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March 2016
Mental Health Feature + Diagnosing autism + Suicide prevention training + Autism spectrum disorder research and developments + 12 hour shifts linked to more nurse errors
HealthTimes - March 2016 | Page 11
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Suicide safety planning app aims to save lives By Karen Keast
A
world-first safety planning smartphone app and website are the latest high-tech tools in the fight to prevent suicide. Thousands of people have already downloaded the free BeyondNow app, a collaboration between Monash University and beyondblue with funding from the Movember Foundation, since it was launched in mid-March. Dr Glenn Melvin, a clinical psychologist and senior lecturer at Monash University who was central to developing the app’s safety planning component, said while health practitioners working with people at risk of suicide have long used safety plans in written paper format, the app provides a user-friendly and easily accessible tool for people in crisis. “I guess one of the advantages of having the app is that people tend to have their phones with them at all times,” he said. “We know that suicidal thinking comes and goes so the role of the app is to be there when the person is in that state, and it’s all prepared beforehand to help them survive that crisis or really tough time that they find themselves in.” Dr Melvin said clinicians can incorporate the app into their practice to use with clients or patients. “We’re encouraging health professionals to download the app, have a look at it, become familiar with it, then consider how they might go about introducing the idea of an app with one of their patients,” he said. “We received a lot of very positive feedback on the app from people who are using the app and clinicians who will be using it in their practice.” The app features a safety planning technique developed by American psychologists and researchers Professor Barbara Stanley and Professor Gregory Brown.
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“We’ve tried to bottle that technique into an app so that it’s accessible and includes relevant Australian health services such as Lifeline and 000,” Dr Melvin said. “It’s been about two years of development and we started out by doing a round of consultation with people with lived experience of suicide and talked to them about what they would like to see in an app, what it should look like, what features it should have. “We also talked to clinicians from a variety of professional backgrounds - psychiatrists, psychologists, social workers, nurses about the features that they would like to see in the app and what would make it a useful thing for them to easily incorporate into their practice with their patients and clients.” The app focuses on enabling people to create a structured plan, either on their own or with a health professional, that lists a series of steps the person can use to help themselves stay safe. Through the app, they can outline their warning signs, ways to keep their environment safe and their reasons for living. “Then we move to internal coping strategies so these are things that a person can do to perhaps distract themselves from suicidal thoughts,” Dr Melvin said. “We know in general that distraction isn’t necessarily a good coping strategy in the longer term but in terms of say riding the waves of suicidal thoughts, distraction can be helpful. “It might be taking a cold shower, going for a walk, doing some exercise, watching a favourite movie, those type of things.”
For the full article visit HealthTimes.com.au
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HealthTimes - March 2016 | Page 13
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Suicide prevention training
S
uicide is preventable yet the latest Australian Bureau of Statistics (ABS) data shows 2864 lives were lost to suicide in 2014, which equates to almost eight a day - an increase of almost 13.5 per cent in a year. Australia’s health practitioners have a vital role to play in preventing suicide. Dr Fiona Shand, a clinical psychologist and Senior Research Fellow at the Black Dog Institute, says it’s imperative nurses, midwives and allied health practitioners tap into suicide prevention training. “We’re seeing an increase in death by suicide unfortunately and also potentially an increase in the number of people who are presenting for self-harm,” she says. “Suicide is the leading cause of death amongst young people in Australia and also certainly one of the leading causes of death for middle-aged men, so I just think that it’s one of those issues that we can’t afford to ignore.” Dr Shand, who has worked in suicide prevention for the past four years, says upskilling in the areas of screening for depression and suicide, responding to suicide attempts, and being able to discuss suicide with patients is a key part of prevention. Evidence shows screening for depression and suicide, and treating depression and distress, are some of the best ways to circumvent a suicide attempt. Dr Shand says while particular groups of people are considered to be at risk of suicide, such as those presenting with a psychiatric
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diagnosis including depression, anxiety or bipolar disorder, it’s also important to identify other patients or clients who may be at risk. “There isn’t any one particular profile of a person who might experience suicidal thoughts, it depends on what’s happening in the person’s life, and suicide risk changes over the course of a person’s lifetime so it’s always important to screen,” she says. Most importantly, it’s crucial health practitioners are able to have the conversation about suicide with patients. Dr Shand says it doesn’t have to be a complicated process. “Even just asking a couple of questions and finding out whether the patient has ever had a suicide attempt or if the person is having those kind of thoughts can be the start of putting some positive things in place,” she says. “Saying it in a way that says - ‘when someone is going through a tough time like you are, it’s not unusual to have these kinds of thoughts and I’m wondering if you’re having them’.
“It’s really just giving the person permission to talk about it. Certainly in our interviews with people who have had a suicide attempt, they said they want to be asked and they want to be asked on the suicide attempt on a regular basis, so they don’t have to be the ones to raise the subject. For the full article visit HealthTimes.com.au
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HealthTimes - March 2016 | Page 17
Autism spectrum disorder research and developments
T
here’s a saying that ‘if you’ve met one person with ASD, you’ve met one person with ASD’. Autism spectrum disorder (ASD) is an extremely heterogeneous disorder that presents differently in the difficulties and abilities of every person, making it harder to detect and diagnose early in children. Autism spectrum disorder is a life-long neuro-developmental disorder that affects both a person’s social and communication abilities and features behaviours that are repetitive and restrictive. It also often includes sensory sensitivities. While it’s estimated one in 100 people have autism spectrum disorder, researchers at La Trobe University’s Olga Tennison Autism Research Centre (OTARC) have found most children are not diagnosed until they are four years old - more than two years after they can be accurately diagnosed and receive life-changing intervention. Autism symptoms The signs and symptoms of autism spectrum disorder fall into two main areas - social and communication as well as fixated interests and repetitive behaviours. Dr Josephine Barbaro is a lead clinician at Australia’s first Early Assessment Clinic for autism spectrum disorder and a post-doctoral research fellow at OTARC.
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Dr Barbaro’s research has made headway in the early diagnosis of autism spectrum disorder and has led to the development of ‘red flag’ markers or autism symptoms, used to identify at-risk babies. “We really need to get the message out there that autism can and should be diagnosed in children under three, in those children who are presenting with symptoms of autism spectrum disorder,” she says. Social and communication deficits Dr Barbaro says concerned parents and health professionals can look for key signs in the social and communication area for babies or children. Signs of autism include difficulties or deficits in the child’s use of eye contact, shared smiles, gestures, responses and when it comes to imitating others. “The behaviours we look for are whether or not children have difficulties or deficits in their use of eye contact, in responding to his or her name when someone calls them, and in engaging in pretend play, so pretending to feed a teddy or give a teddy a drink,” she says. “We also look to see whether they have difficulty in copying other people, so for infants that would be copying facial expressions or blowing raspberries or clapping their hands and in older children that would be in domestic activities like sweeping the floor or pretending to comb their hair or things like that.”
Fixated interests and repetitive behaviours Professor Sylvia Rodgers, director of research and education for the Cooperative Research Centre for Living with Autism (Autism CRC) which works in partnership with OTARC, says autism signs and symptoms are also found in repetitive and restrictive behaviours, such as an intense interest in particular toys or objects, or where a child has a narrow focus on an object, such as playing with the wheels on toy cars or lining cars up. Professor Rodgers says many children with autism prefer the same routines and find it difficult when it comes to changes in their day to day activities, such as parents taking an alternative car route to childcare or kindergarten due to roadworks. “That’s all about the predictability being gone and then there’s severe anxiety around things not being the same,” she says. Most people on the autism spectrum disorder also have sensory sensitivities. Sensory sensitivities Children with autism spectrum disorder can under-react or overreact to sensory stimuli, from enjoying watching a spinning fan or wheels to wanting to only eat foods with a certain texture, such as smooth foods, or trying to block out the noise of a ticking clock. “Certain noises just become disproportionately problematic for them and one of them is the noise of hand-dryers in public toilets,” Professor Rodgers says. “Those can be so distressing that they will avoid them or if a child hears that and is not expecting it, it can cause a meltdown in the shopping centre. “We hear those noises as noisy maybe and unpleasant but they’re tolerable to us, the sounds that they hear are potentially earpiercing, uncomfortable to the point of pain they will sometimes describe.”
Causes of autism spectrum disorder There is no single known cause of autism. Researchers are examining whether there are multiple causes of this complex disorder, and are looking at genetics and whether there are links to environmental factors which could cause the brain to develop differently. Professor Rodgers says while researchers know more today than they did 10 or 20 years ago, there is still a long way to go before researchers uncover the cause of autism spectrum disorder. She says the Autism CRC is creating the nation’s first and largest autism Biobank, which will collect detailed phenotypic and genotypic information from hundreds of families affected by autism. “We are collecting blood and other biological materials from children on the spectrum and their mothers and fathers and we are trying to look at the genetic basis of the children’s situation,” she says. “We need lots of children and families to be involved. We are hoping to be able to bring a whole new understanding together of what’s underpinning the condition.” Assessment and diagnosis In 2013, changes were introduced to the criteria that health professionals use for diagnosing autism spectrum disorder. The previous fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) listed children with autism spectrum disorder as having either Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS). Under the fifth edition of the manual, the DSM-5, there is now a single diagnosis of autism spectrum disorder with a severity ranking of levels one, two or three along the spectrum. There is no single test to diagnose autism spectrum disorder.
For the full article visit HealthTimes.com.au HealthTimes - March 2016 | Page 19
Diagnosing asthma in children While a diagnosis of asthma is important for children, there’s also increasing concerns surrounding overdiagnosis and overtreatment. By Karen Keast
A
sthma is a common and chronic longterm lung disease which affects about one in 10 Australian children. Children with a diagnosis of asthma have sensitive airways in their lungs that react to triggers, such as respiratory infections, cigarette or bushfire smoke, allergies, a change in temperature, high emotions and particular medicines. These triggers can cause flare-ups where the muscles around the airways compress, the airways swell and become narrow while getting thick with mucus, making it more difficult for the child to breathe. People can develop asthma at any stage throughout their life. The signs or symptoms of asthma may come on gradually or suddenly. Researchers are working to understand the causes of asthma, and are examining links between genetics and environmental factors. There is no cure for the condition but in children with an asthma diagnosis, their asthma can be well controlled. Children can lead a healthy, normal life through managing their asthma. Diagnosing asthma in children There is no single reliable test and no standardised diagnostic criteria for asthma.
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A diagnosis of asthma involves demonstrating excessive variation in lung function combined with respiratory symptoms. When making a diagnosis of asthma, a GP or a paediatrician will examine a child presenting with symptoms of the condition, such as breathlessness, wheezing, a continuing cough and a tight feeling in the chest. The doctor will consider the child’s medical history, including whether the child has allergies such as eczema or hay fever and a recurrent or persistent wheeze, conduct a physical examination, and consider other possible causes of the symptoms. The doctor will also consider tests that support the diagnosis, such as a spirometry test to assess the child’s lung function, and may consider a treatment trial. A spirometry test involves the child blowing forcefully into a mouthpiece or tube for several seconds, which is connected to a recording device. The spirometer measures the amount of air pushed through the tube, as well as lung capacity and other measurements. Adam Jaffé is a Professor of Paediatrics at the University of New South Wales, a respiratory paediatrician at the Sydney Children’s Hospital, a member of Asthma Australia’s Medical and Scientific Advisory Committee and he helped write the National Asthma Council Australia’s Australian Asthma
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Handbook, which outlines national guidelines for asthma management. “With every child that presents to the doctor, one would take a proper history, and you ask about the triggers, what the symptoms look like and there are a few clues on examining a child - the shape of their chest, and whether they’re sick at the time or they’re wheezing,” he says. “In those aged over five, you should do lung function testing and look at the response to something like a reliever, to measure the response before and after. “In older children, we can actually do a challenge test where they inhale a substance to try and make them wheeze, which helps with the diagnosis. “Once you think you’ve got the diagnosis of asthma, then it will be about trying this medicine to see if it actually improves and relieves your symptoms or improves your lung function if it’s abnormal.”
Diagnostic challenges It can be incredibly difficult to diagnose asthma with certainty in children under five. Young children are unable to perform the lung test to acceptable standards while wheezing and coughing are common in this age group. There are many causes for coughing and wheezing, and a wheeze does not automatically mean a child has asthma. Professor Jaffé says the most satisfying part of his work, and much of his job, involves undiagnosing asthma. “Nothing gives me greater pleasure than seeing children in my clinic when I say - ‘you haven’t got asthma, take them off their medicines’,” he says.
For the full article visit HealthTimes.com.au HealthTimes - March 2016 | Page 21
12 hour shifts linked to more nurse errors By Karen Keast
N
urses who work at least 12 hours on a single shift face a greater risk of making errors that can injure themselves or their patients, research shows. New Zealand nursing researchers Dr Jill Clendon and Dr Veronique Gibbons, who published their systematic review of research evidence in the International Journal of Nursing Studies last year, found six studies, comprising 60,780 nurses or 89 per cent of the review’s total sample size, revealed a significant rise in error rates among nurses working more than 12 hours on a single shift in acute care hospital settings. One study reported higher rates of care left undone than nurses working up to eight hours, another study found the likelihood of making an error was three times higher while a third study found the risk was almost double. Another study found nurses were more likely to suffer a needlestick injury, a separate study found nurses working more than 13 hours are far more likely to report frequent central line-associated bloodstream infections, while the sixth study found patients’ pain was less likely to be controlled. Out of the 13 studies examined, four found higher rates of error in shifts of up to eight hours while three found no difference between the number of shift hours worked.
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While 12 hour shifts are common and offer flexible working hours for nurses, the researchers said their review shows 12 hour shifts result in an adverse impact on patient and nurse outcomes. “The (12 hour shift) approach has proven popular, with many proponents citing good quality time off work, ease of travel to work, improved relationships with patients, and better family time as benefits,” they state. “However, there is significant debate in the literature regarding the disadvantages of 12 hour or longer shifts with some authors claiming extended shifts cause increased fatigue, greater risk of errors, greater risk of injury to self, and negative physiological outcomes, others claiming no difference in patient outcomes, and yet others attributing greater risk of error to poor scheduling practices rather than length of shift.” Dr Clendon, a New Zealand Nurses Organisation (NZNO) nursing policy advisor, and Dr Gibbons said hospitals and units now using 12 hour shift systems should review the scheduling practice because of the potential negative impact on nurse and patient outcomes.
For the full article visit HealthTimes.com.au
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Best Practice Nursing HealthTimes - March 2016 | Page 23
Diagnosing autism By Karen Keast
T
here is no one simple test to assess and diagnose autism spectrum disorder (ASD). Best practice for a diagnosis of autism spectrum disorder involves a multidisciplinary team of health professionals, including a paediatrician or a child psychiatrist along with a psychologist, speech pathologist or an occupational therapist.
Diagnosis of autism spectrum disorder Dr Josephine Barbaro, a research fellow at the Olga Tennison Autism Research Centre (OTARC) at La Trobe University, says a diagnosis can only occur through behavioural observation and through developmental history. “That involves interviewing parents and observing the child; we don’t have any concrete biological markers that we can pare up with our observations at this stage,” she says. When making a diagnosis of autism spectrum disorder, health professionals will use the latest version of the standard criteria for the classification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders - the DSM-5, produced by the American Psychiatric Association in 2013. The new edition, which replaces the fourth edition of the DSM, introduced major changes to the diagnostic definitions of autism and its related conditions. The fifth edition features a single diagnosis of autism spectrum disorder with a severity
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ranking of levels one, two or three, depending on the amount of support the child requires. Under the DSM-5, a diagnosis of autism spectrum disorder replaces the previous range of conditions such as Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS). Health professionals now diagnose autism spectrum disorder on the basis of difficulties in two areas. The first area is social communication deficits, where the child rarely or never uses language, doesn’t respond to people or doesn’t copy people’s actions. The other area is fixated interests and repetitive behaviours, where the child has an intense interest in certain objects and plays with them in a particular way, such as lining objects up. This area includes sensory sensitivities, where a child will overreact or under-react to stimuli such as the sound of a ticking clock or the noise of a hand-dryer in public toilets. The DSM-5 includes a new diagnostic label of Social Communication Disorder (SCD). SCD is similar to ASD but is diagnosed based on difficulties with both verbal and non-verbal social communication skills and does not include the ASD definition of fixated interests and repetitive behaviours. Under the change, some children who would previously have received a diagnosis of ASD may now receive this new diagnosis of SCD.
Importantly, those diagnosed under the previous DSM retain their diagnosis and are not required to be re-assessed. When it comes to diagnosing autism, there are a range of diagnostic assessment tools clinicians use, including two considered to be gold standard - the Autism Diagnostic Observation Schedule (ADOS-2) and the Autism Diagnostic Interview (ADI-R). Dr Anne Chalfant, a clinical psychologist who specialises in autism and is director of Annie’s Centre, says the ADI-R is a structured interview conducted with parents or the primary caregiver of the child. “For a hypothetical example, John is three and when he and his parents come in for assessment about John, the clinic should sit down with the parents and go through this standardised interview process asking the parents questions all about John’s developmental history to date and his milestones,” she explains. “They’re very detailed questions looking for what we call behavioural evidence - so concrete behaviours that we can code using the assessment tool to do with his social and communication skills and repetitive behaviours. “All of the questions are basically designed to bring to life, if you like, the diagnostic criteria for autism spectrum disorder in a way that clinicians can then analyse and in a standardised way, in a way that’s reliable between one clinician and the next, and makes sense of the information that the parent gives them.” The ADOS-2 is a standardised diagnostic measure used to observe the child which targets the symptoms of autism spectrum disorder. Dr Chalfant says the tool focuses on mostly play-based activities. “Those activities are designed to draw out the features of an autism spectrum disorder if they’re present for that child,” she says. “Another hypothetical example is if you have a two-year-old coming for an assessment at the clinic and they had very little language and there
was high suspicion of autism, the tool might involve things like the way they play with certain toys, certain play routines, things like peekaboo, pretend birthday parties, games to do with bubble or balloon play, etc. “What you’re looking for, in a standardised way, is a certain type of response from the child - so you’re looking for things like repetitive behaviours, lack of eye contact, all of the things that are part of the diagnostic criteria for autism. “We have these activities in order to draw them out and again code them in a way that is standardised and normed against other children their age, against other children with other types of difficulties, so that we can make solid conclusions as to whether it seems like there is quite a high likelihood that the child has a diagnosis or not.” Clinicians require training to use the gold standard diagnostic assessment tools. Training is available through Annie’s Centre in Sydney, La Trobe University and Monash University in Melbourne, and through a Graduate Certificate in Autism Diagnosis at the University of Western Australia. Push for a standardised approach The Cooperative Research Centre for Living with Autism (Autism CRC), which works in partnership with OTARC, is examining diagnostic practices for autism spectrum disorder across Australia and aims to establish a baseline of current assessment processes. The study is an essential first step towards developing national standards for autism spectrum disorder diagnosis in Australia. Dr Chalfant says for too long, assessment of autism spectrum disorder has varied from clinician to clinician depending on their interpretation of social and communication deficits as well as fixated and repetitive behaviours.
For the full article visit HealthTimes.com.au HealthTimes - March 2016 | Page 25
Unnecessary health tests, treatments and procedures to avoid Physiotherapists say routine imaging for non-specific low back pain and for the cervical spine in trauma patients should be avoided. The Australian Physiotherapy Association (APA) advice is part of 61 new recommendations for tests, treatments and procedures that are often unnecessary and can also harm Australian patients. Physiotherapy’s peak professional body has joined 13 colleges and societies representing health practitioners including nurses, hospital pharmacists, pathologists, radiologists, GPs, surgeons and palliative care specialists, as part of the NPS MedicineWise Choosing Wisely Australia campaign. The APA’s six recommendations include urging physiotherapists against routinely using spirometry after upper abdominal and cardiac surgery, to avoid using electrotherapy modalities for patients with low back pain, and to avoid ongoing manual therapy for patients with adhesive capsulitis of the shoulder. It also urged physiotherapists against requesting imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (OAR). APA vice president Phil Calvert said the association’s recommendations are the result of almost 3000 responses to a member survey, which were then put to a panel of physiotherapy experts. “We really recognise that the recommendations are just that - they’re recommendations,
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they’re to be used as a guide. We understand every clinical situation is different,” he said. “I think physiotherapy as a profession is very, very good at looking at what it does critically evaluating what it does. “This forms part of that but I think the real thing that we’re focused on here is the opportunity to actively engage and have good conversations with our patients.” One of the APA recommendations urges physiotherapists against requesting imaging for patients with non-specific low back pain, with trials consistently showing routine imaging has no advantages while there are potential harms, such as exposure to radiation. “Imaging is instead recommended for cases of low back pain where there is a suspicion of an underlying medically serious disease, like cancer or infection. Patients with a higher likelihood of medically serious disease as the cause of their low back pain can be identified by red flags, like a history of cancer,” the recommendation states. Mr Calvert said people presenting with the common problem of acute low back pain often mistakenly believe that imaging will identify the cause of their pain. “We know that people who come to see a health professional will come with often very specific expectations about what their care might be,” he said.
For the full article visit HealthTimes.com.au
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HealthTimes.com.au HealthTimes - March 2016 | Page 27
ANMF calls for around-the-clock registered nurses in aged care The Australian Nursing and Midwifery Federation (ANMF) wants a registered nurse on duty around-the-clock in all of the nation’s aged care facilities to improve care for vulnerable older patients with complex and chronic conditions. The ANMF has called for mandated 24/7 RNs in residential aged care facilities as one of six recommendations outlined in its submission to a Senate inquiry set to shine the spotlight on the future of Australia’s aged care sector workforce. The ANMF has also recommended mandated minimum staffing levels and skill mix for RNs, enrolled nurses (ENs) and assistants-in-nursing (AINs) or personal care workers (PCWs) in aged care, and for minimum education and licensing for AINs. It’s also pushing to close the wages gap between nurses and AINs working in aged care and their public hospital colleagues. ANMF federal secretary Lee Thomas said the recommendations aim to strengthen the underresourced workforce in the midst of a shortage of 20,000 nurses, in a sector where nurses are undervalued and underpaid. Ms Thomas said the size and composition of the direct care workforce is the key ingredient to providing quality, safe care to the nation’s rapidly ageing population. “Staffing levels must be urgently addressed,” she said. “Without legislated requirements in all Australian jurisdictions to mandate a minimum number and type of nursing and care staff, safe and quality care for the elderly cannot be assured. That is a huge concern for all of us.” The inquiry, due to report on June 30, will consider areas including future aged care workforce requirements, challenges in attracting and retaining aged care workers, and aged care
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workforce difficulties in regional towns and remote communities. It will also examine remuneration, working environment, staffing ratios, education and training, skills development and career paths for aged care workers. The ANMF submission shows the changing composition of the aged care workforce at a time when a growing number of residents are being assessed as high care. It states the number of full-time equivalent (FTE) RNs in residential aged care dropped 14 per cent between 2003 and 2012, the number of ENs rose slightly at 0.5 per cent while the number of AINs/PCWs grew 50 per cent. The shift away from employing RNs coincided with a 25 per cent increase in the number of operational residential aged care places, rising from more than 151,000 in 2003 to more than 189,000 in 2014. There’s also been a rise in the number of residents assessed as high care, from 64 per cent in 2003 to 83 per cent in 2014, while more than half of residents had a diagnosis of dementia in 2014. The ANMF says it strongly supports AINs/ PCWs in aged care as an integral part of the nursing team alongside RNs and ENs. “However, the workforce data clearly indicates a substantial shift towards the employment of AINs/PCWs at the expense of registered and enrolled nurses in a care environment where the work in many instances requires the skills and knowledge of either a registered or enrolled nurse,” the submission states. “The consequence of this shift is that the quality of care provided to the elderly has been directly affected.”
For the full article visit HealthTimes.com.au
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HealthTimes - March 2016 | Page 29
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Mental Health Nurses. You are in demand! Medacs Healthcare are currently seeking experienced Mental Health Nurses for the following opportunities: Perth, fulltime - RN with post grad qualification in mental health. Day shifts only. $92k + Super NSW - Short term rural contracts available in hospital and community mental health, 2 - 13 wks Casual and flexible mental health nursing shifts avail in Sydney metro region. Great Pay Rates! Contact us for more temp or perm opportunities.
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