Nursing Review - Feb 2013

Australia independe ’s nt voice of nursing Issue 1 February 2013 www.nursingreview.com.au

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2 | February 2013

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10

clinical practice 26 Hospitals in the home

news 04 Creating graduate positions

An acute care alternative

Forecasting for the future workforce

28 Opinion

06 Limiting access to care

The role of acute care in mental health

Health service turns patients away

29 Men’s health

08 ANMFSA joins group petition

Getting blokes to talk about it

SA nurses contest McCann review

10 Patient participation in care New research into preferences

policy & reform 12 Specialisation

29

workforce 32 Looking after yourself

Tips to tackle the year ahead

34 Have your say

Peter Kieseker on aged care nursing

Is it deskilling the workforce?

16 Climate change

35 Q&A with Molly Carlile

Preparing for future health issues

Career, passion and awards

18 Tasmania troubles

legal column 36 Anorexia nervosa

Budget cuts hit

specialty focus 20 Practice nurses

Advancing holistic care

Audited 15,635 as at Sept 2012

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24 Community nursing

Our health system’s silent crisis

Courts face legal and ethical dilemma

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February 2013 | 3

news

Grads f lock to

By Amie Larter

P

lanning and forecasting for the future workforce should be a nationwide focus to protect the needs of our graduate nurses, says Professor Ged Williams, executive director of nursing and midwifery at Gold Coast Hospitals and Health Service.

As the ANF’s “Stop passing the buck, Australia’s nursing grads need jobs” campaign reaches full swing with more than 2650 emails to politicians, Gold Coast Health (GCH) is using a different approach to ensure future graduate placements.

GCH has taken on more than 25 per cent of the total graduate placements allocated

by Queensland for 2013 – 138 graduates in January, with an expected 30 to 40 more to come on board midyear. This is an increase from last year, where the total intake was 120 students.

Williams suggested this success was due to planning, and that a planning framework and strategic initiatives needed to be applied at a district, state and national level.

“The community cannot afford for all these graduates to not work this year. Because if they do not work this year – they are highly unlikely to come back into the industry and we are going to lose them for good.

What’s lacking is a sense of urgency and a sense of proper measurement to inform the decisions that need to be made,” he said.

The team at GCH uses an in-house designed commercial workforce planning tool WorkMAPP, as well as electronic roster system, eRoster, to effectively manage workforce supply and demand equations that inform both long-term and short-term staff planning respectively.

“Using WorkMAPP, we can model different scenarios like a high attrition rate, nursing shortage, or any other situation that would increase service requirements,” said Williams. “We put the information into the tool and it calculates how many nurses we might require at different levels across the district in the outgoing years.”

The team uses the eRoster tool to gain retrospective data on patterns of sick leave and resignations throughout the year to ascertain when you are more likely to need and or lose more nurses. This information is then applied to prospective forecasting.

“If we know we get a large number of resignations in October or November or if we had a high sick leave rate in August – next year when we are planning our 4 | February 2013

Protecting nursing’s future: Stacey Pickering is one of the many graduates heading to Gold Coast Health.

workforce requirements we make sure we have buffers lined up for those particular periods. Such patterns are likely to be seasonal, and to an extent predictable,” Williams said.

“These two tools are working hand in glove to give us a really good understanding of how our workforce moves and changes over time, so we can re-forecast what our requirements are.”

Data is extracted from the tools and GCH then works collaboratively with universities and other service providers to align what they deliver to create the appropriate amount of opportunities for students once they have completed their studies.

Professor Jenny Gamble, acting head of school at Griffith University’s school of nursing and midwifery, believes that GCH is one of the most innovative districts in relation to workforce planning. She said their collaborative approach allows the university to hear and respond effectively to the needs of the industry. “This kind of approach allows us to be much less reactive,” she said. “We don’t get caught up in that loop of changes in the industry that require sudden tertiary response.”

This system also allows students to focus their study and energy on areas of future need for the hospital. “Forward planning identifies a gap and students know they will be able to profile themselves strongly,” Gamble said.

“This gives them the cutting edge around

employment because they can then target their study to identified work gaps.”

GCH also has also implemented a roster where graduates are only on for three days a week – which means that they have only 86 full-time positions available, however, they have a head count of 138.

“We are accepting 138 graduate nurses and midwives working three days per week on a 12-month temporary contract. There is a vulnerability for this year’s graduates that at the end of 12 months if they do not secure a permanent job with us, then their employment will cease, to make room for next year’s graduates,” explained Williams.

“Our current retention rate following the graduate year is 95 per cent.”

Of the 119 graduates employed in 2012, 117 are staying on beyond the completion of the program. “The benefit is, they have 12 months of employment, they have consolidated their training and they are now competent RNs,” Williams said. “Even if we can’t employ them, they will be much more employable.”

Gamble confirmed that students understand that it is a tight market, and even though many would prefer fulltime employment, they are delighted and grateful to have a three-day a week position. “Many are very amenable to the idea that they and their peers get three days a week rather than a whole lot of people missing out because a few people get five days a week,” she said. n

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• Medico Legal Congress 21 – 22 March 2013 | Sydney Harbour Marriott

• National Dementia Congress 21 – 22 February 2013 | Novotel Melbourne on Collins

• Developing the Role of the Nurse Practitioner Conference 21 – 22 March 2013 | Novotel Melbourne on Collins

• National Forensic Nursing Conference 21 – 22 February 2013 | Radisson Blu Plaza Hotel Sydney

• Hospital Patient Costing Conference 21 – 22 March 2013 | Stamford Plaza Brisbane

• Hospital Bed Management & Patient Flow Conference 25 – 26 February 2013 | Novotel Melbourne on Collins

• Mental Health Units Conference 25 – 26 March 2013 | Marriott Melbourne

• National Telemedicine Conference 20 – 21 March 2013 | Pullman Hotel, Hyde Park Sydney

• Electronic Medication Management Conference 25 – 26 March 2013 | Hilton on the Park Melbourne

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February 2013 | 5

news

Qld hospital

S

10pm SHUT-OUT

taff at a Brisbane hospital have been instructed to turn away patients presenting after 10pm, with management guidelines suggesting nursing staff offer sick patients a “blanket and pillow”.

Nurses and other health professionals at Wynnum Health Services, formerly Wynnum Hospital, have been told that patients presenting between the hours of 10pm and 8am should be treated outside the facility until an ambulance arrives – including those in life-threatening situations.

The guidelines from Metro South Health (MSH) go as far as to state “if BLS [basic life support] is required commence BLS at the front door.”

Dr Rosalind Crawford, MSH director medical services and facility manager Redland and Wynnum hospitals, said the decision to deny after-hours access was

first enforced due to staff and patient safety concerns, and that the staff’s main priority was the patients in the 21-bed ward.

She said the majority of patients at the hospital were frail and elderly and should not be left unattended.

However, Des Elder, Queensland Nurses Union assistant secretary, believes this puts nurses in an untenable situation of having to assess patients without any medical officer support or necessary equipment.

“This means they are torn between their duty of care to the patient and their professional obligations to work within their scope of practice,” Elder said.

“Clearly requiring staff to perform BLS at the front is what is expected.

This is clearly an inappropriate and dangerous requirement. The guidelines are unreasonable and seek to transfer the risk and liability from the health service to the

individual nurse and patient.”

Local residents plan to once again make their voices heard, Elder stating that the community does not accept the “spin” from the board as to why the emergency service was axed in the first place.

“It is on the public record that the hospital board believes the service should be provided by the private sector. It is a plan to slowly privatise health in the area. It is another example of the ham-fisted and disgraceful way the government is handling health services,” Elder said.

MSH has confirmed that the directive is now under review. n

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Breast cancer help

Birth trauma for fathers

• With breast cancer causing the second highest number of deaths in Australia, patients in regional cancer centres and metropolitan areas will now have access to specialist breast care nurses after the federal government committed a further $18.5 million to the McGrath Foundation.

The funding will allow the program to continue and expand from the current 44 existing nurses to add the equivalent of 10 full-time positions.

• The University of Western Sydney’s school of nursing and midwifery will investigate a new side of traumatic births – looking at the impacts on male partners. Researchers will explore men’s experiences of labour and birth where the partners have experienced complications or needed urgent intervention. About 295,000 babies are born in Australia every year and principal researcher Dr Rakime Elmir hopes that the findings of the study will help create greater awareness among health professionals, particularly midwives and child and family health nurses, of the support needed for men following a traumatic birth.

WA nursing shortage

Community package help

• According to a major survey conducted by the Australian Nursing Federation, WA will face major shortages with only about 44 per cent of nurses planning to stay in the industry for longer than a decade. In addition, almost 36 per cent of nurses said they experienced regular shortages, while nearly 16 per cent said the shortages were getting to dangerous levels. Describing the results as alarming, Mark Olson, ANF state secretary, called for the government to act quickly to retain and attract more staff with better pay and conditions.

• Among other providers, Care Connect has recently been awarded a ComPacks (Community Package) contract – a NSW Ministry of Health initiative to minimise the risk of hospital readmissions. The service will allow appropriate patients to be supported for up to six weeks in an early transition home – helping to free vital beds in the state’s public hospitals. Care Connect will be responsible for delivering the program to 5000 patients in six local health districts, providing much needed non-clinical community support to people after they leave hospital.

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4th Annual National Dementia Congress February 21 to 22 Novotel Melbourne on Collins www.healthcareconferences.com.au A national event examining dementia care issues from diagnosis through to palliation, exploring the theme of doing things differently in dementia care.

National Forensic Nursing Conference February 21 to 22 Radisson Blu Plaza Hotel Sydney www.healthcareconferences.com.au The only national event of its kind promoting research and leadership for Australia's Forensic Nursing Community

6th Annual Hospital Bed Management & Patient Flow Conference February 25 to 26 Novotel Melbourne on Collins www.healthcareconferences.com.au Australia's foremost patient flow improvement conference, showcasing innovative case studies and pioneering best practice in the nation’s hospitals

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February 2013 | 7

news

Taking money out of primary and preventative care will cost more in the long term, say nurses and health advocates.

SA $14m cut

‘short-sighted’

L

eading South Australian health groups have joined forces to launch a petition against recommendations for cuts made in the McCann review of non-hospital health services.

SA Health appointed Warren McCann, internal consultant for the Office of Public Employment and Review, last August to undertake the review.

More than 100 jobs and a range of different health programs and services are in the firing line, in a move which the review suggests will save about $14.6 million.

The Australian Nursing and Midwifery Federation (SA Branch), SA Council of Social Service, Health Consumers Alliance of SA, the Public Health Association and the Australian Health Promotion Association have joined forces to fight recommendations they describe as “short-sighted” and “not based on sound evidence”.

ANMF state secretary Elizabeth Dabars said the recommendations contained in McCann’s review are entirely at odds with international research and the Menadue Generational Health review, which emphasises the need for investment in preventative and primary healthcare and was adopted and is in current state government policy.

8 | February 2013

“If you can address issues now, then you can address the long-term costs of healthcare by intervention sooner rather than later,” she said. “This goes back to the basic principle that prevention is better than a cure.”

The groups believe that McCann’s approach will increase the burden on an already overstretched hospital system.

Rather than strip money away from primary healthcare, they suggest putting more investment into it.

“We can save money at the other end – which is not having people lining up at the emergency department which is a very costly exercise,” Dabars said.

“As an example, if you have people that do become obese and morbidly obese – the cost to the system is significant.

You have to buy additional infrastructure, beds, wheelchairs and you would need additional staff.

“Rather than having one nurse at a time you have to at least have four people just to assist them with their basic care needs.

“This is going to be a significant cost to the public and one that is much better avoided.”

Dabars said the community will be the emotional and financial beneficiaries of a health system where investment is based

on promotion and prevention, and it is up to the SA health professionals and community to make it happen.

“As health professionals we are advocates for our patients and really part of our advocacy should always be trying to avoid people from becoming patients in the first instance.

“I see the role of nursing and midwifery at this point to be part of that advocacy and as result I would encourage anyone in the nursing and midwifery professions to sign the petition but also encourage their family and friends and loved ones to also sign,” she said.

SA Health said the review “supports a number of new recommendations which constitute significant reforms to the delivery of some non-hospital based services” and that a two-month public consultation on these services and strategies is currently underway, concluding on February 4.

The department said it welcomes and encourages all feedback as part of this process and “will consider all feedback on the new recommendations before finalising a proposed response to the report for government’s consideration”. n

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February 2013 | 9

news

Patients urged to get involved A joint university research project will examine the success of encouraging patients to have more of a say in their care. Amie Larter reports

P

atient participation in care (PPC) is not a new concept, however, little research has been done in Australia into how hospitals would deliver changes, and whether patients are ready and willing to participate.

The World Health Organisation as well as the Australian Commission on Safety and Quality in Healthcare have been long-time promoters, and recent statistics suggest that this could decrease the rate that patients pick up a secondary illness or injury in hospital.

An Australian Research Discovery grant has recently been awarded to Griffith University’s National Centre for Research Excellence in Nursing (NCREN) and Deakin University to explore patient and nurse responses to PPC and their willingness to participate in it.

“The first phase is exploratory, and we will find out from nurses and patients what they think of active participation in their care,” said Professor Wendy Chaboyer, director of Griffith’s NCREN, who will lead the three-year study.

“We want to find out what nurses think, as we would like to understand some of the barriers and drivers for this actual participation because it means a power

10 | February 2013

sharing.” Chaboyer said patients will now be acting as partners in their care.

The second phase, led by Griffith health economist Dr Jenny Whitty, will be an experiment where scenarios will be presented to nurses and patients to explore preference in care.

Results from this will be used in the third phase to develop recommendations on how hospitals might be able to have patients participate more actively.

The Australian Nursing Federation federal secretary, Lee Thomas, said that nurses try to promote a positive therapeutic relationship using effective communication and advocating for patients. This demonstrates their support for patients making decisions about their own healthcare management.

“Patients need to believe that they can ask questions and feel confident they understand the answers they are given.

By providing empowerment, nurses encourage people to choose and negotiate about their care and take the lead in decision making.”

Thomas suggested that in order for nurses to build upon the PPC approach, they would need time to educate patients – something that was not always available within an acute setting where patients have relatively short stays.

“They need the staffing and resources to do this. Shared decision making and working in partnership with people is important in ensuring a fairer service.

“A PPC approach has great potential and it is our hope that the research will demonstrate whether it will improve patient care and the resources required to achieve this,” Thomas said.

International research suggests that nurses’ responses to the PPC approach have been varied.

“Some nurses feel threatened and challenged if patients speak up,” Chaboyer said.

“On the positive, from these small studies, some nurses embrace patients participation; they value it and see its importance, thus are dedicated to supporting patient participation.

“However, nurses report they still need to maintain some control,” Chaboyer said. n

news

www.nursingreview.com.au

February 2013 | 11

policy & reform

Educators specialisation

12 | February 2013

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• cardi

• em erge n l he ent a

opae dic/s p i h t r o al • c i r g u /s periopera t i ve

Considine believes it was inevitable that the medical profession would become more specialised as medical research revealed more details about particular illnesses and diseases.

The more complex a sickness, the more it requires each area within the medical profession to have greater knowledge and that invariably leads to specialisation.

“If I had a cardiac arrest, I would want an expert emergency nurse, if I was having a baby, I would want an expert midwife, if I've had a stroke, I would want an expert stroke nurse,” Considine says. “No one ever suggests that orthopaedic surgeons take over the plastic surgery list.”

General medical training has advanced greatly in all areas since Considine started out 30 years ago. “When I trained in the late 1980s, there were still general medical and surgical units, but it was common for surgical specialties to be clustered on the same wards like plastics, orthopaedics, gastrointestinal,” she says.

“Now medicine has also sub-specialised and your find medical units with specific expertise in stroke, respiratory problems, diabetes and new areas are developing too. There are many benefits to nurses specialising … such as patients receiving expert care in that area and the nurses can help out with answering questions, thereby comforting the patient.

“It improves the outcome for the patient and specialised nurses might notice something that a general nurse doesn’t. A patient may have broken his or her leg and that is what they are treated for.

A nurse who may have worked with stroke victims would naturally look to see if there was any head trauma rather than just treating the immediate injury.

“Of course, there can also be some disadvantages to nurses specialising as it can lead to a less flexible workforce and nurses might become deskilled in areas other than their

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Complex illnesses

•m

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s a patient, we are both relieved and fraught with nerves when we are told we need to see a specialist doctor. Relieved that there is someone in the field of the unknown illness that our body is carrying, which eases our mind that a cure may be found sooner rather than later.

We are also very nervous that something may be seriously wrong with our health and it may result in a prolonged illness or even death. It is as if our body and feelings are facing a dichotomy.

But where there remains hope, which will always prevail when we know there is a specialist doctor in the field of illness for which we are currently diagnosed, the more positive feeling will generally win through.

While patients take comfort in seeing a specialist doctor, there are mixed feelings within and outside the nursing profession regarding more nurses specialising – in fields such as emergency, aged care, coronary care, midwifery, oncology and palliative care amongst others.

Some see this as a negative, resulting in nurses losing general skills and unable or unwilling to transfer their skills to another section of the hospital or to a completely different area in nursing. This is because of the difficult processes involved in applying for another job, such as getting the required police and reference checks, interviews and preparation. However, others see it as a positive.

“I have never heard anyone complain that we have too many specialist doctors,” says Julie Considine, professor in nursing at the school of nursing and midwifery at Deakin University. “So, I am not sure why people would complain about there being too many specialist nurses?

l

“Nurses have always specialised but I know a lot of nurses that transfer their specialist skills. For example, I have emergency nursing colleagues who now work in ICU and hospital in the home and they have benefited from the experience.

“Personally, I have always worked in emergency care and relished the challenges that it presents.”

n al

Letting too many nurses concentrate on narrow areas of practice depletes the number of general duties staff, say critics. But educators argue that medical advances make it necessary.

Louis White reports

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speciality, which means hospitals have decreased ability to move nurses within their organisation. But I don’t see any of these conversations happening about medical specialists!”

The Nursing and Midwifery Board of Australia says there are just under 337,000 registered nurses and midwifes in Australia as of September 2012.

There about 238,000 registered nurses, 59,000 enrolled nurses and 33,000 registered nurse/midwives. These are the three largest categories in the profession.

The biggest worry for Australia is the age of nurses. There are 51,055 nurses and midwives in the 51- to 55-year-old category.

In the 41- to 60-year-old bracket there are a total of 178,567 nurses and midwives.

Surveys conducted by Monash University, Health Workforce Australia and the Australian Nursing Federation indicate that more and more nurses are looking to leave the profession for a multitude of reasons, including poor pay and lack of career opportunities.

Career progression

By creating more and more specialist nurse roles it increases the opportunities for nurses to gain broader skills, higher pay as well as more job satisfaction.

“There are often better career progression opportunities for specialist nurses,” says Dr Colleen Smith, associate head of the University of South Australia’s school of nursing and midwifery.

“For instance, nurses with specialist qualifications can extend their scope of specialist practice by undertaking the Master of Nursing (Nurse Practitioner) program. By offering specialist nursing positions, nurses can undertake that option and study the necessary qualifications to progress in that field.”

Smith believes there are far more advantages than disadvantages to nurses being able to specialise and it was inevitable that this genre would open up due to medical research.

“Nurses specialising in particular areas of medicine is a response to an increase in technology and advances in medical and health care knowledge,” she says.

“Patient care is much more complex resulting in the need for more specialist nurses to drive the safety and quality agenda and improve patient outcomes.”

The reality is that we are an ageing population. The Australian Bureau of February 2013 | 13

policy & reform

Statistics states that 13.5 per cent of the population are currently aged over 65 years.

By 2050 this age group will make up almost 23 per cent of the population. There will be just 2.7 people of working age (15 to 64 years old) compared with five now for each Australian aged 65 years and over.

The risk of having a stroke rises as you get older. Australians are exercising less, eating more junk food and obesity is on the rise, meaning that diabetes will only increase.

As we get older more illnesses and injuries occur and each year medical research makes discoveries resulting in new diseases coming to the fore requiring more specialist knowledge in that area.

This will flow from what children are immunised with to the way people are treated in hospital to the design and care of patients in hospitals in the future.

“The advantages of nurses having specific knowledge is that they acquire in-depth knowledge and skills in their specialist area of practice and provide advice and support within their specialist scope of practice to other health professionals,” Smith says.

“Of course there is the disadvantage of specialist knowledge and skills not readily transferrable to other areas of nursing practice, so this could result in the potential

to lose skills.

“Overall, their needs to be a sufficient mix of generalist and specialist nurses to ensure a flexible workforce that caters for the needs of the healthcare industry.”

Thomas Harding, professional officer at the NSW Nurses and Midwives Association, believes that it has always been a trend for nurses to find a niche and stay there.

“I don’t think it is that different from other professions, where you find a niche within your field of expertise and choose to remain there,” Harding says.

Technological advances

This school of thought is backed up by the Australian Nursing Federation federal secretary, Lee Thomas, who says that like all occupations some nurses choose to stay in a particular area for many years of their working life.

She says this choice is not unusual and is made generally because of the preference for that type of nursing.

“Skills are broadened and many new skills learned over the years, as medical technology and techniques change. But nurses remain nurses with broad skills irrespective of the areas in which they might choose to spend their working life.

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“However, nurses in rural and remote areas, working in the outback and in small country hospitals don’t have the same opportunities to stay in one area for many years,” says Thomas.

Harding, however, points out that the general public fails to differentiate nurses like they do with doctors.

“Most patients just see a nurse as a nurse,” he says.

“That is unfortunate in that all nurses should be recognised for the skills that they bring on board and specialised nurses do extra study and training.”

He does agree that processes in place within the healthcare sector don’t make it as easy as once before for nurses to chop and change their career path.

“There is no doubt that through all the processes in place these days it is harder for nurses to move from one area of specialty to another or even back to a general nurse once they have specialised,” Harding says.

“The reality is that in the future we will need more specialised nurses due to the advancements in medical technology.

Doctors too want more specialised nurses to work with.

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policy & reform

the country, with less medical assistance available in all areas, we need more general specialised nurses.”

Harding, who previously held a senior position at the Australian Catholic University, says that undergraduate and postgraduate degrees have developed substantially and offer more comprehensive learning, enabling students to better demonstrate their skills and knowledge.

“Nursing degrees offer greater flexibility and improved learning facilities thereby enabling students to have increased knowledge.

“The result of that is students will then want to know more about speciality and there are greater opportunities for them now to undertake such post-graduate courses and training than there has been in the past.

“Of course, this is all determined by labour market activity but the greater skillset one possess the more opportunities afforded to them.

“I don’t believe nurses lose skills if they specialise, they just acquire new ones and that is to everyone’s benefit.”

Professor Ramon Shaban, deputy head of school of nursing and midwifery at Griffith University, actually believes there is less specialisation now than in the past.

Nurses have always specialised but I know a lot that transfer their specialist skills. I have emergency nursing colleagues who now work in ICU and hospital in the home and they have benefited from the experience.

“I don't know that I believe that nursing specialisation is more common,” Shaban says. “Specialisation has been [this way] for many years, and in fact to some extent there is less specialisation.

“Generally speaking, the growth of some specialty areas of practice has been supported by research and evidence-based practice, along with the move of nursing education from the vocational sector to the tertiary sector.

These have afforded the development of specialist, research and evidencebased practice. There is a need for the specialist-generalist.”

Shaban says that specialisation offers mastery of skills, professional standing, expert patient and practice care and flexibility for nurses.

“Increasing specialisation, and multiple specialisation, increases professional portability and employment,” he says.

“In addition, nurses change and expand

specialisation as their careers evolve, as their personal circumstances change.

“To some extent they lose skills, but they gain others. Their skill and expertise evolves – evolution is the best way to describe it. All skills and abilities acquired are relevant to future practice and specialisation. It adds to the individual's practice base. Specialisation is fundamental and important.”

Expect more of the specialised nurse and less of the generalist nurse in the future, though both are needed all around the country. The more money, effort and time invested into medical research means more discoveries and more knowledge acquired.

We all take relief when we hear that a specialist doctor is available, perhaps we should start doing the same with specialist nurses. After all, we generally end up spending more time with them than the doctor anyway. n

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February 2013 | 15

policy & reform

Dealing with

climate change The effects of a warming planet may already be on us and nursing courses need to prepare graduates for the health issues to come.

By Liz Hanna

T

he Australian Senate is running an inquiry to examine “Recent trends in and preparedness for extreme weather events”. Calls for submission closed on January 18. Our politicians are clearly concerned about Australia’s preparedness.

This is a call to arms for the health workforce to step up and prepare. A new world is bearing down upon us in the form of new climate frontiers.

Following the unheralded fire conditions of Black Saturday, in February 2009, fire authorities were obliged to add in the new category of “Catastrophic” to accommodate the increased intensity we are now seeing in fire conditions.

In January this year, the Bureau of Meteorology added two new colours – deep purple and pink – to the interactive weather forecasting chart to extend its previous temperature range. Once capped at 50 degrees, the bureau needed to extend its capability to 54°C, to accommodate these new heat extremes that are now occurring.

Also in January the average maximum temperature across Australia peaked at 40.3°C, a new record, and it remained over 39°C for seven consecutive days, twice as long as the previous record.

This follows a warm end to last year, where for the last four months, the average 16 | February 2013

Australian maximum temperature was the highest on record with a national anomaly of +1.61°C, from records dating back to 1910. On January 4, Hobart reached a maximum of 41.8°C, breaking a record held for 120 years.

We must face it, the world is warming.

Heat extremes are an increasing global phenomenon. Last year was the warmest on record (since 1895) for the 48 contiguous US states. The 2011/12 winter season was nearly non-existent for much of the eastern half of the nation.

2012 was, for the US, the second-worst for weather extremes including drought, hurricanes and wildfires. In addition to the summer being hot, it was also dry, resulting in a drought footprint comparable to the drought episodes of the 1950s.

These aberrant weather patterns are being experienced all across the globe.

Heat extremes which were once at the frequency of 0.1 per cent of the time are now coving 10 per cent of the planet at any one time. Extreme weather events have increased three fold. Globally, climate change is already costing an estimated $US1.6 trillion ($1.5 trillion) per year, rising to over $US4 trillion by 2030.

The summer of 2009 brought extreme heat waves to southern Australia, accompanied by Black Saturday bushfires.

More than 500 people lost their lives in

Victoria due to these climatic events; either due to heat exposure or through severe burns and smoke inhalation from those fires. Then 2010 and 2011 were the two wettest years in Australia’s recorded history, flooding Queensland, NSW and Victoria.

Among the developed nations, Australia is at the forefront of vulnerability to the ravages of climate change, as we face increased threats of droughts, floods, storms, fires and heat waves. We are entering a new and wildly disparate climate to the one in which humans evolved and agriculture flourished allowing villages and cities to develop. Our future will be warmer, with greater extremes of temperatures and precipitation; more intense and more frequent droughts, floods, and storms.

There is now wide scientific agreement that the world is heading for at least 2°C warming, and possibly 4°C, by 2070, and this will bring greater extremes. With global warming currently less than one degree, hot countries, such as Australia are already beginning to experience temperatures that are not compatible with a healthy and active life. It is difficult to imagine how this can further amplify, to a state where a “normal” hot day is 48°C and extremely hot days approach 58°C. Such horrors are inherently difficult to fathom, however, without mitigation, we

policy & reform are on a trajectory to these unimaginable heat extremes. With such warming, outdoor activity will not be possible. Using CSIRO’s projections for Australia of the likely increase in mean annual temperature by 2070 if no mitigation strategies are adopted, a Perth study identified that outdoor activity would be impossible for unacclimatised people on 33–45 days per year, compared with four to six days per year at present. Their core temperature would rise by 2.5°C in less than 2 hours.

Not only will this be too hot for humans to move, work and exercise, but it will also be too hot for animals, cattle and sheep, and for plants.

Their leaves will burn. Even at lesser temperature extremes, our stable food crops will wither, and food production in Australia and globally will decline. By this stage, the oceans will be warmer and more acidic, so we cannot expect protein sources from fish. Food shortages will drive conflict and political unrest.

Unfortunately, this gloomy forecast is not a horror movie, it is realistic. What we do not know is how soon this will occur. But the trend has already begun, and experts are now convinced that current emissions interruptions to infrastructure caused have now exceeded the barrier of keeping by damage to roads, bridges, electricity warming to less than 2°C. [It passed the and communications.

The geographic range of mosquito borne 2°C threshold when the concentration of CO2 reached 330 ppm. It reached 394 ppm diseases will spread southwards. Food borne diseases also increase with rising by the end of 2012]. If nations continue to temperatures. Personal loss will bring procrastinate about reducing greenhouse stress, grief and despair gas emissions, as people struggle projections suggest The geographic to cope with these global warming range of mosquito changes. These will between 4°C and manifest as generating 5.6°C will occur borne diseases greater demand for before the end of will spread mental health services, the century. Some and health sector children alive today southwards. Food responses to other will live to see this. borne diseases also chronic diseases that The pathway to are exacerbated by this sorry state will increase with rising stress, and by stress involve an increasing temperatures. alleviation techniques, array of health Personal loss will such as drug and problems. The need alcohol abuse. Mental for expanded nursing bring stress, grief health services, roles will demand and despair as especially preventive reorientation of services, are lacking in nursing training and people struggle many regions. care provision. In the to cope with these In the short term, all near future, there will changes. new nursing courses be increasing health must prepare nurses threats arising from for a future world, one heat exposure, and quite unlike the one for which we prepared. from exposure to droughts, floods and Australia’s health burden will shift, and storms. health service priorities will change in This will occur against a backdrop of response to economic shifts as countries crop damage, and therefore rising food direct increasing proportions of GDP into prices, potentially food shortages, and www.nursingreview.com.au

reparation of damaged infrastructure.

There is an urgent need for health promotion, as after mitigation, preparedness offers the greatest protection. Preparedness must occur at all levels: individual, community, industry, institutional and government. The health sector and health sector workforce have a key role to protect and advance Australia’s health. The health impacts of climate change should feature prominently in the education curricula of undergraduate and postgraduate health professionals. n Dr. Liz Hanna convenes the National Climate Change Adaptation Research Network for Human Health, and is president of the Climate and Health Alliance. She transitioned from an Intensive Care Nurse to focus on health related research. Hanna is director of the NHMRC research project investigating Working in the heat under climate change: health risks and adaptation needs, and is chief investigator on several other projects.

A fully referenced version of this story is available at www.nursingreview.com.au February 2013 | 17

policy & reform

Apple Isle feels the

squeeze

Amie Larter talks to Neroli Ellis about the state of nursing in Tasmania.

shortages within three years if all graduates were employed. Tasmanian nurses and midwives, on average, are the eldest in the country and the impending retirements will create added pressure in the near future.

What were the main challenges for nurses in Tasmania throughout 2011- 2012?

The significant budget cuts in health in this financial year resulted in the closure of over 100 acute hospital beds, 280 nursing positions slashed, theatres closed, mental health and family child health service and access reduced resulting in major issues with bed block and subsequent ambulance ramping and 25 per cent elective surgery cancellations.

The pressures were on all major Tasmanian hospitals which were operating at about 100 per cent occupancy, which is unsustainable for safe patient care over the long term. This resulted in ambulance ramping, re-admissions, and increasing complexity of medical illnesses due to delays in elective surgery and delayed 18 | February 2013

diagnosis of cancer, which are some of the symptoms demonstrating the poor state of our health system in Tasmania.

Front-line nurses wore the brunt of most of the effects of the budget cuts and yet continued to do their best to deliver quality services. All sectors of primary heatlh were also reduced with cancellations of mental health and family child health apppointments, and community nursing access reduced. Nurses and midwives received enormous public support. The federal Minister for Health, Tanya Plibesek, announced a $325 million four-year package, which if allocated to the crisis areas would have made a difference.

Concurrently, nursing graduate employment was cut by 40 per cent of pre-budget numbers (FTE) despite the Health Workforce Australia projections of

There was extensive coverage of the staff shortages, funding cuts and extensive work hours for nurses. What plans need to be put in place to ensure it’s not the same throughout 2013?

The outcome of this short-term strategy is evident now with nursing roster shortages, reliance of casual staff and ongoing fixedterm contracts and job insecurity and many of the 280 nurses who lost their jobs last financial year have already moved their families interstate.

The ongoing delay in the implementation of the new nursing career structure due to budget cuts is also affecting recruitment with a lack of recognition of the value of nursing and midwifery.

The Australian Nursing Federation (ANF) will pursue the classification reviews and implementation of new classifications through ongoing conciliation in the Tasmanian Industrial Commission and pursuit of the finalisation of the working party for a new career structure for community nurses.

The human resources processes must be improved and the ANF has recommended implementing KPI’s to improve the recruitment timeframe, which is unacceptable at the current four months for a permanent appointment.

The graduate nurse campaign will continue to ensure our graduates can stay in Tasmania for a career pathway.

The ANF will be monitoring and intervening in workload issues through the local workload committees and ensuring that permanent employment is offered to assist in retention.

How did the state government respond to the issues, and was the response satisfactory?

The government made a policy decision to cut the health budgets and reviewed the forward estimates to maintain current

policy & reform cuts without proposed additional cuts this financial year.

However, the cuts remain unsustainable and despite the additional federal funding, which only offers less than $8 million for the state elective surgery per annum, access to both acute and primary care will continue to be compromised for Tasmanians. The government’s response has not been satisfactory and the preliminary findings of the Legislative Council inquiry have determined that the community is being adversely affected.

Coming into an election year, what will be the main issues on the agenda for nurses and the ANF in the state?

1. Development of a statewide health strategic plan. Many expensive consultant reviews have been undertaken over the last 10 years but yet the health system continues to lack direction and strong leadership. Regional parochialism has to be removed and services offered based on a statewide plan.

2. Appropriate resources to implement this plan must be allocated in the relevant budgets.

3. Implementation and funding for the new nursing career structure, which must include models of care recognising the scope of practice of all levels of nurses including funding for nurse practitioners,

nurse-led discharge, walk-in clinics and nurse educators.

4. Development and commitment to a Tasmanian nursing and midwifery workforce plan and graduate nurse program expansion.

5. Funding to reopen critical services in health and ensure Tasmanians have equitable access to the universal health system.

What is your vision for nursing in Tasmania?

Strong nursing leadership to advocate and lead and promote our profession forward.

Support for research and ongoing education to enable nurses and midwives to work at full scope of practice, and value and recognition of the great innovation that continues despite the hardship of the system due to the budget cuts.

Clinical information systems to support our practice and enable accurate data to enable practice improvements.

The ability to deliver quality care that is supported by the appropriate skill mix and support staff re-employed to enable nurses and midwives to be relieved of the non-nursing duties, which continue to be absorbed by nurses particularly as positions are removed through budget cuts.

A dynamic system to enable positive change led by nurses and recognising

The government made a policy decision to cut the health budgets and reviewed the forward estimates to maintain current cuts without proposed additional cuts this financial year. those nurses in clinical leadership positions. Support and recognition for nurses and midwives without the constant fight through the obstructions of the bureaucracy.

A sustainable nursing workforce plan to be developed and supported to avert the predicted workforce crisis.

Aged care funding to ensure nurses and care staffing levels and skill mix to provide quality care to our ageing demographic. n Neroli Ellis is the Tasmanian branch secretary of the Australian Nursing Federation.

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February 2013 | 19

specialty focus

Personal touch at the

practice

Practice nurses perform myriad tasks in doctors’ surgeries, one of the most important is to communicate with patients.

By Flynn Murphy

I

t is 1pm on a Wednesday at Glebe Medical Centre in Sydney’s inner west, and nurse Jessica Turner is sneaking a sandwich in between patients.

“It’s very busy, especially now that I do pap smears as well,” the full-time practice nurse explains between bites.

Last month, Turner completed a course in women’s health at Family Planning NSW, which has allowed her to expand her scope of practice at the centre, qualifying her to perform breast examinations and pap smears. The course was part-funded by the clinic she works at, and part by a government subsidy.

“We encourage our nurses to improve their skill sets in private practice. We see it as an investment in our staff,” says Dr Ryan Quan Vo, co-director of the centre, which took out the Sydney Small Business of the Year award last year.

Glebe Medical Centre is a 10-room, multi-disciplinary practice with GPs, allied health practitioners, and full-time nursing support. It’s busy right now but not chaotic, a wall poster advertises a new smartphone app that lets patients book an appointment at the touch of their screen.

Vo says his clinic caters to a diverse demography, from the socio-economically disadvantaged to young professionals, and is open seven days a week, bulk billing for five. It has sister-clinics in Rozelle and Drummoyne, each of which has a fulltime nurse. Turner joined the centre last

20 | February 2013

Jessica Turner enjoys the work/life balance

September, after six months working in the transplant ward of the Royal Prince Alfred Hospital. She previously worked at a drug and alcohol clinic in Ultimo.

“It’s a completely different skill set here,” she says. Being a practice nurse means “less drama” than working in the hospital system. It also meant a pay cut – with no possibility of overtime – but offers a work/ life balance that suits her better than regular night shifts at the hospital down the road.

“Having practice nurses greatly benefits doctors and patients,” says Vo. “Nurses can provide additional services that the doctor may not have time for – for instance our nurses are responsible for our vaccines inventory: ordering, checking, and administering vaccines to children. This can take quite a while, and having a nurse to do that can really take the pressure off the doctors.”

“These extra skills do greatly help patients

because they mean patients can see nurses to get these procedures done, and often that means there are very minimal waiting times, as opposed to having to book in to see a doctor.”

For Vo, nurses are ideally suited to handle follow-up care and inquiries.

“Also, a lot of the time a patient, when they see a doctor, may not have an opportunity to [get an] answer to all the questions they wanted, or they’ve forgotten during the consultation. Seeing a nurse gives us an opportunity to get more feedback from the patient. If a patient calls up the practice with a query, most of the clinical questions are directed to our nurse first.”

Julianne Badenoch, president of the Australian Practice Nurse Association, which represents about 3500 nurses, says the core benefits offered by practice nurses were in the realm of time, and access. “[Patients will] get time, they will get a qualified professional who knows what they are talking about, and they will be given more opportunities to selfmanage their care.”

“There’s a good business case for practice nurses,” she adds.

specialty focus

Vo says Glebe Medical Centre receives incentive payments from Medicare for employing a practice nurse, but that the practice has been financially worse off since the federal government replaced the nursing item number system with the Practice Nurse Incentive Program last year.

“But there’s a huge benefit to the practice having a full-time nurse,” he said.

“We still see the benefits outweighing the financial costs. It also lets the doctors see more patients.

“The GPs that have had nurses in their clinics for a long time, most of them tell me they wouldn’t survive without them,” adds Badenoch. “They may well say that with a smile, but I think they actually mean it. We share the load.”

For a former actor, and a direct descendent of legendary Irish writer James Joyce, Turner is plain-spoken. For her, this is just part of the job.

“We free [doctors] up to get more patients, but between the two of us, patients get that complete, holistic care. I can’t tell you the amount of times I’ve been researching stuff out of work hours and contacting patients with information. That’s www.nursingreview.com.au

what nurses do. It’s our job to manage vulnerability and fear.

“Good doctors know the value of nurses, and know how we’re supposed to work as a team. Half the time that means explaining to patients in language they can understand what their issue is, and what the treatment is. A lot of time patients come to me and are still a bit confused about what it all means. They need reassurance.

“I had a woman recently who was diagnosed with gestational diabetes, and she walked out of the doctor’s office thinking it was her fault. Her way of rectifying that was she was just not going to eat. I explained what it was, how it wasn’t her fault, and that by all means she had to keep eating and just lay off the sugar. English was her second language, and she needed a simple explanation.”

Badenoch would like to see the scope of practice expanded for more practice nurses like Turner. “I think it’s happening – at the end of the day, nurses just need to be able to demonstrate they are educated, authorised and competent to perform new roles. They just need to back them up and demonstrate it.”

We free [doctors] up to get more patients, but between the two of us, patients get that complete, holistic care. I can’t tell you the amount of times I’ve been researching stuff out of work hours and contacting patients with information.

February 2013 | 21

specialty focus

Turner is positive about her career prospects, and says nurses need to be proactive about building careers for themselves in clinics.

Vo agrees: “There are a gamut of roles within private practice, and opportunities for nurses to expand their skill sets and do more procedures in women’s health, chronic disease management, diabetes, and then further on if a practice is large enough they will run clinics and manage clinics, overseeing junior nurses. There are opportunities to become senior nurses and practice managers.”

Asked whether these opportunities would be available at his own clinics, Vo said he wanted to bring on more nurses, and planned to open a women’s health clinic – the lynchpin of which would be Turner.

Badenoch said the “negativity and turf wars of the past” were coming to an end when it came to GPs and practice nurses, though the nurse practitioner role, which included the expansion of the scope of nurses to prescribe certain medications, remained controversial.

Badenoch, who herself works as an RN at a beach resort clinic in South Australia, said at her site, collaboration was key.

“You never know what it’s going to be next – a broken arm, a kid scalping themselves on the pool – in the practice I work in it’s a team effort. We are consulted all the way along. Patients generally see the nurse before they see the doctor, and half the work is done. “[APNA is] still constantly told by our members that they want a career pathway,

The busy Glebe Medical Centre is open seven days a week.

they want a direction that lets them build on their skills,” she said.

To that end, this year APNA is working on a proposed education and career pathways structure for nurses in primary health care.

“We’ve found that a lot of practice nurses love the work they’re doing, their hours and the variety of their care, but far fewer were satisfied with the recognition they received, and their opportunities [for career advancement].”

Badenoch said the organisation would invite the Australian Nurses Federation to partner with them in order to tackle unioncentred issues such as equitable pay.

“The practices that welcome nurses benefit, and the community benefits.

Particularly in rural areas where there are such significant workforce shortages.”

Turner says when it comes to collaborations between GPs and practice nurses, as long as the patients come first, it doesn’t matter whose egos are bruised.

“Many doctors don’t mean to come off as being dismissive, but often they are so

busy, and patients don’t understand what’s going through their heads – so they feel like they’re not getting listened to, or that the doctor doesn’t care. If you look at the reality of some doctors, they’ve spent their whole life studying, and then you’ve got these very intelligent people who lack social skills and whose identity is wrapped up in being a doctor.

“I was doing a pap smear the other day with a woman, who is about 50. She’d been having crazy menopausal symptoms for years, but was still menstruating. So the doctor said ‘nope, it’s not menopause, you’re fine’.

“So I get to her and she’s saying ‘I’m going crazy, I’m having mood swings, I’m newly married and accusing my husband of cheating but I know he’s not cheating!’

– the symptoms were unmanageable for her. It was just a case of listening to her and saying ‘you’re perimenopausal, you’re not crazy, it’s going to come’.

“Problem shared, problem halved.” n

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For more information contact ZOLL on 1-800-605-555 or visit www.zoll.com.au 22 | February 2013

specialty focus Australian College of Nursing

Nursing’s role in medication management N ACN does not support the use of medications as chemical restraints in place of expert nursing care.

By Debra Thoms

urses have a key role in supporting the appropriate management of medication.

Late last year ABC’s Lateline program sparked debate about the potential over-use of antipsychotic medications in the management of dementia within residential aged care settings.

The program interviewed the Minister for Ageing, Mark Butler, about the issue. Subsequent to the program airing, a round table discussion was called

by Butler to shed further light on the issue. The Australian College of Nursing (ACN) was one of the key stakeholders invited to attend the discussion.

Following the airing of the Lateline program, various organisations released media statements condemning the overuse of antipsychotic medications in the management of people with dementia. There was a strong view expressed that antipsychotics should only be used in the short term and should not be used as an intentional form of chemical restraint.

The definition of “chemical restraint” that is used by the federal government is, “the intentional use of medication to control a resident’s behaviour when no medically identified condition is being treated, where the treatment is not necessary for the condition or amounts to over-treatment of the condition (DoHA, 2004).”

It is acknowledged that early diagnosis of dementia itself can be a difficult process due to a range of other conditions presenting similar symptoms to that of dementia. As a result of misdiagnosis, patients may receive incorrect treatment (including medication), symptoms may persist unnecessarily and the underlying cause of symptoms may go unaddressed.

ACN supports a greater role for nurses in the care of people with dementia including the assessment

Side effects seriously impair the self-care capacity of those receiving the medication and increase the need for assistance and very close supervision. www.nursingreview.com.au

of client behaviours, dedicated nursing time within a client’s day, care planning developed around behaviours associated with dementia, and coordination of care.

The Therapeutic Goods Administration has proposed the rescheduling of benzodiazepines from Schedule 4 to Schedule 8. These drugs include: diazepam, nitrazepam, oxazepam and temazepam and are used for sedation, chemical control of behaviours and anxiety, usually in the presence of a psychiatric diagnosis.

A range of adverse effects may be experienced by those receiving benzodiazepine and include confusion, impaired memory, drowsiness, unsteady gait, falls and fracture risk, depression, dependency, blurred vision and amnesia. Such side effects seriously impair the self-care capacity of those receiving the medication and increase the need for assistance and very close supervision.

ACN is aware of reports of the increasing use of benzodiazepines in residential care to control “behaviours” in people with dementia symptoms and advocates for increased registered nurse (RN) participation in the care of the elderly in residential settings. The alternative to using these drugs is having RNs assess behavioural patterns and plan care that will maximise options for residents with minimal use of powerful medications.

RNs can then provide support and guidance to other members of the care team. Appropriate staffing levels are required in all care settings and ACN does not support the use of medications as chemical restraints in the place of expert nursing care.

ACN looks forward to the progress on discussions and the development of strategies across the country on this important issue. n

Reference: Department of Health and Ageing (DoHA).

(2004). Decision Making Tool: Responding to issues of restraint in aged care. Retrieved from www.health.gov.au

Adjunct Professor Debra Thoms is chief executive of the Australian College of Nursing.

February 2013 | 23

specialty focus

Keeping

community care affordable Private providers and government must work together to keep costs down in this growing area of nursing.

By Mary Casey

T

here have been many changes in the care and nursing industry in the past 10 years, especially in the community sector. However, there is much more to do to fill the enormous gaps that exist in the system.

There is a silent crisis lurking that the general public do not notice, unless they have someone who requires care; it is only then that people realise how enormous the crisis is.

With an increasing aging population and the concept of keeping the aged community in their homes for as long as possible, doing so does not go without its challenges.

Admissions to nursing homes is not as easy as it used to be because of the criteria that needs to be met before becoming a candidate. There are also long waiting lists, so government incentives to maintain care or assistance to the elderly within the home is much needed. Service provision is often only an hour a day or much less.

Due to society’s changes whereby families used to care for sick or aged relatives, this no longer occurs. As a result, many aged citizens are left to fend for themselves and/or their partner and while they manage to survive, in many cases it is with great difficulty.

Service providers are the ones who see the need for aged care, however, they are restricted by lack of funding to meet those needs. Therefore care is only provided on a “high needs” or “dire straits” basis.

The nursing side of things has also changed dramatically in the past decade whereby care provision was once only attended by registered nurses. While this was satisfactory at the time, it was 24 | February 2013

recognised that basic personal care or assistance with menial tasks did not require the need for university trained nurses.

Carers were therefore introduced into the industry, however, there we no guidelines in place as to what training was required. There were many untrained personnel going into homes without proper knowledge, not just in nursing duties, but also safety education, professional boundaries or knowledge of aged care.

For some time it was a case of anything goes and nursing care and assistance were of poor quality. Thank goodness this situation has been addressed and no longer exists. Tougher guidelines were introduced with the training of assistant nurses and personal carers. This of course increased the quality of care and assisted in the nursing shortage in general but it has not resolved the shortage of care.

I lead a nursing service, Nursing Group, which has been operating for 20 years.

We have seen firsthand the problems associated with this silent crisis and believe that with some proper planning, the government could resolve the problem.

Nursing Group added an educative component to our service and established Casey College to train and upskill nurses to resolve the shortage of quality staff in the community for our own company.

Assistant nurses and personal carers are in good supply so it is not the lack of staff that is causing the crisis. The training of assistant nurses has increased to such a level that nurses now have a career path whereby they can start with the basic course and choose to continue.

In fact, I believe that we will see a

healthcare system receiving a long needed influx of highly trained, competent and confident assistants in nursing that have the knowledge and skill set to jump between community care and our public hospitals.

Once these nurses reach the appropriate level with their training it won’t be long before we see them being classed as vital and prominent figures in healthcare industry.

Due to the increase in the need for community nursing and the nursing shortage in hospitals, this pathway to a career might very well be one of the fastest growing professional occupations we have seen in the industry for many years.

More funding is always the answer to additional care provision, however, I think that good planning by both the government and private sector could see a well thought out, comprehensive and structured care plan that will be cost effective – with a high standard of care provision for our aged care community.

Currently there are many community services that provide packages for aged care. These consist of personal care, transport, dressings, medication, palliative care, etc.

The care can be provided by the community service or outsourced to private agencies. The latter of course incurs a “middle man” fee which is not cost effective.

In my opinion this is the reason why both private and government agencies need to work closer to cut out the additional costs that are incurred by not understanding the broader picture of care provision. Coming up with a solution that will work is what is required.

I believe that community care in all

specialty focus

We will see a healthcare system receiving a long needed influx of highly trained, competent assistants in nursing that have the knowledge and skill set to jump between community care and public hospitals. aspects is slowly improving but as always the success is in the planning and to consider both private and public sectors to be involved is necessary because just one sector cannot do the lot. We need backup and to build relationships so we support one another and work well together.

It is possible for this to occur because many years ago our company worked alongside a local area health service providing a 24-hour palliative care service.

The service worked extremely effectively and efficiently for many years until the funding was cut.

Over those years we (the public community centre and Nursing Group) provided a quality service to those with a terminal illness. The community centre provided the service between 8am and 4.30pm and Nursing Group did the afterhours, weekends and public holidays.

The reason why the service was so successful was because the clients knew that they had access to a nurse at any time. In the beginning, we did numerous call-out visits but the number decreased because we were available via phone and could support and guide the clients or their loved one. We could tell them what they needed to do and they were satisfied to do many things themselves that they would otherwise be afraid to do.

They mostly needed the support more than anything else; it gave them the confidence to do those things that they hadn’t done before. Patients and relatives over time became much more independent and that was because they knew we were there for them. Of course there were times when we did need to visit or there were planned visits for one reason or another, however, overall it was a very cost-effective

inTernaTional FaculTY

Dr Mary Casey (PhD psychology) has more than 30 years’ experience in health and education. She is founder and CEO of the Casey Centre, an integrated health and education service with more than 250 nurses and carers, and 700 graduates a year in three centres across NSW, see www.caseycentre.com.au. Through the centre, Casey also specialises in designing and implementing health and education programs and products. She also has qualifications in nursing and applied science.

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2013

service and became more so.

A similar model for aged care services would work in the same way. Obviously in the beginning all the leg work needs to be done such as patient or carer education, information packages, visits, etc.

Once implemented the service becomes more streamlined and effective in every regard. The upfront costs are also high, however, by looking at the bigger picture in time we have a service that is cost effective and at the same time meets the needs of all those requiring care in the community. n

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February 2013 | 25

clinical practice

Home sweet

Financial pressure on the health system is being eased by a scheme which allows patients to be treated in their own residence.

t

he Hospital in the Home (HITH) program is becoming increasingly popular with patients, and contributed to the NSW government’s allocation of a further 2009 beds last year.

Reports from patients and medical staff have been positive, with the program being as clinically effective as in-hospital treatment.

In Sydney’s Campbelltown region, there are about 30 beds allocated under the program, which is the equivalent of a regular ward full of patients. This frees up much needed space in the standard hospital system.

The director of Ambulatory Care at Campbelltown Hospital, Dr Nicholas Collins, said that patients receive the

26 | February 2013

same treatment as they would in hospital for a variety of acute and subacute conditions.

“The aspiration of most Hospital in the Home services is to provide an equivalent care to that which you would get in hospitals,” he said.

“They will get everything from nurses who will perform standard observations – blood pressure, pulse and the like, who

may have the ability to perform point of care testing for certain things like blood sugar or INR monitoring.”

Pauline Dobson, a clinical nurse consultant in the immunology and infectious diseases unit at John Hunter Hospital, Newcastle, has witnessed the positive impacts of this alternate model of care.

She says that patients experience a

clinical practice variety of benefits from receiving care in an environment that is familiar.

Dobson explained that the nurse may tailor treatment to a once or twice daily visit. Everything is undertaken at this visit – so a daily/continuous antibiotic may be given rather than one that need to be given bolus qid.

“Point of care testing may be utilised to give the HITH nurse an immediate pathology result and some services are using mobile technology as well,” she said.

A systematic review printed in the Medical Journal of Australia last year suggested that the review “demonstrated that HITH reduces delirium, but it may also reduce iatrogenic infections, galls and adverse events”.

Dr Collins said that the majority of patients think the program is a great idea, with about 99 per cent taking up the opportunity of a hospital in the home program when offered.

“They get to sleep in their own bed, eat their own food, watch their own TV, and for some there is an opportunity to engage with the workforce – through mobile technology and internet-based technology,” he said.

There is not only significant patient and carer satisfaction and confidence with such programs, but nurses and medical professionals are quick to provide positive feedback of the privileges of working within someone’s home. “Generally,

once being managed on their own turf and not in a foreign environment of a clinical unit or ward, patients are far more receptive,” Collins said.

“So I think staff get a greater level of satisfaction out of the process.”

There is presently much concern around the country over emergency departments failing to meet national standards and governments are also seeking to reign in health costs.

This program could help ease the financial pressure on hospitals by reducing bed block by allowing patients to be discharged earlier and cutting inpatient bed day costs.

Cost depends on the individual clinical case, so there are some situations where this is clearly more cost effective – such as the management of deep vein thrombosis.

With a suggested $775 million being pulled from the NSW health budget, Collins believes that this is effective alternative model to providing acute care in hospitals.

“What it does is utilise the available technology and clinical experience of usually very experienced nursing staff in particular – medical and allied health staff also,” he said.

“It uses those staff in a very patient-focused multidisciplinary way to deliver care in an alternative setting – so it’s able to identify and risk manage patients.

“It’s not all rocket science, some of it is pretty simple, but is a logistical change moving slightly away from the bigger institution.” n

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February 2013 | 27

clinical practice

Multi-tasking on road to

recovery Michael Robertson discusses the provision of acute care for those with mental health problems and what is lacking for such patients.

N

ursing professionals working in acute care settings frequently provide the only clinical contact such patients receive. Acute care teams in mental health services encounter clinical problems including adjustment reactions, episodes or deteriorations in established severe mental illnesses, and problems arising from the abuse of illicit drugs and alcohol.

The challenges faced by those clinicians include the assessment and initial engagement of the patient or “client”, formulation of the risks posed by these problems, provision of psychological interventions and the co-ordination of medical care.

A typical day for a nurse clinician working on an acute care mental health service may involve: • assessments of “walk-in presentations”, referrals from other health services, government agencies or police • provision of education, counselling, clinical review and psychological therapies to patients • home visits, medication supervision and clinical review of patients in their homes • transporting patients to medical appointments, liaising with psychiatrists or GPs and the implementation and supervision of medications • participation in care planning or multidisciplinary meetings with other mental health clinicians • counselling and supporting carers and families.

Nursing clinicians are part of the patient journey for a patient with an acute mental health problem at every point.

28 | February 2013

Like many people with mental health difficulties, the primary challenges faced by people in acute distress arise from the lack of resources needed to provide adequate services.

Consider the example of a young man with an adjustment disorder who has expressed suicidal ideas to his GP. The GP contacts the acute care service and the patient is assessed by a nurse clinician including details of symptoms, life stressors, personal background, current lifestyle choices and previous history.

The nurse clinician then formulates an initial management plan focused on risk, and the patient’s clinical team is tasked with this care. Nurse clinicians will then engage the patient in a care program, regularly assessing the patient’s progress and modifying the management plan in response to this.

The patient may require advocacy to different government agencies, clinical services or interventions aimed at resolving the crisis that brought the patient to the point of distress. Once the crisis resolves, the nurse clinicians participate in discharge planning, referral to further medical care and provision of follow-up. The process of appropriate continuity of care requires close attention to clinical handover and the provision of a comprehensive account of the patient’s care.

Like many people with mental health difficulties, the primary challenges faced by people in acute distress arise from the lack of resources needed to provide adequate

services. Mental health services have been consistently under-resourced and politically attractive funding programs are usually “one-off” and tended to flow towards the well-advocated needs of the youth mental health sector.

The kind of mental health services needed to contain patients with severe disturbances are state-funded, meaning that any funds directed towards them tend to disappear into the quagmire of state treasuries.

Nurses working in acute care mental health settings face increasing burdens of administrative duties, and work in institutions with low-tolerance of risk. They are tasked with multiple responsibilities in the face of an ever-diminishing pot of resources. Despite this, their professionalism, dedication and the high standards of care they provide to those in distress is an inspiration to work beside. n Michael Robertson is a clinical associate professor of psychiatric ethics at the Centre for Values, Ethics and the Law in Medicine at the University of Sydney. He has worked in community mental health for well over a decade and works as a psychiatrist in the Marrickville Community Mental Health Service.

clinical practice

Healthy blokes

talk about it

Getting men to discuss health issues, especially with their mates, could help reduce the gap between male and female life expectancy.

By Amie Larter

C

ompared with their counterparts around the world, Australian men fair well and generally can expect better health and longer life expectancy than males in most other countries. However, on average Australian men have a shorter life expectancy than the women, leaving many questioning why this is so?

Mens’ lifestyle choices could be contributing factors seen in the results of recent research that suggests they are 84 per cent more likely to die from gendercommon cancers than women.

According to research from Cancer Council NSW in 2011- 2012, by combining less healthy lifestyles that include smoking, obesity and excessive alcohol consumption with ignoring warning signs of a health problem – men are more likely to develop these serious conditions.

Professor David Smith, research fellow in the Cancer Research Division says there are a number of reasons for this.

“Firstly, men are more likely to develop the cancers that are deadly – they have higher rates of lung cancer, bowel cancer and cancers of the head and neck,” he said.

“In 2011–2012, more men were overweight or obese than women (70.3 per cent compared with 56.2 per cent), men were more likely to smoke daily than women (18.2 per cent compared with 14.4 per cent) and men were also three times more likely to exceed the alcohol guidelines than women (29.1 per cent compared with 10.1 per cent).”

www.nursingreview.com.au

Men are more likely to develop the cancers that are deadly – they have higher rates of lung cancer, bowel cancer and cancers of the head and neck.

Risky lifestyles This leads Smith to the second element skewing the health outcomes of Australian males – lifestyle choices.

“Men are putting their lives in danger by drinking more alcohol, smoking more tobacco and having higher overweight and obesity rates than women.”

Smith said health professionals should be vigilant by checking male patients’ health, ensure they are adhering to screening guidelines, talk to them about their general diet, lifestyle habits and wellbeing. Encouraging them to actively look after their health and to come forward with symptoms rather than ignoring them.

The Cancer Council NSW has launched the Sh*t Mates Don’t Say campaign to get blokes talking and acting on their health.

The campaign is the first in a number of Cancer Council initiatives solely aimed at men, in particular those in the 30-50 age bracket.

“This is the age where lifestyle habits and behaviours can have the greatest impact on later risks for deadly cancers,”

Smith said. “Men are encouraged at any age to look after their health, but we are encouraging men to start good habits early in the hope they stick with them throughout their lives.”

Engagement The professor of primary healthcare and director of the Men’s Health Information & Resource Centre at the University of Western Sydney, John McDonald, believes that a lack of communication and engaging with males could be part of the problem.

“Why is it that the health services – doctors, clinical health and nurses – have not been as involved in engaging men as they have been in engaging women?” he asked.

“Some of these answers are easy to get because of child-bearing, but that doesn’t justify the neglect I perceive in the services reaching out to men.”

While he does admit that overall men do attend fewer services, he believes that a lack of communication in general should be to blame, rather than “only blaming men for not taking care of their health”.

In order for medical professionals to be able to connect with males on a more effective basis, MacDonald says our medical services need to become more male friendly.

“We want men to men – we want part of men’s agenda to be able to talk to their mates, talk to doctors and nurses – given the occasion. It also requires genders sensitivity. We need to think February 2013 | 29

clinical practice

about men and how nurses, doctors and other professionals can be more gender sensitive.”

MacDonald’s thoughts are backed up by the National Male Health Policy, created in 2010 as a framework for improving male health across Australia – with a focus on taking action on multiple fronts.

It listed six main priority areas to focus on which included a greater focus on health equity between population groups of males, improved health for males at different life stages and improved access to healthcare for males.

Accessibility and personal ownership Stephen Lillie, men’s health co-ordinator at Hawkesbury District Health Service believes that in addition to better engagement with men, which should include a focus on making services more accessible, that men need to be encouraged to take personal ownership over their health.

“In some sense, the best way of saying it is: ‘why would you take your car for a service every six to 12 months but forget your body?’.

“Men do need to take their own health more seriously – it’s the biggest vehicle they have got, it’s going to last them a lifetime so they need to look after it.”

Education Dr Devesh Oberoi, doctoral research fellow at Curtin Health Innovation Research Institute (CHIRI), believes greater education is necessary to encourage men to take better care of their health.

“There is a need for mass education programs to emphasise the requirement for being more careful about health, not neglecting or ignoring symptoms and to curb delay in seeing a GP for their symptoms even if they are non-specific,” he said.

“Mass screening programs for various cancers and limited use of cigarettes and alcohol should be promoted and implemented in the society. There is also a need to check if medical and nursing staff are adequately prepared to address the health needs of men.”

Oberoi is currently conducting research into the help-seeking behavior of men in regard to the lower bowel symptoms such as rectal bleeding, persistent change in bowel habit and abdominal pain.

In Western countries, these symptoms are common – with 15-20 per cent of people experiencing these problems.

However, the problem lies in how many people are actually addressing the problem with medical attention.

“The rate of seeking medical advice for lower bowel symptoms is quite low with 6080 per cent of people with these symptoms not seeking medical advice,” Oberoi said.

“Thus, my research focuses on the factors that may influence men’s decision to seek help.” n

Over-eating, smoking and drinking

According to Cancer Council NSW and the Australian Bureau of Statistics: • Compared with women, Australian men are 84 per cent more likely to die of cancers that are common to both.

(Source ABS:3303.0_1 – Causes of Deaths)

• In 2007–08, men were less likely to

report that they have GP check-ups at least annually than were women (49% compared with 62%). (ABS: 4102.0 Australian Social Trends, Jun 2010)

• Overweight and obesity: in 2011-12,

more men were overweight or obese than women (70.3% compared with 56.2%). (ABS: 4364.0.55.001 - Australian Health Survey: First Results, 2011-12)

• Smoking: Men were more likely to

smoke daily than women in 2011-12 (18.2% compared with 14.4%) • Alcohol consumption: Overall, men were almost three times more likely to exceed the guidelines than women (29.1% compared with 10.1%, respectively)

• Fruit and vegetable intake: taking

both guidelines into account, only 5.6% of Australian adults had an adequate usual daily intake of fruit and vegetables. Women were more likely to meet both guidelines than men (6.6% and 4.5% respectively).

30 | February 2013

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February 2013 | 31

workforce

Remember,

look after

yourself

Looking after the sick can be demanding so nurses need to keep fit and healthy and plan for holidays.

Crafting a plan on how you anticipate and envision the year ahead is the first step.

However, it’s important to be realistic, Murray said.

“Take baby steps – too grand an ambition could cause early disappointment when things don’t go as we hoped,” she said. Plans and goals need to be attainable and should focus on both personal and professional development.

Stay motivated and focused

Nurses are constantly exposed to sickness, which is always stressful for the patient and their families, as well as the carers. Murray suggests that it is important to be able to step back and remain strong, in order to successfully help others.

“It is best to be empathetic, however, not involved or we can become emotional wrecks.”

Another significant contributor of workplace stress can be other staff. Office politics are rife throughout all industries – and nursing is no exception.

Making a conscious decision 32 | February 2013

of

el he

Make a plan

Furthering knowledge and skills is an excellent tool for boosting confidence as well as opening up career opportunities and pathways. A key element of the job, professional development courses and training will help nurses stay abreast of new standards, methods and competencies.

Murray said to remember that some of the worst things that happen can turn out to be blessings in disguise – though at the time it never seems that way.

“Often it presents as a ‘crossroads’ and it is why you make the decision you do that will determine the next path you choose.”

lif e

T

he normal cycle of events means we return to work after a break feeling refreshed and ready to tackle a new year of work. However, planning how to maintain that feeling and survive the rest of the working year can be more challenging.

Patricia Murray, author, positive life coach and nursing veteran of more than 50 years, gave Nursing Review her tips on how to ensure the year ahead is a good one – on a personal and professional level.

W

If you look at the Wheel of Life the sections are for career, personal growth, friends, money, significant other, fitness, family, fun and recreation, health and physical environment. before you start the year to be professional, and not enter into discussing other staff will bode well for your sanity as well as reputation. When people know that you don’t gossip, you build up respect and will not involve you.

Murray explains that the working environment itself poses its own challenges, “Accident and emergency work has its own problems with inebriated and sometimes violent patients, there should be protocols in place to protect you, report it if not. Join the nurses association, they are there for you.”

workforce Realistically, there will be a couple of bad days, but Murray suggests it is how you cope with problems when they arise. “Of course there will be some disappointments, but if we have strategies to turn problems into stepping stones we will grow through the process,” she said. “The Zen saying is that the road that appears to be the hardest is often the best road to take.”

Work/life balance

If you look at the Wheel of Life the sections are for career, personal growth, friends, money, significant other, fitness, family, fun and recreation, health and physical environment. All segments need to be fulfilled for a well-balanced life.

Creating an effective work/life balance is essential to make it through the working year.

“When you are on duty, be on duty – not discussing the great night out you had with patients having to listen in,” Murray explains. “It is inconsiderate and unprofessional but I have seen it happen so often.”

Just as important, is not letting work occupy you when you are off duty. Time off is precious and relaxation is a must. If you get the opportunity for a change of

scenery, even if it is just for a weekend, this can be a fantastic way to break up routine.

“Hobbies, cultural pursuits, dancing and most important friends and family all help keep us sane and revitalised off duty,” Murray said. “It is not called REcreation for nothing!”

Healthy living

Maintaining a healthy diet might sound cliched, but choosing the right foods not only reduces the risk of serious illness but also improves mental and emotional health. Regularly adding fruit, salads and vegetables to your diet will keep you on the right track.

Staying fit will also increase your physical and mental health – we live in a great country where outdoor exercise can be enjoyed nearly all year round.

“Make your own health a top priority, good dietary choices and lots of healthy outdoor exercise is important to maintain wellness so you can care for others,” Murray said.

“Plan the years’ holidays and breaks as well as the work; get sufficient sleep especially if doing shift work. Our circadian rhythms are really upset with night duty or travelling overseas.” n

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1

February 2013 15/01/13 2:18| 33 PM

workforce

Aged care

divide

Some nurses consider working with the elderly is not ‘real’ nursing but nothing could be further from the truth, writes Peter Kieseker

T

he implicit – and often explicit - message received during my study was: “Aged care – it’s not real nursing.” This care was apparently for those who themselves were only one step from moving from nurse to resident.

It wasn’t real nursing; just baby-sitting with copious hygiene regimes. Real nursing was gung-ho procedures and fast critical thinking.

Well that might be so on television, but in the real world it seems to this writer that aged care comes closer to real nursing than one finds on the average ward in an urban hospital.

Jazwiec says it really well. Paraphrased she writes: “Healthcare, and especially nursing, was created to make people feel better. Even in its most basic, original form, it made people less anxious and more comfortable. It made a difference.

“Many say: ‘No, healthcare was started to heal and cure’. But this is wrong.

“When healthcare first began, we didn’t know how to heal and cure. All those first caretakers could do is make people more comfortable, help them feel better, and do a lot of praying that they hoped would make a difference.” (Liz Jazwiec, Eat that Cookie, 2009).

In aged care often all that can be done is to give care and comfort, but this is the original and hopefully still the essence of nursing. When compared to ward nursing it is, arguably, aged care that is real nursing.

Consider the facts. Ward nursing in many instances resembles a conveyer belt of endless medications, observations, hygiene and ordered procedures. There is usually simply not enough time amidst all the tasks, and especially amidst all the paperwork, to truly see the individuality of each patient.

There is little time for the healing touches of meaningful conversation, reminiscence therapy, or even the moisturising of dry skin; and time to share

Healthcare, and especially nursing, was created to make people feel better. Even in its most basic, original form, it made people less anxious and more comfortable. It made a difference.

34 | February 2013

a cup of tea with a patient is a fantasy. There is little time for the basic human connection that was once the soul of nursing.

Yet in age care the opportunity for such gentleness is often not only possible but it in fact forms a therapeutic cornerstone of the person-centred care that aged care nurses strive to deliver.

Oh yes, says the haughty ward nurse, but there is little scope for critical thinking in aged care. Again, the facts. Ward nurses may do all the critical thinking they like, but the only autonomy they really have is to consult the doctor.

Most ward nurses, even with years of experience, can not initiate as much as a paracetamol table without written permission.

In contrast, it is the aged care nurse who most often makes the routine, and the critical decisions, in a nursing home. Nurse initiated medication and procedures are second nature to the aged care nurse. For these nurses there is no safety net of a ward doctor to call upon when in doubt.

It is the aged care nurse who most needs critical thinking to assess deterioration in a patient and to make and enact intervention decisions; decisions usually made alone or with only fellow nurses to consult with.

This is only an opinion but perhaps it is time that many in the profession ceased their condescending and often degrading comments of aged care nursing because it is in fact, very much real nursing. n Peter Kieseker is in the second half of a graduate transition year (mature age graduate). He is currently working on a medical ward at Caloundra Hospital and before that worked at an aged care/aged psychiatric facility.

workforce

Removing the

mystique of death

Internationally recognised palliative care nurse Molly Carlile spoke to Amie Larter about her career, recent awards and thoughts on the future of nursing.

When did you realise you wanted to have a career in nursing?

I fell into nursing through circumstance and if I’m honest, struggled for the first couple of years. The change for me came when I looked after my first dying patient.

It was then I knew I’d found my purpose and from that point on, I specialised in palliative care and my subsequent studies and experience were guided by what I needed to learn to help people die in a way that was right for them.

I knew I needed to be able to support grieving patients and families so I studied counselling, then grief and loss, as well as education to be able to teach young nurses how to care for dying patients.

I then went on to study management and leadership, so I could make sure that structures were in place to support personcentred care for dying patients and families.

Finally, I became drawn to health promotion by the need to inform and educate communities so that death would no longer be a taboo subject and that people would feel confident to support grieving friends, families and neighbours.

Is this how you acquired the title ‘Deathtalker’ and what does it involve?

I call myself the Deathtalker because that’s what I do. I encourage people to talk about death in order to become better informed and empowered to have meaningful conversations in their families and in the wider community. What does dying look like? What happens? What can I say to a dying or grieving person? How can I help?

These are all questions that the public struggle with, because no one has conversations about stuff that matters. I try to raise awareness by speaking at public events, in the media and at conferences, etc, and have written books and plays as a way of getting people to think about these issues. www.nursingreview.com.au

What does your current Monday to Friday job role entail?

I manage palliative care services at Austin Health in Melbourne. We have a 20-bed unit and an acute consultancy team that provides services to our acute tertiary hospital. My role is a strategic and operational one. I’m responsible for ensuring that patients and families get the best possible care, that staff are supported in providing that care and that our services constantly evolve based on the needs of people in our community.

I’m also responsible for planning the transition of our services into the new Olivia Newton-John Cancer and Wellness Centre, which will open for inpatient services in July, so there’s lots going on at the moment. My other role is as manager of arts in healthcare at the cancer and wellness centre, which involves planning an integrated arts program for the centre that will humanise the facility and provide arts based programs that engage patients and families and create a “safe space” for them.

person to express their fears and concerns, a nurse can change a dying person’s whole experience and facilitate a “good death” as defined by that person. So I try to get nurses to explore their own feelings about death, their own “hang-ups” and reflect on how their personal views can influence the care they provide to dying patients.

What prompted your passion for generating awareness of death and grief issues for nurses?

Nurses are no different from the general public, we are a people first, nursing is just what we do, so lots of nurses have the same “hang-ups” as everybody else.

Most nurses choose their career because they want to make people better, they want to make a difference and when they are caring for a person for whom cure is an unrealistic expectation, they feel like they’ve failed and they take it personally.

This can really eat away at them. They too, don’t know what to say, don’t know what to do - they feel like they can’t make a difference. But you know what? They can. They can make a huge difference, by connecting with the person, listening, supporting, nurturing and allowing the

You received an international, national and state award last year.

What were the awards and what were they recognising?

What advice do you have for nurses that are regularly faced with death?

Understand yourself first. What are your fears and apprehensions you have about your eventual death? What does a “good death” look like to you? What are the elements of caring for dying people that stress you? Once you are more self-aware, you are better able to establish self-care practices that ensure your resilience and once you are more resilient you are better equipped to provide truly individualised care for patients that is not influenced by your own judgments, beliefs and values.

Self-awareness, self-knowledge and selfcare … that’s the trifecta!

I received the International Journal of Palliative Nursing Educator of the Year Award in London, in March, for my work in educating nurses about death, grief and palliative care. The Deakin University and HealthSuper Leadership in Nursing and Midwifery Award was for outstanding leadership and commitment to the profession, for my work promoting and educating nurses. And the Minister’s Award for outstanding achievement by an individual or team in healthcare, at the 2012 Victorian Public Healthcare Awards was for work in palliative care in the public health environment and for my health promotion work in the community. n February 2013 | 35

legal corner

Anorexics force legal decision The courts can face a real dilemma, legally and ethically, when it comes to patients with a lifethreatening eating disorder.

By Scott Trueman

36 | February 2013

A

highly cherished ethical principle that courts jealously guard is that of autonomy; the patient’s right to exercise selfdetermining choice.

Accordingly, it is for the patient to decide what treatment or procedure they consent to.

The principle does come under challenge in circumstances where a patient is not competent (lacks capacity) to make such decisions.

The difficulty is that a person’s level of “competency” is not always easy to determine.

Perceived unreasonableness of a patient’s decision is not enough, it must be that the patient lacks the ability to undertake rational decision making.

The eating disorder anorexia nervosa can pose many dilemmas in this area; at what stage is it an illness which triggers provisions under a Mental Health Act (thereby overriding issues of consent on the basis of treatment being in the patient’s “best interests”).

At what stage of malnutrition does the patient physically become cognitively incompetent, if the patient gives an Advanced Directive when competent can this be overridden or should a patient be allowed to die by not eating if that is their choice?

A 2012 case is enlightening in response to these questions. It related to a UK woman, referred to as patient E, who as a former medical student was suffering from several chronic health conditions, including alcoholism, anorexia nervosa and unstable personality disorder.

Her anorexia was thought to stem from sexual abuse she suffered, unbeknown to her family, earlier in her life. She had a long history of admissions to hospitals for physical and mental conditions.

In mid-2012, she signed advance consent forms stipulating that she did not want any medical intervention to prolong her life. At the time of the court hearing later in 2012 patient E had not eaten solid foods for more than a year, had a BMI of 11 to 12 and she was in poor physical condition. Patient E described her life as “pure torment”. According to a psychiatrist and eating disorder specialist her chances of recovery in any event was between 10 and 20 per cent.

There existed a number of unique circumstances that made decisions very challenging for the court. Patient E appeared to be fully aware of her circumstances in that, whilst she did not desire to die (i.e. no suicide ideation) she did not desire to eat, she was aware of the certainty of death from such a decision and the actions of being “force fed” would deprive her of a relatively peaceful death.

Further complicating the matter was the existence of two previously drawn up Advance Directives, written whilst not subject to any Mental Health legislation, making her intentions and wishes abundantly clear.

A question which the court (retrospectively) had to determine was whether patient E had capacity at

the time of making the Advanced Directives; could she understand all relevant information, retain it, use or weigh it to make a rational decision.

Such an assessment necessarily employs inexact science and a degree of subjectivity. Patient E was found to lack capacity to make a rational judgment at the time of the Advanced Directives and hence, her wishes (and autonomy) would be overridden. On the balance of probabilities, the court thought that force feeding would do more good than harm, whilst acknowledging it would deprive her of a relatively peaceful death.

The other concept is that of “best interests” often at the heart of thorny decisions involving medical ethics. Would patient E’s best interests be served by letting her die or by forcing her to live? How does a court define what are those best interests in the face of someone wishing to die?

The court believed that, although force feeding patient E would be intrusive and difficult, this course of action had a chance of saving her life. The court stated it would not have ordered so if it felt that force feeding would be futile.

The judgment makes it clear that preservation of life must be accorded a very high value and in this case justified intervention. Yet in the balancing act of respecting the right to autonomy, against overriding the same the court acknowledged there were no prescriptive set of guidelines or rules which it could follow. In the final analysis the court stated it had to rely on “intuition” that it was making the right decision.

It may be that a civil libertarian does not believe in patient E’s wishes being overridden due to the violence, duration, and trauma of forced feeding (with evidence equating this to being re-traumatisation of the child sexual abuse experiences) in circumstances of a grim prognosis, and that patient E’s clearly articulated wishes (even without legal capacity) outweigh the preservation of life. In such a weighing process there is no easy and certainly no definitive “right” answer provided by either law or ethics.

As a footnote, contrast patient E’s case with that of patient L who was 29 and during her last 15 years of life spent 90 per cent as an in-patient. At the time of the court hearing she weighed just 20kg and her BMI was 7.7. Like E, patient L did not express a desire to die, but stated that her severe anorexia “did not allow her to eat” – a “morbid fear” of ingesting any calories might lead to an increase in weight. In patient L ’s case the court concluded that although nutrition and hydration should be offered, staff were not permitted to use force to administer food, water or medicine. Her autonomy was preserved; she died just as she wished. n Scott Trueman is a lecturer in the school of nursing, midwifery and nutrition at James Cook University.

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The Cancer Nurses Society of Australia’s 16th Winter Congress heads to the Brisbane Convention and Exhibition Centre from the 25 – 27 July 2013. This Congress is the premier annual event for all nurses involved in the care of the patient with cancer.

Under the theme of ‘Connecting Cancer Care’ the Congress will bring together highly regarded, internationally renowned experts in their field who will share their knowledge and experiences.

This year’s Congress will feature a keynote speech from Professor Brenda Nevidjon, who is Professor and Faculty Coordinator of the Health Care Systems Instructional Area in the MSN Program, Duke University School of Nursing, North Carolina, USA. She is also President-Elect of the International Society of Nurses in Cancer Care and a past President of the Oncology Nurses Society.

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A stellar international faculty from Europe, Asia and North America will join us - Horst Neuhaus, John Anderson, James Lau, Ping Hong Zhou and Paul Kortan. The Symposium will cover all new directions and themes in endoscopy, including enhanced imaging, real time histology, endoscopic resection and haemostasis. The popular mini – symposium will focus on colonoscopy and polypectomy.

NURSES WORKSHOP - 6 March, 2013 A dedicated Nurses Workshop is available prior to the commencement of the Symposium. Nurses are welcomed and encouraged to attend. This as a great opportunity for industry interaction, networking, and learning new developments in Gastrointestinal Endoscopy Nursing.

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Sydney International Endoscopy Symposium Through live demonstrations and ‘State of the Art’ lectures, the Sydney International Endoscopy Symposium will take you abreast of all the latest developments in gastrointestinal endoscopy and their implications for future practice. The latest technology in microwave transmission will ensure that one of the true hallmarks of the meeting, live high quality transmission from the Westmead Endoscopy Suite will be a feature. The program will be relevant and informative to all those involved in Endoscopy, be that primarily diagnostic, complex interventional or surgical.

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The 2013 ACIPC Conference will embrace the accomplishments of the preceding 12 months in establishing the Australasian College for Infection Prevention and Control.

It will showcase science to practice advances, the latest innovations from industry, and provide invaluable networking opportunities. Ground-breaking approaches to surveillance, infection prevention management, standards compliance and demonstrated improvement in patient/client outcomes will be a vital part of this conference.

Infection prevention is everyone’s business and whether you are a novice or expert in infection prevention and control, infectious diseases, microbiology or quality improvement and risk management this conference will offer unrivalled prospects for sharing of skills and experience, and discussing your current practical needs.

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February 2013 | 37

1/25/2013 12:01:55 PM

technology

Treating invisible

battle wounds

Community nurses will be assisted by an online course to help them understand the health issues of war veterans.

A

new online course launched by the federal government will give nurses greater understanding of the common mental health issues faced by Australia’s 325,000 war veterans, widows and widowers.

The issue of mental health disorders amongst Australian Defence Force personnel, both serving and retired, has gained prominence in recent years, with health officials expressing concern at the extent of illnesses.

The vetAWARE course was developed to raise further awareness and provide up-to-date information to nurses supporting these patients.

Minister for Veterans’ Affairs Warren Snowdon announced the course in January, a commitment from the government to provide appropriate, accessible and evidence-

based mental health care for veterans.

“Working with the medical community to increase their awareness and understanding of veterans’ mental health conditions is an important part of this work,” he said.

“The vetAWARE course increases nurses’ understanding of the common mental health challenges faced by veterans, and how best support them and their families.”

Dr Stephanie Hodson, mental health adviser for the Department of Veterans’ Affairs, is a ADF veteran herself – awarded the Conspicuous Service Cross for service in the Middle East area of operations and East Timor.

She described the course as an interactive tool that focused on using a range of different techniques to appeal to different types of learners.

“The course has a number of different media platforms in the online training to make it engaging. It has short videos, short presentations from military experts, engaging hypothetical scenarios and includes puzzles to solve and regular quizzes to test knowledge.”

Those that undertake the 90-minute course can expect to gain a better understanding of a range of mental health issues faced by veterans including how to identify them, what’s the best ways to initially deal with them – and what are the specific issues you should be looking at for veterans in particular.

“Community nurses in particular have regular contact with and are major parts of the lives of some of our very vulnerable clients,” Hodson said. “They are likely to be some of the first people who are likely to see problems developing.”

Mental health problems common to those who have served in the military include post-traumatic stress disorder, depression and alcohol-related disorders.

“Across a service or military career, veterans will have been through a number of potentially traumatic events or stressful deployments,” Hodson said. “This is training specifically for nurses dealing with veterans who may have more complex trauma problems.”

The vetAWARE course is endorsed by the RCNA and offers 10 Continuing Nursing Education points and Continuing Professional Development points.

At present it is only available to DVA contracted community nurses, however, due to positive feedback the department is now working to make it generally available to nurses. n For more information, visit the DVA website www.dva.gov.au

Key components of the training • Understanding the veteran experience • Overcoming the stigma related to mental health issues • Understanding the role of community nurses • Identifying factors that can affect or co-exist with mental disorders • Recognising and responding to mental health disorders • Building skills to establish trust, communicate effectively and work with resistance • Setting boundaries and applying self-care strategies • Understanding referral pathways and available resources

38 | February 2013

www.nursingreview.com.au

February 2013 | 39

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