It’s just that all the standards and formats that people use vary and no real thought has been given up front to try and make everything compatible.”

Professor Maeder believes consumers are embracing new technologies available, such as health apps, because they’ve become

empowered from taking an active role in managing their own health. “Devices really range from smartphones that are just logging stuff on a little app through to dedicated Telecare stations. You can get Telecare devices with inbuilt spirometers that measure blood pressure and heart rate.

“So the sophistication range varies widely. I think wearable devices are becoming more popular. You see that at the consumer end of the market with Fitbits and the like. I think those single measurement or range of measurement wearable devices is probably where the market will expand more rapidly in the future.”

In response to misgivings regarding the accuracy of such devices, Professor Maeder argues their reliability is no more or no less risky than the likelihood of human error.

He adds that the ripple effect of increased consumer engagement also provides untold benefits.

“I think there’s an interesting social effect here which is the empowerment of patients.

By giving them information, by giving them management duties or the gathering duties for that data, you’re getting buy in and you’re getting interest in their own health status and hopefully then some responsibility for managing their health status.”

Utilising consumers

Researchers from the University of Queensland (UQ) are among the swarm of app developers tackling health conditions through technology.

Last year, researchers from the university’s Institute for Molecular Bioscience created PainPal, a smartphone app to help chronic pain sufferers.

PainPal works by recording the level of chronic pain a person experiences day-to-day and personalising the data to generate graphs that illustrate an individual’s pain pattern.

PainPal is still in development, with the team at UQ conducting an extensive survey of consumers in a bid to refine the app’s design and features before hitting the market.

Researcher Prashanth Jutty Rajan says gauging the views of consumers should be an essential component of the developmental process .“Ultimately, they are the end users. They have to be able to decide what they would like because without the end users being in agreement with the kinds of ideas that we as app developers have it is almost futile going through this entire process.”

Mr Jutty Rajan concedes the increasing use of health apps triggers valid concerns regarding the reliability of data, as well as newfound dangers in the shift to self-care, but he believes their use, once evidence and efficacy has been established, should be supported.

September 2016 Volume 24, No. 3 15

FEATURE

A HEALTHY “APP”ETITE

A SNAPSHOT OF HEALTH APPS ON THE MARKET

MENTAL HEALTH

FIGHTING DEMENTIA

beyondblue’s mental health app BeyondNow helps people suffering mental health issues by creating a safety plan for people contemplating suicide to get through tough times. The safety plan starts with things people can do by themselves, such as thinking about reasons to live, and distracting oneself with enjoyable activities. It then moves on to coping strategies and people you can contact for support.

Alzheimer’s Australia’s BrainyApp was developed in 2011 to raise awareness of the risk factors of Alzheimer’s disease and other types of dementia and to help keep the brain healthy. BrainyApp works by promoting physical activity, brain challenges, and an active social life.

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HIGH-TECH REHAB FOR SURGERY PATIENTS SPORTSMED.SA has developed an interactive mobile phone app to help hip replacement patients prepare for surgery and manage their rehab. A ‘virtual physio’ provides users with a step-bystep animated program to guide them through pre and postsurgery processes. The app helps strengthen muscles, relieve pain, increase mobility, and ultimately restore normal levels of function.

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IMPROVING BLADDER CONTROL PREVENTING HEART ATTACKS University of Sydney researchers have created a game-based app to prevent heart attacks among people who have previously had an episode. Prevention programs are a key part of cardiac rehabilitation, and the MyHeartMate uses interactive games, quizzes and challenges to help people make lifestyle changes in order to improve their heart health, such as increasing physical activity, changing their diet, quitting smoking, and reducing stress. It also helps people track their blood pressure and blood sugar levels.

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The Continence Foundation of Australia’s Pelvic Floor First app allows people of all fitness levels and pelvic floor function to undertake pelvic floor safe workouts. It also teaches you how to exercise your pelvic floor muscles in order to maintain or improve bladder control.

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REDUCING STRESS AND ANXIETY ReachOut Australia’s ReachOut Breathe app was created to help reduce the physical symptoms of stress and anxiety by slowing down your breathing and heart rate. The apps helps you control your breath and measures your heart-rate in real-time using the camera in your smartphone.

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“I THINK DIGITAL HEALTH HAS A GREAT FUTURE AHEAD OF IT. I PERSONALLY BELIEVE THAT HEALTHCARE APPS SHOULD BE COMPLIMENTARY RATHER THAN ANTAGONISTIC TO THE DOCTORS. IF ANYTHING, APPS SHOULD ENCOURAGE PEOPLE TO ENGAGE MORE WITH THEIR DOCTORS, RATHER THAN LESS.” Researcher Kathleen Yin

“It’s very important to remember that these are just tools to help patients communicate better with their doctors so it’s absolutely important to remember that doctors do play a really important role in any sort of therapeutic regime that a patient may have.”

Fellow researcher Kathleen Yin echoes the attitude. “I think that digital health has a great future ahead of it. I personally believe that healthcare apps should be complimentary rather than antagonistic to the doctors. If anything, these apps should encourage people to engage more with their doctors, rather than less.”

Impacting behaviour

Another innovative health app making a difference is AirRater, an app that helps Tasmanians breathe easier by pinpointing the dangers of pollen and smoke that can affect sufferers of hay fever, allergies, asthma, and other lung diseases.

Developed by Sense-T, a partnership between the University of Tasmania, CSIRO, and State government, AirRater was launched in October last year.

Asthma affects almost 12% of Tasmanians higher than the national average.

The app is linked to a network of data sensors across Tasmania which capture information, including from the state’s Environmental Protection Authority and Bureau of Meteorology, as well as pollen stations deployed by the project team.

The information is gathered in real-time and fed back to a central database which gives users vital information about current levels

of pollution and potential triggers in their immediate area.

Over time, once users have entered their daily symptoms of asthma, allergies and hay fever into the AirRater smartphone app, they will also be provided with an individualised report showing how environmental conditions impact their symptoms and even providing them with danger alerts.

Project Manager Sharon Campbell says the app is the first of its kind to pool such data together to create a case history and pinpoint a person’s triggers. “If, for example, over winter, there’s a lot of wood smoke in certain parts of Tasmania as conditions are really cool and people use wood heaters, if that’s a trigger for people’s asthma, then we’re able to give them a little bit of warning that the wood smoke is quite high and then they can take their own steps towards managing that. That might be avoiding those areas, avoiding going outside, limiting the amount of physical activity they do or taking preventative medications.”

Hobart resident Mike Cain is among the 1,000 Tasmanians who have already downloaded AirRater. The 33-year-old was born with heart valve problems that affect his circulation and cause dizziness and chest pains when an immediate burst of energy or oxygen is required.

AirRater has already made an impact, with Mr Cain cancelling a trip to Port Sorell earlier this year after a quick check of conditions revealed extra high smoke concentrations. On other occasions, during forestry burn-offs, he has monitored the situation before planning his day accordingly and limiting exposure

and physical activity. “To be honest, it’s not life-threatening. It’s a comfort thing. I get dizzy and can’t concentrate and sometimes get a little bit of chest pain. It’s nothing serious but I’d prefer not to have those symptoms.”

Nurses adopting digital tools

As consumers become increasingly empowered by technology, nurses and other health professionals have arguably been slower to adapt, depending on the individual or the organisation.

Nurse Practitioner Chris Helms works in Canberra for National Health Co-op, a large group of general practices that operates across multiple sites.

Chris works as a generalist, specialising in cardiology, and provides care for complex clients who might have chronic heart or other long-term conditions. He believes health apps can be useful in empowering clients as well as clinicians.

As a nurse, he has embraced technology and regularly uses a variety of smartphone apps to streamline his delivery of care.

One of them, Orca, boasts a suite of apps that provide graphics and videos related to numerous acute and chronic health issues affecting areas like the spine, eyes heart, and knee, in a bid to enhance patient understanding.

The apps also provide a patient engagement platform which delivers tailored information and advice for various conditions, as well as individualised care plans that can be emailed to the client.

For example, if a person suffers chronic

FOCUS: Education Peri / Post Op part Care 2 AUSTRALIA ENJOYS INTERNATIONAL ACCLAIM FOR ITS REVOLUTIONARY RESPONSE TO HIV, AND MOST RECENTLY, HEPATITIS C... ...YET DEPITE THESE SUCCESSES, STIGMA AND DISRIMINATION WITHIN OUR HEALTH STYSTEMS THEATEN TO

INTEGRAL ROLE OF NURSES IN REDUCING STIGMA AND DISCRIMINATION IN THE CARE OF PEOPLE WITH BLOOD BORNE VIRUSES (BBVS)

By Melinda Hassall, Sami Stewart and Elizabeth Crock Barriers to healthcare for people with blood borne viruses (BBVs)

Nurses are integral to the provision of care in the treatment and management of people with hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV).

There are now increasing opportunities for nurses to provide care to people with BBVs due to: • introduction of direct-acting antiviral medication for HCV; • increase in nurse led models of care for management of BBVs in community settings; • availability of pre-exposure prophylaxis (PrEP) and post exposure prophylaxis (PEP) for HIV; and • a population of people living longer and more people ageing with HIV due to successful treatment.

Despite these advances, significant barriers can exist within health systems that impact people with BBVs accessing treatment and care. Stigma and discrimination can sometimes be both an intended consequence of certain practices, or a direct cause of healthcare avoidance. For example, generic intake policies, excessive use of infection control precautions and 18 May 2017 18 August 2017 Volume Volume 24,25, No.No. 10 2

policies implemented by healthcare sites and healthcare workers (HCW) can support discriminatory behaviour and influence individuals’ decisions to access care (Crock 2013; Crooks 2016; Paterson et al. 2007; Richmond et al 2007).

Studies undertaken with HCW, including nurses, have highlighted myths surrounding transmission of BBVs, misconceptions about potential transmission, lack of trust in standard precautions, fears/stereotypes about people who inject drugs, and concerns about behaviours due to mental health, as issues that affect HCW decisions about care (Crock 2013; Paterson et al. 2007; Richmond 2007).

If not addressed, these issues can influence nurses’ responses to people with BBV (Richmond, 2007) and negatively impact health outcomes (Crooks 2016).

A strategy for action

A key objective of Australia’s National BBV strategies is to eliminate the negative impact that stigma and discrimination have on an individual’s health (Department of Health 2014). To support this objective, a Commonwealth funded collaborative project is developing

an online learning module (OLM) for nurses. The OLM aims to reinforce knowledge about transmission, prevention and management of BBVs, outline nurses’ role in reducing stigma and discrimination and enhance their capacity to identify these experiences of people with BBVs. The OLM will enable nurses to reflect on structural workplace barriers, individual perceptions and encourage change.

Development of the OLM is guided by an expert working group (with representation from ASHM, ANMF, health services, research, community partners) and feedback obtained from focus groups held at the Australian Primary Health Care Nurses Association Conference.

Outcomes

References Crock, E. 2013. The Royal District Nursing Service HIV Program in a changing epidemic: an action evaluation.

Final report. Melbourne, Australia.

This OLM combines interventions to build skills and develop strategies to identify opportunities to change behaviours, review approaches to identify discriminatory policies within the workplace and discuss biomedical advances in BBV treatment (Hopwood 2016). The OLM will be accessible in early 2017. Completion of the OLM will enhance nurses’ potential to enact changes to practice and assist with reducing stigma and discrimination experienced by people with BBV seeking to access healthcare.

Crooks, L. 2016.

Addressing systemic barriers, stigma and discrimination for people living with viral hepatitis and HIV. Primary Times.

16(4):14-15.

Melinda Hassall is Clinical Nurse at the Lead-Nursing Program at the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM)

Hopwood, M. 2016.

Interventions to reduce stigma: A narrative review of the literature.

UNSW Sydney, Australia.

Sami Stewart is Project Officer-Nursing Program at the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) Dr Elizabeth Crock is HIV Clinical Nurse Consultant and HIV Team Coordinator at the Royal District Nursing Service HIV Program

Department of Health (2016) National Strategies for bloodborne viruses and sexually transmissible infections www.health. gov.au/internet/main/ publishing.nsf/Content/ ohp-national-strategies Accessed May 2017

Paterson, B.L., Backmund, M., Hirsch, G. and Yim, C. 2007. The depiction of stigmatization in research about hepatitis C. International Journal of Drug Policy.

18(2007):364-373.

Richmond, J.A., Dunning, T.L. and Desmond, P.V. 2007.

Health professionals’ attitudes toward caring for people with hepatitis C. Journal of Viral Hepatitis. 14:624-632.

anmf.org.au

Peri / Post FOCUS: Op Care Sexual : FOCUS Health

Daniel Cordner Reference: SBS, World’s fourth Aidsmap, Denmark shows first clear evidence of the success of treatment as prevention in gay men in a high in-come country: www.aidsmap.com/ Denmark-shows-firstclear-evidence-of-thesuccess-of-treatmentas-prevention-in-gay-

men-in-a-high-incomecountry/page/3057494/ (Accessed: Aug 2017) National Institutes of Health, NIH Statement on World Aids Day 2016: www.nih.gov/ news-events/newsreleases/nih-statementworld-aids-day-2016 (Accessed: Aug 2017) Poz.com, PrEP fails in a third man, but this time HIV drug resistance is not to blame: www. poz.com/article/prepfails-third-man-time-hivdrug-resistance-blame (Accessed: Feb 2017) SBS, World’s fourth case of HIV infection while on PrEP reported in Victoria: www.sbs.com.au/topics/ sexuality/agenda/ article/2017/05/23/ worlds-fourth-casehiv-infection-whileprep-reported-victoria (Accessed: May 2017) Star Observer, Zero HIV transmissions between Aussie couples with different HIV statuses: www.starobserver.com. au/news/national-news/ no-hiv-transmissionshiv-positive-australiansstudy/160480 (Accessed: July 2017) The Body, Why, for HIV, Undetectable = Untransmittable: www.thebody.com/ content/79761/whyfor-hiv-undetectable-untransmittable.html (Accessed: Aug 2017) The Guardian, Fifty years of the pill, www. theguardian.com/ society/2010/jun/06/ rachel-cooke-fiftyyears-the-pill-oralcontraceptive (Accessed: June 2010) World Health Organization, With PrEP

anmf.org.au

PrEP AND TREATMENT AS PREVENTION: WHAT DOES THIS MEAN FOR HIV IN AUSTRALIA?

By Daniel Cordner As a HIV positive gay male I never thought this day would come, that by taking daily medication, I cannot transmit HIV. There is also now a new way to end all new HIV transmissions. PrEP, (pre-exposure prophylaxis), is making that a reality.

What is PrEP?

PrEP is the use of HIV antiretroviral drugs, taken by HIV negative people to prevent HIV transmission. PrEP when taken daily provides proven protection against HIV. Men who have sex with men (MSM), partners in sero-different relationships (including heterosexuals) on PrEP receive regular three monthly check-ups including sexual health screening. This means MSM are having more regular sexual health checks, in-turn picking up and treating STI’s earlier. The idea that STI’s are on the increase due to some MSM taking condoms out of the equation is not true. MSM are having a conversation around sex and STI’s more openly than ever before. People are making more informed decisions about risk factors and choices they make.

By taking PrEP, as directed, you are always prepared. Condoms must be used correctly every time, to provide protection. Condoms do not provide full protection against all STI’s, like chlamydia, syphilis and gonorrhea. Condoms are no longer the only solution to preventing HIV transmissions.

The NAM Aidsmap website points out that condom usage began to fall long before PrEP became available.

Globally there have only been four cases of HIV transmissions, one of those in Australia for people using PrEP (SBS 2017). Two of those involved rare drug-resistant strains, one being thought to be via very high risk sexual activity (Poz.com 2017) and the fourth is under investigation. Let’s not focus on these four cases and forget about thousands of people

that have not acquired HIV while taking PrEP.

Prevention is better than cure

By understanding that PrEP is part of the equation, not the whole solution, we can see how it can be used to engage in new conversations around sexual practice. By accepting that condoms are only part of that solution, not the whole solution, it allows for alternatives. In places like San Francisco ( WHO 2017) and Denmark (Aidsmap 2017), HIV transmissions are reducing for the first time since the epidemic began. It’s been proven as an effective tool in the kit for HIV prevention.

Treatment as prevention (TasP) Part of this equation is that now someone living with HIV who takes their HIV antiretroviral medicine can reach an undetectable viral load (UVL is someone with a viral load under 50 copies/ml) (Aidsmap 2017). People living with HIV on (antiretroviral treatment) with a sustained undetectable viral load in their blood have a zero risk of sexual transmission of HIV. Numerous studies have confirmed this. The most recent study, Opposites Attract, has shown zero HIV transmissions for couples with different HIV statuses (Star Observer 2017).

The study, which is the largest to date, looked at HIV transmission risk among gay male couples where one partner in the couple is HIV positive and the other partner is negative. The research followed 358 couples from Thailand, Brazil and Australia from 2012–2016, with almost half of the participants from Australia.

The couples in the study engaged in over 12,000 acts of condomless sex where the positive partner had UVL through antiretroviral therapy, and the

negative partner was not taking pre exposure prophylaxis (PrEP), resulting in zero cases of HIV transmission.

Conclusions from the study were: “In terms of HIV prevention, if condom use is safer sex, then sex with someone who has maintained an UVL is even safer sex.”

The results of this study were presented at the International AIDS Society Conference in Paris.

Taking the shame and fear out of HIV

In the 1960’s birth control was provided to prevent unwanted pregnancies. It was another tool to prevent conception, along with condoms. Until now, there has only been one way to prevent HIV. At the time the pill was blamed for promiscuity, hideous side effects and even destroying marriage. Now, the pill is widely prescribed and has helped liberate millions of women (The Guardian 2010).

If you were to take a daily preventative pill for heart disease or diabetes, there is no judgement. It’s time we move past the shame and the fear around blood borne viruses and sexually transmitted infections. Let’s stop denying access to preventative medicine that can change the landscape of HIV forever. Let’s stop placing judgement on how the virus can be transmitted and provide healthcare that is fair to all.

PrEP and Undetectable are both bio-medical evidence based methods for reducing new HIV transmissions.

It’s time to start believing in the research and put our personal opinions aside on what is seen as ‘safer sex’.

There is still a long way to go with the fight against HIV. But with the help of PrEP and Treatment as Prevention it is opening up new conversations, helping reduce new transmissions and is even bringing some hope to end all new HIV transmissions.

Further information:

http://endinghiv.org.au/au/ September May 2017 2017Volume Volume24, 25,No. No.10 19 3 19

FOCUS: Peri / Post Op Care

SOCIAL SUPPORT NETWORKS OF PEOPLE RECENTLY DIAGNOSED WITH HIV IN QLD

By Olivia Hollingdrake, Judith Dean, Chi-Wai Lui, Allyson Mutch and Lisa Fitzgerald Advances in treatment have resulted in longer life expectancy for people living with HIV (PLHIV), but ensuring people are living well remains a challenge for nursing practice (Bradley-Springer et al. 2010).

The quality of life (QOL) of PLHIV is affected by comorbidities, social isolation and persisting societal stigma and discrimination (Lazarus et al. 2016). Nurses are uniquely positioned at the interface between the clinical and social aspects that influence QOL for PLHIV. With the evolution of HIV nursing roles from acute to primary care models, nurses are increasingly involved with supporting individuals to ‘selfmanage’ (Dean et al. 2014).

Although social support is important to self-management (Vassilev et al. 2014), current literature focusing on self-management of HIV predominately targets individual health behaviours (Bolsewicz et al.

2015). There is little evidence of the role and function of social support networks and their interface with models of nursing care and selfmanagement.

Method

Using qualitative social network mapping, this study examines the informal and formal social support networks of Queenslanders recently diagnosed with HIV (<5 years). Phase one, indepth interviews with 15 recently diagnosed PLHIV, will map 20 May 2017 Volume 24, No. 10

and describe supportive networks and provide insight into their experiences of mobilising network support following diagnosis. Phase two will involve interviews with a selection of the key support providers identified through the mapping as being pivotal in meeting the support needs of PLHIV.

Preliminary results

The social support networks of participants are diverse, ranging from sparse connections through to tight networks of family, friends and a range of formal providers. Disruption of social networks following diagnosis creates challenges for sourcing and maintaining support. Several participants revealed that nurses had been pivotal in helping address their fear of disclosing their status to their networks and assisting them to access support and services. A comprehensive network of services (including peers) is important to support self-management, particularly for those with limited informal networks. The broader social challenges of living with HIV remain central areas of concern, particularly in relation to health service access, stigma and social isolation.

Implications for nursing practice

This research will provide insight into network support beyond the clinical environment, contributing to a broader picture of HIV selfmanagement. Supportive care networks, often shaped following diagnosis, may play a role in determining PLHIVs ability to selfmanage in the longer term. The nursing role remains vital, especially for those with sparse social networks and fractured family connections.

Nurses are in a unique position to provide care and education not only to recently diagnosed PLHIV, but also their broader support networks.

Supporting these wider networks will assist PLHIV to live well in the longterm, a key priority of contemporary HIV nursing care.

Olivia Hollingdrake is an RN and PhD Candidate; Dr Judith Dean is an RN and Post Doctoral Research Fellow; Dr Chi-Wai Lui is a Lecturer; Dr Allyson Mutch is Senior Lecturer and Dr Lisa Fitzgerald is a Lecturer.

All are in the School of Public Health at the University of Queensland, Brisbane

References Bolsewicz, K., Debattista, J., Vallely, A., Whittaker, A., & Fitzgerald, L. 2015.

Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom. AIDS Care, 27(12), 1429-1438.

Bradley-Springer, L., Stevens, L., & Webb, A. 2010. Every nurse is an HIV nurse. American Journal of Nursing, 110(3), 32-39.

Dean, J., Staunton, S., Lambert, S., Batch, M., Fitzgerald, W., & Leamy, J. 2014. The evolution of HIV education for nurses in Australia. Journal of the Association of Nurses in AIDS Care, 25(5), 458-464.

Lazarus, J.V., SafreedHarmon, K., Barton, S.E., Costagliola, D., Dedes, N., Del Amo Valero, J., Gatell, J., Baptista-Leite, R., Mendao, L., Porter, K., Vella, S., & Rockstroh, J.K. 2016. Beyond viral suppression of HIV the new quality of life frontier. BMC Medicine, 14:94.

Vassilev, I., Rogers, A., Kennedy, A., & Koetsenruijter, J. 2014.

The influence of social networks on selfmanagement support: A metasynthesis. BMC Public Health, 14 (1).

anmf.org.au

Peri / Post Op Care : FOCUS

ANDREA STONE

References Hoenigl, M., Chaillon, A., Moore, D., Morris, S., Smith, D. 2016. Sexual risk behavior: A cohort study among men who have sex with men.

Journal of Acquired Immune Deficiency Syndromes 71 (5): 551–557.

Kang, M., Rochford, A., Skinner, R., Mindel , A., Webb, M., Peat, J., Usherwood, T. 2014.

Sexual behaviour, sexually transmitted infections and attitudes to chlamydia testing among a unique national sample of young Australians: Baseline data from a randomised controlled trial. BMC Public Health 14(12):1-12.

LITERATURE SEARCH: STI SCREENING AND DRUG USE IN YOUNG PEOPLE

Lea, T., Bryant, J., Ellard, J., Howard, J., Treloar., C. 2015. Young people at risk of transitioning to injecting drug use in Sydney, Australia: Social disadvantage and other correlates of higher levels of exposure to injecting.

Health and Social Care in the Community 23(2): 200-207.

By Andrea Stone Alcohol and other drug use are almost synonymous with increased risky sexual activity in young people (12-25 years). There is a direct correlation between initiation into methamphetamine use and an increase in sexual risk behaviours (Hoenigl et al. 2015).

It has been identified in several studies that risk taking behaviours in young people tend to ‘cluster’ – these include drug and alcohol misuse (alcohol consumption until intoxication) and unsafe, risky sex (Madkpour et al. 2010; Kang et al.

2014).

To date the current focus within health services has been the significant increases in psychotic behaviours associated with methamphetamine use thus creating numerous problems for staff in emergency departments (Roxburgh and Burns, 2013).

However of equal concern is that enhanced sexual activity/arousal and often poor decision making whilst intoxicated increases the likelihood of unsafe sex and an increase in the number of sex partners and the end consequence is undiagnosed STI’s and increased risk of blood borne anmf.org.au

viruses (BBVs) (Lea et al. 2015).

Young people referred to drug and alcohol services are primarily screened for drug and alcohol use and mental health, given the high incidence of STIs in young people, particularly chlamydia (The Kirby Institute, 2013) it is imperative that STI screening is included in all assessments both symptomatic and asymptomatic. If left untreated the complications from STIs can range from reproductive morbidity and HIV transmission (Natoli et al. 2015).

Sexual health screening should be included and promoted as an integral component of a drug and alcohol assessment. Staff must be encouraged to complete and attend education and training on STIs and BBVs and include safe sex as a component of harm minimisation education to all clients that access the service.

HOWEVER OF EQUAL CONCERN IS THAT ENHANCED SEXUAL ACTIVITY/AROUSAL AND OFTEN POOR DECISION MAKING WHILST INTOXICATED INCREASES THE LIKELIHOOD OF UNSAFE SEX AND AN INCREASE IN THE NUMBER OF SEX PARTNERS AND THE END CONSEQUENCE IS UNDIAGNOSED STI’S AND INCREASED RISK OF BLOOD BORNE VIRUSES. Andrea Stone is a Nurse Practitioner, Drug Health Service at Sydney Local Health District

Madkour, A.S., Farhart, T., Halpern, C.T. 2010.

Early adolescent sexual initiation as a problem behaviour: A comparative study of five nations. Journal of Adolescent Health 47: 389–398.

Natoli, L., Guy, R.J., Shephard, M., Donovan, B., Fairley, C.K., Ward, J., Regan, D.G., Hengel, B., Maher, L. 2015. Chlamydia and gonorrhoea point-ofcare testing in Australia: where should it be used? Sexual Health 12(1) 51-58. http:// dx.doi.org/10.1071/ SH14213.

Roxburgh, A. and Burns, L. 2013. Drugrelated hospital stays in Australia, 1993-2012.

Sydney: National Drug and Alcohol Research Centre.

The Kirby Institute.

HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2013. Sydney: The University of New South Wales; 2013.

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References Australian Institute of Health and Welfare.

2011. Drugs in Australia 2010: Tobacco, alcohol and other drugs. Cat. no. PHE 154. Canberra: AIHW Australian Institute of Health and Welfare.

2007. Statistics on drug use in Australia 2006. Cat. no. PHE 80.

Canberra: AIHW

NEONATAL ABSTINENCE SYNDROME AND THE ATTACHMENT RELATIONSHIP

By Jaylene Shannon, Stacy Blythe and Kath Peters Approximately 4.2% of pregnant women consume illicit drugs during pregnancy (AIHW, 2011). Drug exposed infants are more likely to be born small for gestational age, be preterm, and be admitted to special care or intensive care nurseries (AIHW, 2007).

In addition to this, drug exposed infants are more likely to demonstrate insecure attachment patterns with their caregivers (Swanson et al. 2000; Twomey et al. 2010) and are more at risk of mental health concerns later in life (Behnke et al. 2013).

The post-natal period is crucial for infants in establishing a connection and security in a primary-caregiver and can have long-standing impacts on emotional-regulation and attachment patterns (Bystrova et al. 2009). However due to the need for symptom management, many infants born with Neonatal Abstinence Syndrome (a compilation of withdrawal symptoms after prenatal drug exposure) may be separated from primary caregivers and cared for in special care nurseries soon after birth (Backes et al. 2012; Hudak et al.

2012).

Research project

Australian guidelines have limited recommendations for enhancing infant attachment for drug exposed infants and fail to identify specific interventions for nurses/midwives to implement into practice (New South Wales Health, 2013). Therefore, 22 May 2017 Volume 24, No. 10

THIS RESEARCH HAS THE POTENTIAL TO PROVIDE INSIGHTS INTO HOW NURSES/MIDWIVES PROMOTE AND SUSTAIN AN ATTACHMENT RELATIONSHIP FOR DRUG EXPOSED INFANTS.

further research is needed in order to identify the role nurses play in promoting the infant-caregiver attachment for substance exposed infants in the post-natal period.

After gaining ethical approval, this qualitative study will explore nurses’/ midwives’ experiences of promoting the infant-caregiver attachment for infants with Neonatal Abstinence Syndrome and explore methods

they use to facilitate an attachmentrelationship for these infants.

Registered nurses and/or midwives who fit the outlined criteria will be recruited using purposive sampling and data will be collected via semistructured interviews.

Practical outcomes

This research has the potential to provide insights into how nurses/ midwives promote and sustain an attachment relationship for drug exposed infants. These insights may provide the basis for nursing/ midwifery interventions that ensure drug exposed new-borns have the opportunity to develop an attachment relationship.

Jaylene Shannon is an Honours Candidate and Registered Nurse at Port Macquarie Base Hospital; Dr Stacy Blythe is Lecturer and Director of Engagement & International and Associate Professor Kath Peters is Director of Academic Programs (International Programs).

All are in the School of Nursing and Midwifery at Western Sydney University

Backes, C.H., Backes, C.R., Gardner, D., Nankervis, C.A., Giannone, P.J., & Cordero, L. 2012.

Neonatal abstinence syndrome: Transitioning methadone-treated infants from an inpatient to an outpatient setting.

Journal of Perinatology, 32(6): 425-430.

Behnke, M., Smith, V.C., Levy, S., Ammerman, S.D., Gonzalez, P.K., Ryan, S.A., & Cummings, J.J. 2013.

Prenatal substance abuse: short-and long-term effects on the exposed fetus.

Pediatrics, 131(3): e1009-e1024.

Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A., Ransjö-Arvidson, A., Mukhamedrakhimov, R., & Widström, A. 2009.

Early contact versus separation: effects on mother-infant interaction one year later. Birth: Issues in Perinatal Care, 36(2): 97-109.

New South Wales Health. 2013. Neonatal Abstinence Syndrome Guidelines. Document No. GL2013_008. NSW Health.

Swanson, K., Beckwith, L., & Howard, J. 2000.

Intrusive caregiving and quality of attachment in prenatally drug-exposed toddlers and their primary caregivers.

Attachment & Human Development, 2(2): 130-148.

Twomey, J.E., MillerLoncar, C., Hinckley, M., & Lester, B.M. 2010.

After family treatment drug court: Maternal, infant, and permanency outcomes. Child Welfare, 89(6): 23-41.

anmf.org.au

Peri / Post Op Care : FOCUS

ELEANOR KITSON

WHERE THERE’S SMOKE: UNCOVERING THE BENEFITS OF A NON-RESIDENTIAL CANNABIS WITHDRAWAL

By Eleanor Kitson Drug and alcohol dependence continues to ignite the interest of the media. The ‘epidemic’ of methamphetamine use, the controversy of private residential rehabs and the burden of substance use on the healthcare system are prominent in the news and across social media.

Service review and improvement within the Drug and Alcohol sector is not a new phenomenon.

Nevertheless, despite extensive industry demand and public outcry, there are still no miracle ‘cures’ for substance abuse. Chronic relapsing and remitting conditions such as drug and alcohol dependence, rarely have miracle cures.

If my role as a Pharmacotherapy Nurse Practitioner Candidate in the Drug and Alcohol sector has taught me one thing, it is that achieving reduction or abstinence from substances takes time. For the majority of users, simply physically ceasing and experiencing withdrawal from a substance is not treatment enough. I have repeatedly observed the impact of a client having completed withdrawal, relapsing on return to their substance use home environment.

With a limited number of public residential rehabilitation beds and the cost of private facilities being too high for the majority, the alternative of a non-residential withdrawal (NRW) program should be considered. A anmf.org.au

nurse facilitated NRW offers clients the opportunity for cessation and medication of withdrawal in their own home or to have NRW nurse support following a week of residential withdrawal.

Previously working as a NRW nurse assisting clients with cannabis dependence, has for me highlighted a number of unexpected benefits to the ‘at home’ approach. Firstly, it allows for an enhanced therapeutic relationship with clients and their family in their own context. The benefits of professional, consistent, honest positive regard cannot be overestimated for this client group. Secondly, it allows for family involvement in the process, as well as education and support to family and friends. Thirdly, it allows for the exploration and modification of triggers at home.

Sights, smells, sounds and environments trigger memories of cannabis use and often lead to relapse. Helping clients to recognise and modify these triggers in the home can significantly help to reconfigure their smoking context to promote a

holistically drugfree environment.

An effective example of this in practice was to encourage clients to improve ventilation and use room

A NURSE FACILITATED NRW OFFERS CLIENTS THE OPPORTUNITY FOR CESSATION AND MEDICATION OF WITHDRAWAL IN THEIR OWN HOME OR TO HAVE NRW NURSE SUPPORT FOLLOWING A WEEK OF RESIDENTIAL WITHDRAWAL.

fragrances and scented candles to eliminate the smell of cannabis.

Unsurprisingly, people need ongoing support as the neurobiological changes of dependence of cannabis persist for months to years and risk of relapse is high. Many clients bring with them motivating factors for reducing their substance use including exacerbation of mental health issues or involvement with the legal system. For people who use cannabis, harm minimisation strategies to reduce the risk associated with its use is fundamental.

Helping clients to recognise and alter the triggers in their home environment, which prompt them to use cannabis, enhances the likelihood of changing their substance use.

Whilst helping them to clear the smoke, we must also help them extinguish the fire.

Eleanor Kitson is a May 2017 Volume 24, No. 10 23