Nurses where you need them eBook 2015

Community Nurses where & Primary you need them Health Care Nursing Week 21–27 September 2015

eBook www.acn.edu.au/primaryhealthcarenursingweek2015 #nurseswhereyouneedthem

Advancing nurse leadership

www.acn.edu.au

Get involved We encourage all community and primary health care nurses to contribute to the Nurses where you need them 2015 eBook and profile their role and how it impacts the health and welfare of individuals and communities. The book will remain open to receiving entries until the commencement of Community and Primary Health Care Week on 21 September 2015 when the book will officially be released.

Community and primary health care nurses, health services and members of the public will be holding a range of events during Community and Primary Health Care Nursing Week (September 21-27) such as lectures, networking events, social gatherings, and readings from the eBook.

Click here to submit your story for the 2016 eBook

Foreword The Australian College of Nursing (ACN) is pleased to present a special collection of stories in our eBook Community and Primary Health Care: Nurses where you need them. Written by community and primary health care nurses from across the country, these stories highlight the important contribution of nurses in our communities.

These registered nurses, enrolled nurses and nurse practitioners are leading and providing care in a broad range of community settings, from community health centres and outreach clinics to homes, schools and prisons. Community and primary health care nurses play a vital role in ensuring that health services are accessible to all, especially in rural and remote communities. As the government focuses its attention on reform of the primary health care system, it is critical that community and primary health care nursing services and their impact on the health status of individuals and communities are highlighted.

This collection will focus on the vast geographical distribution of nurses across Australia and the many varied roles they undertake.

We hope you enjoy these inspiring reads.

Kathleen McLaughlin FACN, ACN Acting Chief Executive Officer

Kate Partington MACN, ACN Community and Primary Health Care COI Key Contact

Supporters With thanks to our supporters Key supporters

Other supporters

Are you a community and primary health care nurse?

ACN wants to tell your story Click here to submit your story for the 2016 eBook

Mapping community and primary health care nurses across Australia We are mapping out locations of where community and primary health care nurses who are involved in our campaign can be found. To get your town or city on the map submit your story or register your event with ACN. Click here to submit your story for the 2016 eBook

Cairns, QLD

Alice Springs, NT

Eight Mile Plains, QLD Brisbane, QLD

Wacol, QLD

Orange, NSW

St Leonards, NSW

Liverpool, NSW

Bexley, NSW

Canberra Melbourne, VIC

Where can you find community and primary health care nurses?

• Community health centres

• Aged care facilities

• In home care

• Outreach services

• Schools

• Rehabilitation

• Prisons and correctional centres

• Drug and alcohol services

• Maternal and child health centres

• Research and education facilities

• General practice

Pregnancy and mental illness – clinical research nursing Heather Gilbert MACN Senior Clinical Research Nurse Monash Alfred Psychiatry Research Centre Melbourne, VIC Working in the community as a Clinical Research Nurse has many advantages, not the least of which is the humbling opportunity to make a positive difference in the lives of others. I work with pregnant women and new mothers who have mental illness, supporting and nurturing them during the perinatal phase and into the first year of their infant’s life.

In this role, I co-ordinate The National Register of Antipsychotic Medication in Pregnancy (NRAMP), an observational research study which tracks the progress of women, from around Australia, who take antipsychotic medication during pregnancy. This unique role incorporates the physical and mental health aspects encountered during pregnancy and early motherhood, while also integrating a support and advocacy model to encourage robust maternal and infant outcomes.

Women in this highly vulnerable population group are immediately marginalised by mental illness and the associated stigma which accompanies it, not only from the general public but also from clinicians.

Such stigma can exert enormous pressure on pregnant women and new mothers.

Generally speaking, society expects women to just ‘get on with it’, no matter what their situation, however this is not always their reality. Pregnancy, motherhood and mental illness create a triangle of high risk, requiring careful screening, management, monitoring and intervention for all women, in a timely and sensitive manner. The opportunities to support such women are multi-faceted, incorporating collaboration between clinical and allied health disciplines, with an integrated, holistic approach for individual care.

My role focusses on mother and infant-centred outcomes, taking into account maternal values, expectations, choices and needs, whilst also providing support through clinical knowledge, expertise and evidence-based models of care. This is where NRAMP comes into its own. Regular face to face or telephone contact is maintained with women during pregnancy, birth and the postpartum period, including up to the first 12 months of life. This timeframe allows for the collection, collation and analysis of maternal and infant data, looking specifically at

demographic, medical, psychiatric, medication and obstetric history for the mother, while infant information includes in-utero development, birth details and developmental milestones. Such comprehensive data collection will lead to the future development of essential best-practice perinatal antipsychotic medication guidelines with which to support and educate women and their clinicians alike.

A further advantage of contact with women involved in this study is the development of ongoing support mechanisms which are put into place from day one.

This important facet of my role has developed over time as a result of regular contact with pregnant women and new mothers, who often seek advice on medication-based matters. Women also choose to stay in touch once their involvement with the study has concluded, to access updated information and to continue sharing their own news. These relationships are largely built on trust and compassion, while the anonymity of phone calls, in particular, adds an extra layer of confidentiality and empowerment. I feel very privileged to work closely with these women and their families.

Answering your call for ‘stories from the field’ M Ruth Sheahan Clinical Nurse Specialist Refugee Health NSW Refugee Health Service Liverpool, NSW Answering your call for ‘stories from the field’, I would like to share my primary health story with you.

It is a tale of passion and compassion.

I feel very lucky to have been selected to work within the NSW Refugee Health Service as a member of the NSW Refugee Health Nurse Program (RHNP) which commenced service in October 2012. This recent and innovative NSW Health initiative aims to address the health needs of this marginalised population group whom arrive in our country often in poor health, with meagre health literacy and more often than not no English language skills to speak of.

The RHNP focuses upon newly arrived refugees holding a valid Australian Humanitarian Entry Visa. It aims to settle them into our complex health system by linking them with a local General Practitioner and other area health services such as Dietetics, Oral Health, Early Childhood and Woman’s Health Clinics as required. We do our best to link those that

need psychological healing into trauma counselling (STARTTS) as soon as possible. The RHNP also offers in-house services such as immunisation, treatment of vitamin D deficiency and QUIT smoking programs. Those whom arrive with more urgent and complex health issues are managed as a priority.

My position requires that I operate in an often autonomous role, drawing on a broad spectrum of nursing knowledge and experience. The ability to advocate on behalf of my clients is especially pertinent as a great deal of my time is spent assisting them gain access to services such as disability and aged support, access to specialist outpatient clinics and sourcing professionals and services that will provide Pro-Bono or Bulk-Billing services.

I am based at the Refugee Health Service Head Office in Liverpool. The Liverpool district hosts a large proportion of Arabic speaking refugees whom have arrived fleeing conflict and persecution in Iraq and more recently Syria. I find it very important to be culturally informed in regard to my client’s respective customs, beliefs and sensitive toward the situations they have fled. Iraq was once a very cultural and diverse country with peoples from many faiths and ethnicities living in relative harmony. During the recent civil upheaval this ethnically cohesive society has been torn to shreds, Muslim sects turned against each other, ethnic minorities such as the Mandaean peoples have been particularly victimised, prominent Christian communities such as the Assyrian and Chaldean peoples have also suffered persecution.

People of secular and liberal Muslim views came under threat of attack as did anyone who ran a profitable businesses. Many have suffered torture, kidnap and witnessed unspeakable atrocities.

None the less the strength and resilience of our refugee individuals and families never ceases to amaze me and it is such a great privilege to welcome and care for these folk on behalf of NSW Health and the greater Australian public. Our service aims to strengthen the community as a whole by providing the most optimal health pathways possible to assist these new members of our society make Australia home.

Introduction of a palliative care nurse practitioner into Blue Care Metro North Brisbane Karen Gower Blue Care Nurse Practitioner Metro North Brisbane, QLD As Blue Care Community has continued to provide palliative care nursing support for clients across Queensland and Northern New South Wales, the opportunity to introduce the Nurse Practitioner role was the next piece of the puzzle to ensure clients and residents had choice of where they would like to be cared for.

Providing palliative care for these clients and residents, in community or a residential aged care facility as they and their family journeyed with a life limiting illness was a privilege and a challenge in the current health care environment.

As the first employed nurse practitioner (NP) for Blue Care Metro North Brisbane area, my project was to see if having access to an NP in the community would provide this group of clients with an opportunity to remain in their own home for end of life care. The NP role has an extended scope of practice with the ability to provide assessment, investigation, diagnose and prescribe treatment for referred clients. These clients may not be able to visit their General practitioner (GP) or outpatient clinic and not be fortunate to have a medical practitioner who will home visit. The role of the NP is to provide that layer of support for the client and their family in collaboration with the GP or medical specialist to provide timely and appropriate support.

This support for the community nurses who provide the day to day care of these clients and residents is also a vital role; the NP is a mentor and provides ongoing education to enable these nurses to continue this service to the community.

The last two years has been challenging but rewarding in providing this service to the community. The pilot program has completed and the results were positive for the introduction of the NP into the palliative care service in Metro North. This service was seen as a vital component of Blue Care’s community involvement in caring for this group of clients and enabling them to remain in the place of their choice for end of life care. The families were very grateful for the increased support to feel they could care for their relative at a very difficult time.

Behind the razor wire: nursing in the Prison Health Service Ashleigh Djachenko Prison Health Services – West Moreton Wacol, QLD When people think about community nursing and primary health care, a variety of settings come to mind: schools, community health centres, child health clinics and home-based nursing, to name a few.

However, there is a unique cohort of nurses who rarely enjoy the limelight, despite serving a population of nearly 40, 000 people across the country. These are the health care staff of Australia’s correctional centres.

In the West Moreton Hospital and Health Service in Queensland, the division of Prison Health Services (PHS) hosts three adult maximum-security correctional centres and one youth detention centre, with a population of around 1700 men, women and children. PHS delivers primary health care to some of the most dangerous - and also the most vulnerable - members of the prison community. The health of Australia’s prisoners is generally poorer than in the general public, with higher rates of mental illness, chronic disease, substance abuse and communicable disease. As the median prison sentence is less than two years, incarceration can be seen as a golden opportunity to address these health needs and reduce the impact on the public health system when the person is discharged from custody.

Nursing staff conduct a full patient history and health assessment for all prisoners and young people on the day of their arrival in custody. Immediate health care needs are addressed, including issues such as wound care, management of drug and alcohol withdrawal, mental health assessment and screening for communicable diseases. Referrals are made when necessary to other health disciplines (such as mental health, oral health and dietician services) or to hospital. Triage of prisoner’s health concerns and response to emergency situations is also a daily occurrence. Nurses may be dressing an ingrown toenail one minute and performing CPR the next, resulting in the development of an extensive range of patient assessment skills.

PHS features a structured career pathway for nursing staff. The pathway into correctional nursing begins with Enrolled Nurses, who may advance to the role of Enrolled Nurse (Advanced Practice). PHS accepts clinical placement of undergraduate student registered nurses in their final year. A 12-month Transition Support Program is available for graduate RNs, with placement and rotation across all four facilities. Beyond first-year, RNs can work toward career development into the roles of Clinical Nurse, Nurse Educator, Nurse Practitioner and Nurse Unit Manager.

Safety is the highest priority and PHS staff enjoy a close working relationship with the custodial officers of Queensland Corrective Services and the Department of Justice and the Attorney-General.

Correctional health nurses are often heard to say that the prison is the safest place in which they have ever worked.

People in custody are drawn from the most vulnerable persons in our society. Correctional health nursing is unique opportunity to care and advocate for a truly marginalised community. If you would like a career providing high quality, evidence-based, nurse-led health care and one in which no two days are ever the same, correctional nursing might just be for you.

Education key in whole of community treatment program Lyn Byers Remote area nurse, Utira Kulintjaku project Alice Springs, NT I work as the remote area nurse in a remote Aboriginal community. Remote Aboriginal communities have high rates of trachoma, although individual communities can vary. When the trachoma team came for their annual screen in 2014, for the first time in five years, high rates of trachoma infection were found amongst the children. The amount of trachoma found meant a whole of community treatment would be required.

As the community had been trachoma-free for so long, a whole of community treatment program required extensive education and information to be disseminated. It was crucial that community members understood the implications of trachoma and its longterm consequences. Without this understanding the health team would struggle for community support for the proposed regime.

Following the initial annual screen and its findings, the trachoma team sent out extra posters and information leaflets to the remote health clinic. Using the resources provided, I discussed trachoma with the trainee Aboriginal health practitioner, the local clinic drivers and clinic community worker. This refreshed their existing knowledge of trachoma, its causes and consequences. We especially discussed how it spreads and the importance of good hygiene.

The drivers and clinic community worker then took the resources provided to the local school, youth worker, shop and municipal offices to put on display. Along with the posters and resources distributed around the community, these workers also talked about the importance of clean faces and washing hands.

The clean faces and hand hygiene messages were reinforced not only to other service providers but to family members and by word of mouth throughout the community. The local workers led by example, reinforced by the resources provided.

At the clinic level, the trainee health practitioner, the community worker and one of the drivers planned with myself and the trachoma team how to manage the whole of community treatment. A date was agreed on, extra medication ordered, the community worker would dress up as Milpa the trachoma goanna, the trainee health worker updated her skills in trachoma assessment and treatment, the drivers collected consents. Health promotion goods and rewards were sourced to encourage participation and spread the message of clean face and hands.

Over the four months between the annual screen which detected high rates of trachoma and the proposed whole of community treatment week, the message of clean hands, clean face, reduce trachoma was communicated, reinforced and emphasised at all levels in the community. When the trachoma team returned for the whole of community treatment, not one positive case of trachoma could be found. This was an example of primary health care at its best.

Many team members had worked together with the community members to eradicate a bacteria through information, education and use of readily available simple strategies. The trachoma team will continue to perform annual checks, however, it is hoped that following the success of the 2014 program, they will never have to do a whole of community treatment in this remote community.

Women’s Health Nurses: ‘Passaging women across a lifespan’ Anne Smart MACN Women’s Health Clinical Nurse Consultant Orange, NSW Throughout history, women have been responsible for caring for themselves and their families. When a woman’s health is good, her family’s needs are also met in a healthy way and the family functions better.

As a woman’s health spans across her life, she faces a multitude of gender specific changes and decisions that impact on her health and wellbeing. One initiated improvement in women’s health care is the primary health care initiative of holistic well women’s services, offered by women’s health nurses working in townships closer to where women live. In regional and rural areas, women’s health nurses are often based within community health centres, traversing areas beyond their work site.

These specialised and gender-specific services blend counselling, health promotion, prevention, early intervention, partnership, education, self-help, community development, consumer advocacy as well as research and evaluation.

Women’s health nurses work closely with women, their local doctor and other health providers, assisting women in making informed affordable and accessible choices for managing personal needs, ensuring better health outcomes.

Unique outreach clinical services by women’s health nurses meet the needs of women in isolated areas where there may not be a local doctor. Comments such as, “It is good that we have this service in our town,” express gratitude, show trust and appreciation, driving passion for continuity of these unique services.

When a woman drives three times around the block finding courage to come into a clinic for her overdue Pap test, then saying,“Thank you, that wasn’t so bad … I will tell other women,” I know I’m doing well!

The young, anxious woman with an unplanned pregnancy tells me, “I didn’t know I had these choices.

You’ve helped me today,” I know I’m doing well!

The woman telling me she’s living in a violent controlling relationship and is “now ready to ask for help” because I gave her the time to talk – and listened. I know I’m doing well!

Many community education programs with a women’s health focus, and often led by women’s health nurses, have an endless positive and whole community health impact. For example, the LoveBites program addreses sexual assault and domestic and family violence, teaches young women (and men) about the importance of a respectful relationship and how changes in peoples’ attitudes are required for the safe health and welfare of women, children and pets.

My role requires careful balance in meeting my professional requirements and focus. Taking ‘me time’ is an essential part, along with reflective supervision.

The many roles and responsibilities held by women in our communities sometimes means that a woman’s commitment to looking after herself may fall by the wayside, and my role goes a long way to underpinning the health and wellbeing of all women. I encourage women to recommit regularly to their own health needs by attending regular check-ups with their local doctor and in some instances with their local women’s health service.

No two days are alike: an insight into general practice nursing Hana Yassin General Practice Nurse Bexley, NSW

and coordinate patient care. I work alongside a supportive team of medical professionals. The demographics of patients presenting to the clinic are variable, ranging from the newborn to senior populations. Little Bay is an emerging coastal suburb, bustling with young families, including retirees from the local retirement villages. We offer services specifically for Aboriginal and Torres Straight Islander people. My day is filled with endless activity, ranging from clinical nursing services, such as wound care, encompassing preventative health screening and patient education.

As a general practice nurse, my daily duties range from triage of the sick patient to organising chronic disease management (CDM) plans. There is no such thing as a ‘typical’ day as no two days are alike!

A snapshot of a given work day might include the following: - newborn and childhood health screening and immunisations according to the national immunisation program - managing chronic leg ulcers amongst other wounds - performing a spirometry exam on a patient presenting with signs of altered lung function - compiling a CDM management plan that involves collating patient data and making goals and achievable targets in order to assist a patient reach their health potential – this involves referring to services including dieticians, physiotherapists, audiologists and specialist practitioners - performing an electrocardiogram (ECG) on a patient experiencing heart palpitations or chest pain

The immediate response from family, friends and the wider community when asked about my profession as a registered nurse is, “Which hospital do you work in?” There is almost an automated inclination to believe that nurses only work in a hospital setting.

I am a registered nurse currently working in general practice. This often leaves people puzzled and unable to comprehend what a general practice nurse’s role actually involves.

According to the Australian Institute of Health and Welfare (AIHW), in 2011 there were 8,334 nurses and midwives employed in a general practice setting, out of a total of 283,577 working nurses and midwives Australia-wide. Granting there is a growing number of nurses seeking general practice roles due to increased job availability and awareness, general practice nursing nonetheless remains a grey area for the community sector including the nursing population who have not ever come across the job description before.

With patient-centred care being the core focus, general practice nursing relies heavily on a combination of independent thinking in conjunction with working with general practitioners to plan

- performing holistic health assessments which target the social, emotional and physical wellbeing of a patient, including medication reviews - attending to emergencies including asthma attacks, work injuries and the acute patient, and coordinating emergency services where necessary - measuring the International Normalised Ratio (INR) of patients undergoing treatment with warfarin - maintenance of medical equipment and stock rotations - vaccinations for individuals travelling abroad - assisting with small surgical procedures and removal of sutures - involvement in accreditation of the practice, including cold chain process and routine infection control in the workplace General practice nurses are a great asset to medical centres. Not only do we provide primary care services and reduce the workload of a general practice, but we also play a key role in disease management and prevention using health promotion strategies.

Fostering an understanding across cultures Lyn Byers Remote area nurse, Utira Kulintjaku project Alice Springs, NT Primary health care encompasses health promotion, illness prevention, care of the sick, advocacy and community development. As a remote area nurse – an endorsed nurse practitioner in the speciality of remote – delivering primary health care, I have been privileged to participate in the Utira Kulintjaku project (trans. to understand clearly), initiated by the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council (NPYWC), Central Australia. This ongoing project is a unique example of a primary health care project initiated, managed and evaluated by community members who invited health professionals to participate and contribute. The project was initiated by senior Anangu, including Ngangkari (traditional healers), from the Anangu Pitjantjatjara Yankunytjatjara lands. It began as a grass roots response to concerns community members had about the delivery of health care by mainstream health professionals, for a population with a very different paradigm of health. It aims to facilitate health practice through a shared understanding of language and meaning. Understanding each other is the key.

Delivery of effective health care for Aboriginal and Torres Strait Islander people requires service providers to orient their responses toward Aboriginal and Torres Strait Islander understandings of health, investing in mutual partnerships and to work from a strengths based foundation. Without effective personalised communication, social and health inequities remain.

Part of the Utira Kulintjaku project requires senior Anangu, including Ngangkari, to meet regularly in Alice Springs in a series of workshops. In these workshops, word meanings and concepts specific to health and wellbeing in English and Anangu languages are explored. For instance; neurobiology, along with psychiatric assessment, diagnosis and evaluation processes as used by non-Indigenous clinicians, were described in English and pictograms.

Anangu then developed these concepts into appropriate metaphors and stories aligning with Anangu world view of health. As a Nurse Practitioner my role has been to provide knowledge and be a resource person, from my paradigm of health, which can then be used by Anangu to clarify understanding across cultures.

From the beginning there has been a desire to ensure shared understanding of health practices.

A graphic story poster, featuring emotions and disturbed states of mind and behaviour has been developed and widely distributed. A phone app is in development providing a dictionary of words and phrases, both written and spoken. Contributions can be provided by Anangu and non-Anangu to ensure two-way dialogue. A compendium of words has been placed on the NPYWC website for public access. Fridge magnets are available and other resources are in development.

The project was awarded a Northern Territory Chronic Diseases Network Recognition Award in 2014 and is a finalist for the Northern Territory Administrators Team Award in Primary Health Care 2015. These awards recognise and acknowledge the collaboration between senior clinicians, including nursing, and senior Anangu in making a difference at a primary health care level for remote Aboriginal people.

More information about the Utira Kulintjaku project can be found on the NPYWC website: http://www.npywc.org.au/ http://www.npywc.org.au/ngangkari/ngangkari-news/

Walking into one-of-a-kind care Michelle Lambert MACN Advanced practice nurse, Walk-in Centre Canberra, ACT I work as an advanced practice nurse in one of the two nurse-led Walk-in Centres in Australia. I started here in 2013 when there was only one centre.

My previous career was in rural and regional emergency departments where I had worked in all roles, including as a clinical initiatives nurse, especially where doctors were not readily available.

I was used to the world where general practitioner (GP) access was insufficient, if at all, and many low acuity, minor illness and incidences presented to the emergency department as there was no alternative. I did not know what a Walk-in Centre was when I first applied, but now I am well into my third year and I can tell you all about it!

We are a team of nurse practitioners and advanced practice nurses based in a community setting in two sites. We operate within an extended scope of nursing practice that allows the public the opportunity of accessing a health service in a timely manner. I believe we support other health providers in offering a service aimed at delivering treatment for minor illness and injury.

The nurses can write sick letters, order X-rays on limbs, apply back slabs and dressings, suture minor wounds, treat urinary tract infections, ear infections and examine eyes. We reassure, educate and refer if required.

We do this autonomously, knowing that we are oneof-a-kind and that, although we are well supported and have a high standing in the community, there is a very real pressure that comes with being the first of your kind in Australia. We treat the patient within our scope and may put a partial treatment plan in place and send to GP for follow up. We can try and arrange an appointment with their GP if it’s not within our scope of practice or we can send to emergency for urgent care.

It is a role that really requires your assessment skills to be honed. Clinicians need a sound knowledge of differential diagnoses, a confidence in your assessment skills and an awareness of the limitations of the role to be successful.

It’s a collaborative team with lots of support and recognition of individual experience. We have a great relationship with our patients and this is reflected in the large volume of positive feedback we receive.

The patients are highly supportive of our place in the community and will often use us as a first base to other services.

We are thorough and patient in our consults, taking time to educate in regard to disease processes, symptom relief and lifestyle changes that may be necessary.

Coming from my background of rural and regional emergency nursing, the Walk-in Centre has provided a place to really adapt and stretch my skills within a collegial environment and provides a marvellous career pathway for nurses in primary health care and the community. http://health.act.gov.au/our-services/walk-centre

Primary Health Care Nursing with Shoalhaven City Council Ros Rolleston MACN RN, Nurse Immuniser, Shoalhaven City Council Nowra NSW Three days a month we pack the camp fridge, load up the van and drive off into the wide blue yonder. As we travel down the highway we chat about the month just gone, family, friends and thought-provoking events.

Journeying along our regular path to destinations known, we listen to ABC Illawarra, which extends our curiosity of the world and leads to interesting discussions. The conversation always turns to wonders of who we may meet and have the privilege to encounter on this month’s expedition.

Our travelling group of three are an unlikely mix of characters, two middle-aged women and a young adult male, who always assumes the driving seat much to the pleasure of his older companions. Tom is a unique young man who goes against the grain of his Gen Y counterparts with his laid-back, no-fuss, chivalrous nature. He enjoys great coffee, good books and has an infectious laugh to go with his quirky sense of humour. Jill is a kind, humble soul who cares deeply for the world and is the partner of one of our local church leaders. She senses where there are needs and gently searches for expression while leaving her trademark of compassion as a reminder of the hope and beauty in the world. And me? Well, I’m a friendly, enquiring baby boomer who enjoys a nice cup of tea while I interact with the world on my journey of learning.

Tom is in his final year of a Bachelor of Environmental Science. He is a dedicated student that always achieves excellent marks and is currently undertaking a research project on submerged septic tanks, which Jill and I are fascinated by. Jill has studied counseling, which seems a natural for her empathetic disposition.

She listens attentively and has a wonderful way of fostering reflectivity. And me? Well, I’m studying a Master of Nursing through the contemporary online environment with the University of Wollongong (UOW).

I still like face-to-face learning – I tutor undergraduate nurses at UOW as well as the immunisation course for the Australian College of Nursing (ACN). My marks?

Well they are unpredictable, yet so far respectable.

So what is it that brings this eclectic group together and leads us on a regular adventure each month?

Our combined purpose is the important public health mission of early childhood vaccination. We are the Shoalhaven City Council (SCC) immunisation team which is generously funded through a partnership with the Illawarra Shoalhaven Public Health Unit. Each month the free, mobile clinic visits seven locations within the Shoalhaven, including major centres and

small coastal villages, to provide affordable and accessible vaccination to children up to 5-years-old.

The SCC clinics have been available to local residents, and sometimes visiting families, for more than 20 years. In fact, my children received their vaccinations through these complimentary clinics at a time when I did not envisage being an immunisation nurse.

Originally, the SCC community service contracted local doctors but has since evolved into nurse clinics facilitated by the introduction of the ACN immunisation course for registered nurses. The course has resulted in the provision of expert nursing services to the Shoalhaven community through collaborative and resourceful use of community services.

The SCC clinics are provided from a mix of facilities, including churches, civic centres, libraries and community centres. Times are regular for each clinic and include an evening session, which is very popular with dads and working families. Consumers of the service include Indigenous families, foster families, defence force families, culturally diverse families, those with distinct vaccination requirements and families who want an alternative to general practice.

It is truly rewarding to provide early childhood vaccinations in a nurturing environment where there are no time pressures for mothers and babies to vacate the room. Many mothers enjoy the friendly atmosphere, spending time chatting with each other and the immunisation team. Indeed, a recent clinic saw a group of mothers who were new to the area join together in an ongoing friendship.

The most gratifying element of early childhood vaccination is when the babies and children settle after vaccination and smile warmly, waving goodbye as they leave. Watching the babies grow from six weeks through to five years of age, along with listening to the stories of their milestone achievements and preschool adventures is one of the pleasures

of primary health care nursing. They are remarkable little humans with individual personalities and the interactions with their parents are incredibly worthwhile to witness. We are also fortunate when older siblings, and sometimes the whole family, come to visit and provide support.

We have close connections and open referral pathways with the local health services. These include the Illawarra Shoalhaven Local Health District (ISLHD) early childhood nurses and general practices. One of our clinics is co-located with a general practice (GP) clinic along with the ISLHD early childhood services.

While uncommon, we have also given input on GP vaccination consultations when they do not have a nurse immuniser available. The Illawarra Shoalhaven Medicare Local also assists with regular data logging, statistical analysis, ongoing education and networking opportunities.

The support of the SCC Environmental Health Team is integral to the success of the program. During the clinics, Tom checks ages and vaccination history, then records the new vaccinations in the blue book and gathers the information for the Australian Childhood Immunisation Register (ACIR). Consumers can ring the team on any working day to discuss vaccination issues or gain advice. When questions are outside of the scope of staff they contact Jill or myself by email or refer the caller to the Illawarra Shoalhaven Public Health Unit. The SCC team sends reminders to families every month and ensures that the clinics are sufficiently advertised. The SCC team also has a role in the collection and mapping of local data.

In the 2013-14 financial year, the SCC immunisation team provided 410 early childhood vaccination encounters. This is a significant contribution to the vaccination coverage rates for children 5 years and under, which, in the Shoalhaven were reported at 94.6% in June 2014 (NSW Health, 2014). It is gratifying

Snapshot of the Shoalhaven The Shoalhaven is located on the south coast of NSW and boasts some of the world's most beautiful beaches. The population is 99,546 with 5409 under 5 years of age. The SEIFA rating is 954.6 with an unemployment rate of 13% and limited public transport services.

Within the local government area, 7% of the population identify as Indigenous, higher than the NSW state average of 2.5%. The percentage of single parents within the catchment is at 11.3%, which increases to 31.5% of families with children under 15 years in the Nowra-Bomaderry area (Gosh, MacDonald & Marshall 2013).

to know that our work plays a part in these great immunisation rates as well as the herd or indirect immunity of our community.

So as we load our equipment in the mobile van and climb aboard to commence this month’s journey and wonder what rewarding encounters we may have, I am proud to say that I am a primary health care nurse and part of the Shoalhaven City Council Early Childhood Mobile Vaccination Team.

References Ghosh, A McDonald, K and Marshall, K 2013, ‘Illawarra-Shoalhaven Medicare Local Population Health Profile’, Grand Pacific Health Ltd, NSW NSW Health 2014, Percentage of children in NSW fully immunised by age group and Local Health, viewed 29 August 2014 <http://www.health.nsw.gov.au/immunisation/ Documents/LGA-by-LHD.pdf>

Community Mental Health from a Private Perspective The Adelaide Clinic Ramsay Health Care, South Australia.

Pauline Blane Director of Clinical Services I am delighted to raise awareness to the excellent contribution our MH Nurse Incentive programme and our Community service make to our consumers wellbeing. Our nurses work with patients who experience mental health issues and make a real difference to their quality of life. Our nurses work specifically around consumers’ needs and empower them to achieve positive mental health outcomes.

Thank you team for facilitating tremendous clinical outcome with our patients.

Chris Bindon is a credentialed Mental Health Nurse working in our Mental Health Nurse Initiative programme. Chris gives us an overview of the programme and its benefits to patients.

The Mental health Nurse Incentive programme provides clinical care for patients who have severe & persistent mental health disorders. The majority of patients do not have private health insurance, but do choose to consult a private psychiatrist.

This primary health care role requires a very comprehensive skill set to work with patients, often in their homes & can be very different from our colleagues working in the acute mental health wards/ units. Our focus working in primary mental health care is on maintaining/optimising good health, rather than treating illness. One of our aims in working in primary mental health care, is to work with patients, who are often disadvantaged & marginalised, to support them (& their families) to manage their own health & thereby take ownership of their treatment plan & clinical care.

Often there are physical co-morbidities associated with ill mental health. These physical health risks can arise from poor lifestyle choices and/or side effect of psychotropic medications that are often prescribed in an attempt to manage illness symptomology. It is important to work with patients in primary mental health care to strive for a healthy balance with both physical & mental health. Often for the person, this involves considering the benefits of their medication vs. the unwanted side effects.

Georgina Smith is the Manager of our Community Team. Gina tells us of the important role her team plays in assisting the recovery of patients, and how her service has prevented hospital admission for many patients.

Too often services providing assistance to people with mental health have a set time frame by which the patient is deemed to be in the” recovery phase”.

The ability to have realistic expectations regarding “recovery” is invaluable. Our team recognises the importance of engaging early with our patients. Our role encompasses many aspects including; advocacy, mentoring, educator, encouraging positive changes and enhancing an overall higher level of functioning.

We take an Early Intervention approach and assertively contact patients who require a timely response to their deteriorating mental status.

The team offer visits and/ or phone contact within 24 hr period of receiving referrals and promote treated and care within the patient’s own environment.

The Specialty of Palliative Care Carolyn Hastie MACN RDNS (SA) Palliative Care Team The speciality of palliative care conjures up an array of feelings and attitudes from the general community.

Many do not really understand what palliative care means, many more think actually working in that field must be utterly depressing. My role, as a community palliative care nurse, is to not only provide excellent end of life care to my patients, but to be an advocate for my speciality by educating the families and carers I meet and demystifying the dying process.

I love my job because it involves hands on nursing.

It utilises the essential nursing skills I learnt over 25 years ago and have been developing ever since.

There is an ‘art’ to nursing care and in palliative nursing that art is significant. It involves the unspoken communication when you are bed bathing a patient, the meaningful relationships you build, the emotional experiences you reflect upon and the intuition you develop which unconsciously guides your practice.

My role also challenges me intellectually as I attempt to understand disease processes more fully and keep up-to-date with recent evidence based best practice.

As a nurse I am also a life-long learner.

Having worked in various inpatient settings, I had to develop new skills as I transitioned to the community environment. I see and get to know more of the person and less of the patient. I develop closer relationships with family members who are the primary carers and become an integral part of the multi-disciplinary team. As a result of this, a large part of my role is patient and family education. Many of my visits are more focused on education than patient care but it is essential that families and carers feel resourced to manage the death of their loved one at home. We are expecting carers to negotiate a journey they are likely to have never taken before, so part of my role is to instil confidence in those carers to realise they have the ability to manage what is, in effect, a normal human event. Being able to facilitate a family to manage a death at home is a privilege and sharing the journey up to that point is just as important.

In palliative care we only get one chance to ‘get it right’. To ensure this can happen, I have to have impeccable assessment skills to recognise where symptom management is not at an optimum level.

This is especially evident when a patient chooses to die at home. I may only have a short time with them in which to develop a clear picture of what is happening, what their needs are as well as anticipate what could eventuate. Uncontrolled symptoms, whether physical, social, psychological or spiritual on the part of the patient or family are likely to lead to a hospital admission which may well have been prevented.

Working in the community setting is the most natural place for nursing to take place. It is where life happens and it can also be where death occurs.

I am welcomed into the homes of people from all backgrounds and cultures. I am stepping into their space and not them into mine. As I drive from one home to another I am reminded that we never really know what goes on behind the closed doors we pass, except I often do. Many of those doors are opened for the community nurse who gains an insight into the realities of life that we can never truly appreciate in the inpatient setting.

Primary Health Care Passion Genevieve Fitzpatrick (RN) Maclean Community Health Northern NSW LHD

I enjoy being able to make a difference to peoples’ quality of life by taking the time to find out how they perceive and manage their respiratory condition, and most importantly, to provide them with comprehensive respiratory education to help improve self-management of their conditions. I frequently find clients who are not taking their respiratory medications as prescribed and/or are not using their devices correctly. The combination of explaining how their medications work differently and making small adjustments to device technique, in my experience, improves adherence and symptom control. I spend over an hour with clients and the feedback I get on a regular basis is “no one has ever explained this to me before in a way that I understand”.

I motivate and support clients to improve their respiratory and overall health by: • Encouraging smoking cessation • Promoting the benefits of regular exercise • Explaining the importance of taking respiratory medications as prescribed • Helping clients to recognise deteriorating symptoms of a flare up and implementing their Action Plan • Promoting healthy lifestyle choices

My current Primary Health Care (PHC) role of Respiratory Liaison Nurse includes comprehensive assessment and education for people with asthma, chronic obstructive pulmonary disease (COPD) and other respiratory conditions, in an outpatient setting within Maclean Community Health. I also co-ordinate and co-facilitate Pulmonary Rehabilitation programs which are conducted in the community health gym, with the assistance of the physiotherapy team.

I also have the opportunity to acknowledge other issues impacting on my client’s health and refer on to other appropriate health professionals.

I’ve been a PHC nurse for 25 years working in community health settings as a generalist community nurse, Oncology & Palliative Care CNC, Asthma Educator and have been in my current Respiratory role for five years. Primary health care is my passion – it is important and beneficial for the client and a source of great satisfaction for me as a clinician.

Diabetes Services Michelle Johnson What a year in diabetes services! As we progress into the second half of the year, it is hard to believe how quickly it has gone. But, then again, with a dynamic diabetes team that provides a variety of services it can be easy to see why time moves along so quickly.

The team provides support for a range of individuals affected by diabetes, from children and adults, to pregnant women. We provide services in a range of different settings that include outpatient clinics in Coffs Harbour, Macksville and up to Woolgoolga.

Services are also provided through the hospital for inpatients, specialist clinics and Aboriginal services.

We are getting more and more tech savvy in diabetes with insulin pumps, sensor downloads and glucometers that take the guess work out of insulin dosing at meal times and provide insight into nighttime hypoglycaemia, which can go unrecognised.

We have a team of four diabetes educators and two dieticians. As a team, we like to work together to provide a service that promotes healthy choices around diet and lifestyle habits to improve Diabetes outcomes.

Being based at Coffs Harbour, community health appointments can be made to come in have a review of your diabetes.

“The ache for home lives in all of us. The safe place where we can go as we are and not be questioned.”

– Maya Angelou Vanessa Crossley Registered Nurse Generalist Community Health / CAPACS – Coffs Harbour Community Health

The role of the community nurse differs greatly from the role of the ward nurse, the emergency nurse, the theatre nurse or the midwife.

The 92-year-old man with the swollen legs is the man who is overjoyed when you help him tune in his television so he can watch the cricket.

Away from the bleeping monitors, the sterility and the bustle of the wards, you often discover the real person that lies beneath the patient.

The 80-year-old lady with the skin tear is the lady who thanks you for finding the number and calling someone to come and wash her dog as she no longer can.

It goes without saying that we ask the hard questions to our patients when they lie in a hospital bed. We enquire about pain levels, bowels that have opened (or not), allergies, medications, previous medical history and what the home environment is like that they will soon return to.

However, until you stand in that home environment with them, you do not get a true picture of their life outside the walls of the hospital.

Like an onion, they have layers that you often discover when they are able to relax in the comfort of their home.

The concept of total patient care and problem solving changes from the model we know when the safety net of the hospital is left behind.

As nurses, in all areas of practice, we are trained to look beyond “the man with the ulcer”, “the lady with the breast drain” or “the child with the burn” and discover other issues they may have.

In the home setting, that journey of discovery takes on a whole new meaning and even though the medical side of our practice may be our number one priority, the little things we discover help to make up the big picture of community nursing.

The elderly man who lost his wife many years ago, who has no family in this country and who cannot remember the last time he had a home-cooked cake, is not just the old man with the leg ulcer; he is the man who smiles and hugs you when you bring him a plate of cupcakes.

The lady who has just lost her husband, who cries with you and thanks you over and over for helping her to re-frame her wedding photo.

The 45-year-old man who fought (and lost) against the roadway when he fell from his bike is the same man who is grateful when you run to take his sheets from the line as the rain starts to fall.

The sweet old man who fell in his driveway and broke his hand will grasp your hand and thank you when you help him with the “wretched fitted sheet” on his bed.

The 90-year-old lady who lives alone in a doublestorey house with a steep driveway will be pleased to see you drag her bin up that driveway for her and bring her mail up the stairs. She is the same lady whose husband was your school principal many years ago.

After six long months it is hard to know if the patient’s wife is happier about his ulcer finally healing or the fact that you have successfully removed a coffee pod stuck in their machine with a pair of forceps. She hasn’t been this happy since you helped her take a photo with her mobile phone on your last visit.

The 68-year-old man who loves your visits because you make him laugh and his wife who loves your visits because you bought a tin of WD40 along and finally removed the grandkids crayon masterpieces from the kitchen cupboard door.

The paraplegic man who has just lost his old dog and who sits and looks through the “dogologue” book you have bought him to think about the shape his new best friend will take.

The four-year-old boy with a burn who hates you at first sight but is smiling through his tears at the end of the visit when you successfully name all his Thomas the Tank engine trains. “She even knows the white one Mum.” The wheelchair-bound man who is ecstatic when you find, in your travels, a flag from his favourite football team to replace the one stolen from his chair. He takes your hand and says, “Mate, you have made a really rotten day so much better.”

The lady with the breast drain is the lady who smiles when you bend to pat her cat. She is glad you like him as he is her world.

There are many challenges in community nursing.

The driving, the distance, the weather, the decision making, the animals, the driveways and the nursing itself.

You need to think on your feet and be clinically skilled in many varied areas. You don’t need qualifications or knowledge in baking, cleaning, animal care, football teams or appliance repair, but it sure helps.

I love my job as a Child and Family Health Nurse Louise Scott Child and Family Health Registered Nurse Child and Family Health – Coffs Clinical Network I love my job as a Child and Family Health (C&FH) Nurse, going out to home visit mothers and families with their new baby, helping them to make the transition from hospital birthing out into the wider community. It is a privilege to go into people’s homes and to be able to support families with what they need to do to enjoy their baby and to normalise what it is to be parents. We monitor the mental health of the mother and family, making sure all are coping with their new role. We identify if there are any issues in the family that we can support in an individual way and we work in a wonderful team where we can draw on a variety of resources.

C&FH nurses carry out developmental assessments on babies and children to check that they are travelling along a normal pathway of development and meeting their milestones. Sometimes we discover something that hadn’t been expected, a delay of some sort or something that may need a little tweaking so that the child can move on to the next developmental milestone. We take into account that all children have a wide range of abilities and our role is not to judge parents but to provide information and support on child safety and realistic expectations for their children for their age and developmental stage. We encourage clinic visits for support in groups and individual consultations and have information on local services for parents such as playgroups. We work as part of the Primary Health Care Team, with access to paediatric OTs, physios, C&FH counsellors, speech pathology, StEP’s vision screening, audiometry and genetic counselling. We work as part of a team to provide the best outcomes for families.

It’s all about prevention. We are not working in the sickness model as other nurses are, we are in a wellness model, which means our focus is very different. We are not seeing disease or disability in our clients; we see and support wellness and optimising parenting ability and functionality. We coordinate care and support and nourish the community with our knowledge base. Knowledge that has been built up over many years through not only our original C&FH nurse degree but also through in-services, updates and conferences that we are expected to attend and feed back to our team. Some of us are also International Board Certified Lactation Consultants.

All of us are immunisation providers. Some of us run groups and we all home visit and run our C&FH clinics in whichever area we are in, meeting the needs of our community.

It is lovely to know that when a family leaves our area as they often do with workforce transience, there are C&FH nurses all over Australia. We can find a local C&FH nurse in the area they will be moving to and, with their permission, transition a family on to the their next support if needed. We may be called slightly different names – “early childhood nurse”, “baby health nurse” or “infant and family nurse” – but we are one and the same in that we are there in the community to support and grow our next generation of children and parents in a caring and respectful way for optimal community and individual outcomes.

There is no place like home!

Clinical excellence in the community Jude Foster RN Clinical Director, Regal Home Health

Next there is a new admission, Frank, who requires a comprehensive health assessment to determine his ongoing needs. Nurses in the community have the privilege of being invited into people’s homes, which provides a lot of extra information that isn’t available in an acute setting. Nurses can see who they live with and what their interests are. They can assess the risks around the home and the level of mobility which determines whether risk assessments need to be undertaken.

Regal nurses need to be strong advocates for the client and this can be challenging at times. Patricia will need to develop strong negotiation skills to monitor if/when the risks for clients being at home become too great. Patricia works closely with the GPs and pharmacists in her area as well as the specialist medical teams to flag any concerns early and to link clients up to local health services.

The next client is Peter who had a complex gangrenous ischaemic ulcer with poor circulation and plans for amputation. Patricia is determined to heal the wound and persisted with this rigorous wound regime for two years and recently achieved a healed wound when many people would have given up and Peter would have suffered amputation.

I am writing about a day in the life of a Regal nurse in Sydney. I hope as the Clinical Director I can honour the work of all the wonderful Regal Nurses who care for people across Sydney, 365 days a year. I’ve created a pseudonym, ‘Patricia’, out of respect for the founder of Regal 50 years ago, who identified the need for veterans to have clinical support at home.

Regal has now expanded their clinical services to assist private health funds, workers compensation insurers and not-for-profit organisations and they continue to support veterans at home.

Fast forward to today. Patricia runs an independent clinical practice in Sydney. She sees clients with a range of different clinical and holistic needs. Patricia sees many of the clients regularly, which provides continuity and enables Patricia to identify deterioration early, in consultation with the GP, carers and family.

Patricia starts work around 7.30am and, on a typical day, she might start by checking the blood glucose and supervising the insulin of Maureen who has recently been diagnosed with diabetes and needs support until she is confident.

Regal makes healing visible Patricia has completed training to deliver intravenous antibiotics to people like Maria at home. Maria is a 41-year-old woman who, following debridement of a leg ulcer in hospital, returned home with a PICC (peripherally inserted central catheter) in situ. Regal nurses visited daily for six weeks to review the PICC and change the Flucloxacillin infuser.

When I’ve asked Regal nurses what they enjoy about working in the community, they respond that they love the relationships they develop with their clients, they enjoy the flexibility of working autonomously and they appreciate the clinical variety.

Community Nursing â&#x20AC;&#x201C; a reflection of one passionate community nurse Karen Sergeev Nurse Unit Manager Aged Care Transitional Intervention Program / Transitional Aged Care / Palliative Care Community Health Coffs Clinical Network Nursing in the community is a passion of mine and I have had the privilege to work as a community nurse in various parts of NSW since 1987. In that time there have been many changes from working alone with no mobile phone, no educator support, no allied health support, no weekend services and washing your own fleet car.

The role of a community nurse has changed over time in line with changes in technology and society.

In 1987 I was responsible for the general nursing care of clients living in a geographical area, from children to aged seniors. If a client required equipment, such as a shower chair or oxygen cylinder, the nurse would load the items in the car and deliver/set up. Bandages were washed and reused by clients; there were no clinical rooms for sterile procedures and no Dopplers, pulse oximeters or bladder scanners. School screening was provided in the local schools with vision, hearing, height, weight, gross motor and scoliosis checks and immunisation.

Health promotion was also a requirement of the position and general health checks and education were provided to teachers, council workers and local businesses. The only specialist nursing available was for diabetes and palliative care. Home care and Meals on Wheels were the only services available to support people at home. GPs did home visits even at night if called.

By comparison, in the mid-2000s as a community nurse I had a mobile phone, a computer and a fully serviced and well-stocked fleet car. Allied health is available in some areas and specialist nursing is the norm from wound management and stomal therapy to cardiac and respiratory rehabilitation. Education is provided by online modules and in services supported by a nurse educator. The amount of clinical competencies and mandatories has continued to grow.

The influx of non-government service providers requires a broad knowledge of the local services to ensure clients could access the necessary support.

Clients live in diverse environments, from public housing, caravans and remote farming properties to city apartments and multimillion dollar mansions.

Facilities in homes range from boiling a kettle for hot water to under floor heating in the bathroom. Some clients have a fully equipped bedroom and others share a mattress on the floor. Clientâ&#x20AC;&#x2122;s family situations also vary from living alone to sharing a house with several generations. Some families provide unconditional support to their loved ones and others visit rarely and offer minimal support. I have done wound dressings in garages, under trees, at school or at places of work. I have walked across snowy paddocks for home visits, opened farm gates and driven on gravel roads and highways. I have fed chickens and collected eggs, had gifts of home-grown produce, washed clothes, made sandwiches and emptied bins, all to assist a client to remain at home.

Through it all I have met many wonderful people: clients, carers and colleagues who have helped shaped my experience of life and death. It is very humbling to be allowed to care for someone in their own home and as a community nurse you are investing in the health and well-being of your local community.

Overcoming barriers in Aboriginal and Torres Strait Islander health Lesley Salem Nurse Practitioner My name is Lesley Salem. I am an Aboriginal nurse of 34 years and, of that, a nurse practitioner of nearly 13 years. I initially worked as a nurse practitioner in a tertiary referral hospital for eight years, looking after patients with end-stage organ failure, but have now been in private practice in the primary health care sector for over four years.

I work as a generalist with primary interest in chronic disease (cardiovascular, respiratory, diabetes and nephrology) as well as simple trauma, pain management and infections. I subcontract to two Aboriginal medical services and the NSW Rural Doctors (NSWRD) Medical Specialist Outreach in rural locations throughout the state. My work entails acute presentations (infectious, pain, trauma), screening for and/ or managing chronic disease.

The work I do predominantly entails care for Aboriginal and Torres Strait Islander people who experience many of the social and geographical determinants that contribute to poor health. These include geographical isolation, socioeconomic disadvantage (income, housing, overcrowding), poor lifestyle and so on.

There are several unique models of care that I am privileged to be allowed to nurse in. With Walhallow Aboriginal Corporation (WAC) I provide two services. The first is an outreach clinic within a very low socioeconomic area of outer Tamworth based at the Coledale Community Centre. The University of New England (UNE) auspice a student nurse clinic and, in conjunction with this, I provide clinical care to over 1200 clients (enrolled through WAC) as well as simultaneously mentoring undergraduates from UNE as well as nurse practitioner candidates.

WAC is based in Quirindi and the model of care is provided to the outlying communities, including the old mission at Walhallow. We take bookings as well as undertake regular monitoring of clients with a chronic disease by providing care in the home.

With an Aboriginal Health Worker (AHW) we visit all clients in their home. Often, with other family members visiting or sharing accommodation, we opportunistically are able to treat other clients during each occasion of service.

The third model of care is provided at Durri Aboriginal Medical Service through the NSWRD Medical Specialist Outreach. This work entails screening for kidney disease or determining existing chronic kidney disease (CKD) though previously attended pathology, forming a management plan and trying to achieve remission or regression of the CKD. This has been highly successful, going from eight patients initially with a diagnosis of CKD to over 220 patients now and around 40% in remission or regression.

This was achieved within 60 days (two days a week work each month, 10 months a year for three years).

Nurse practitioners are able to overcome many of the geographical barriers, social and cultural barriers and economic barriers. The sustainability of nurse practitioners in private practice, especially in rural and remote locations depends on viable Medicare item remuneration that reflects the work performed, being unleashed from collaborative arrangements where bias and prejudice can restrict scope of practice and being able to provide management plans that offer allied health referral and no restrictions on allied health referral, such as a dietician.

Nurses provide much of the service provision in rural and remote locations and the addition of nurse practitioners, who can offer management, is a viable consideration to â&#x20AC;&#x2DC;closing the gapâ&#x20AC;&#x2122; for all those living in these areas.

The diverse role of community health nurses in Centacare – child protection and substance abuse Susan Timpani Children who have experienced abuse or neglect often have significant health and developmental needs. Centacare’s Targeted Intervention Service provides a 12-month home visiting program to families who have come to the attention of the statutory system. Child protection concerns are explicit.

Addressing these commences with a transparent discussion with the parents. The allocated case manager, nurse and family establish goals and create an action plan.

Our program acknowledges that child abuse and neglect occur within a social context. For example, if a family are facing homelessness, their priority may not be immunisations. By co-working, the nurse and the case manager support the parent to address both needs concurrently.

If parents are illiterate, they may discard health appointment letters. After missing multiple appointments, the fear of judgement further precludes attendance. The nurses can support the family to reconnect with health professionals. Writing letters, making phone calls, or accompanying clients to appointments are important interventions.

Where parents are struggling to pay bills, manage their own mental health, survive domestic violence, deal with addictions and parent with minimal capacity, the needs of the children are often unmet.

We cannot underestimate the value of a multi-disciplinary approach in peeling back and addressing these layers.

Nurses address family health needs from a child protection perspective. This is a unique role, as every member of the family is a client and this involves multiple person advocacy skills. Nurses and case managers access each other’s professional knowledge and expertise continuously to achieve this wholistic approach.

Nurses use a range of evidence based assessment tools to identify needs. Some include the Ages and Stages Questionnaire, Edinburgh Postnatal Depression Scale, Ante / Post Natal Risk Questionnaire, Growth Charts and Short Sensory Profile. Age appropriate health assessments provide opportunities to uncover concerns in daily routines such as hygiene, nutrition, sleep, toileting, sexuality, substance abuse, mental health, self-harm, psychological trauma and unmet medical needs.

Connecting children and families into established health and community services is a critical component of our intervention. Where we identify health and developmental concerns, our role is to support the family to access the standard referral pathway.

Working in child protection is at once heartbreaking and rewarding. Nurses are fortunate to have the partnership of case managers to address the underlying complex social factors. Nurses consider it a privilege to work with families to achieve robust and sustainable health outcomes for their children.

Centacare also employs a clinical nurse in their Drug and Alcohol Service. An outreach service across metropolitan Adelaide, this supports young people under the age of 30 with substance use issues, along with their families. The nurse manages clients who choose to undertake a supported home detoxification for their drug use. She visits the client within their home environment and provides clinical management throughout the detoxification period. This includes implementing clinical withdrawal observations, monitoring the client’s mental status, exercising clinical judgement and management of medication.

The role also includes Nursing Health Assessments.

The assessment includes medical, surgical, psychosocial and psychiatric history. A physical examination includes assessing the client’s blood pressure and other baseline assessments. These provide opportunities for clients to identify and discuss any health concerns. The nurse can then explore appropriated health promotion and illness prevention education and strategies for better managing their health. Along with other members of the Drug and Alcohol Service team, the nurse also provides counselling specific to the client's drug and alcohol use.

Targeted Intervention Service: Susan Timpani Lynn Copper Annette Brown Gaynor Trezona Drug and Alcohol Service: Jane Deer

The development of a community palliative care service Beverley Morris Clinical Nurse Consultant Palliative Care Service Community Health â&#x20AC;&#x201C; Coffs Clinical Network Like life itself, the palliative care service in this district has undergone many facets of change in its 24-year journey.

Two part-time clinical registered nurses with training in symptom management end of life care and communication skills commenced home visiting service to patients across the community. Traditionally these patients were palliative from a cancer diagnosis.

A part-time counsellor, bereavement support, volunteers and coordinator, equipment loan pool and weekend nursing service soon followed to complement the holistic need for patient focused care. Each patient was medically supported by their general practitioner (GP).

Commonwealth funding provided a second monthly fly-in-fly-out medical service from an oncology staff specialist from Sydney. Two years later, a palliative care staff specialist was supported by Calvary hospital Kogarah, to provide monthly fly-in services to the community. Finally, funding was secured for a full-time palliative staff specialist; this position commenced in 2012.

With increasing need, two full-time equivalent registered nurses, and one full-time clinical nurse consultant were covering the ever increasing workload.

The opening of North Coast Cancer Institute in 2007 brought improved outcomes for palliative care patients by providing timely best practice care,

especially for palliative care patients with potentially devastating end of life scenarios. This further increased the number of palliative care occasions of service.

Currently, palliative care is complemented by parttime administration support, part-time palliative nursing throughout inpatient areas, Silver Chain service supporting existing care with afterhours service, personal care and symptom management, Aged Care Transitional Intervention Program (ACTIP) providing occupational therapy, wound management and personal care expertise.

With support from GPs, we currently receive 300 community based referrals each year; one-third have end stage chronic diseases, and we consult more widely across inpatient settings in Coffs Harbour and Bellingen, outpatient clinics, consultation to GPs and aged care.

Priority and full support is given to those choosing to remain in their own homes.

Cairns Older Persons Mental Health Service Belinda Sharpe The Older Persons Mental Health Service (OPMHS) Cairns operates within the Cairns and Hinterland Hospital and Health Service Mental Health and ATOD Service. Using the consultation liaison model, we provide mental health assessments, diagnoses, brief psychosocial interventions, treatment recommendations, education and ongoing support to consumers, carers, GPs and Aged Care Facilities.

Our consumer group is adults over 50, for Indigenous Australians and over 65 for non-Indigenous Australians.

We are a small team of four registered nurses (RNs), an occupational therapist, consultant psychiatrist (.8), psychiatric registrar (.5) and an admin officer.

OPMHS Cairns was the first OPMHS outside Brisbane and services a large area of Tropical North Queensland. We believe we may be unique in that three of our team members, including the psychiatrist and founding RNs, have been working together for over 11 years, providing exceptional continuity and a well-respected level of care for consumers, families and clinicians in our area.

The team as a whole feels honoured to be working with a fascinating demographic in such a magnificent part of the country. Our territory includes world heritage areas. Our patients, who come from all walks of life, many with agricultural backgrounds, include ex-tobacco farmers, cane farmers and many first generation Australians. A growing number are over 90 years old; they all have amazing, as well as some harrowing, stories to tell. Older people are a complex group to assess and treat, due to ageing body systems and the number of co-morbidities. As you would probably expect our biggest challenge is often to distinguish between mental illness, dementia syndrome and physical illness.

The average number of referrals each year for the past five years has been 250. We are supporting around 80 to 100 consumers at any one time, both

in the Cairns area and outreach areas, which we visit on average monthly. We go down to Tully in the south and up to just north of Mossman; west to Mareeba, Dimbulah, Atherton, Herberton and Malanda.

We are privileged to visit people in their homes, in aged care facilities and in small regional hospitals, adding another dimension to our work. We believe that assessing people in their home environment is a great privilege and invaluable for providing an accurate psychiatric diagnosis together with the most appropriate, individualised treatment plan and recommendations for the GPs. In turn, most consumers and carers are extremely grateful and sometimes most impressed to have a home visit from a Consultant Psychiatrist or Registrar.

We enjoy our work! No two days are the same! We never know what is around the corner and with the projected increase in the number of Australians in our demographic, we are hopeful of increasing the number of clinicians in our team over time.

School nurses: Where do you find them?

Britta Crozier The school nurse in NSW is typically found working in Private and Catholic systemic schools. They work independently and are called upon to assess student health, develop and execute plans for management for many medical conditions including diabetes and anaphylaxis, epilepsy and other chronic illness. They are often the first responders at medical emergencies and injuries that occur within the school environment and oversee the immunisation of school students and often staff members. School nurses are involved in health promotion and collaborate with school staff members, parents and community members to keep students safe at school.

The role of the school nurse is very broad and is dependent on factors such as the school setting and the health needs of the student population. School nurses strive to facilitate the wellbeing, safety and health of students of all age groups within the school setting.

Images: school nurses at work

Putting the patient at the centre of health care services Claudia Pollauszach I am a clinical nurse specialist with Sydney District Nursing, and have been working in community nursing for the past eight years. As the nurse liaison for general practitioners (GPs) and Hospital in the Home (HITH), I represent the service on multidisciplinary committees and am focused on improving our working relationship with GPs and HITH service. There is a lot of work to be done on improving communication between health care providers, improving health literacy in vulnerable and disadvantaged populations, such as those with mental health issues, and putting the patient at the centre of care. Patients usually struggle if there are inconsistencies in the information and advice provided by health care providers. Patients show a great appreciation for my liaising role and appreciate when they are involved in decisions about their health and put at the centre of care.

The best part of my role is that it’s multifaceted, it’s clinical, collaborative and research based. My clinical role is extensive and includes acute and postacute care, and case management of patients with complex needs and co-morbidities. In collaboration with the Sydney Local Health District cardiac chronic care nurses, I have been involved in the development and expansion our service to include care for patients with heart failure in the community. This allows patients with chronic heart failure to receive IV diuretics in their home and therefore reduce hospital admissions and health care costs.

Over the past couple of years I have been involved in the implementation of quality improvement projects, research projects and clinical evidence based research for the development of service policies and procedures. My involvement in research is very exciting and new. I am a co-investigator in research and am a clinical provider of care in a cancer study.

There certainly are a lot of advantages to my job. It is interesting, never boring and very rewarding. With an ageing population the demands for specialised nursing care for patients with complex needs and multiple co-morbidities in their home is increasing.

At times, these demands are associated with a difficult socio-economic environment that can be variable and challenging. I get a sense of professional pride when my team and I are able to provide high-level care to complex patients in their homes.

This job allows you to develop a relationship and to have a significant impact on patients in the community. Patients in the community generally acknowledge our contribution to health management and after a while you become a member of the family.

This is the first job that has allowed me the time and opportunity to expand my knowledge through vocational studies and allowed me to become a “better” nurse. My previous jobs have helped me build my experience in nursing, but district nursing has helped me to grow professionally. The demands of the nursing profession have increased exponentially in recent times and nurses need to stay abreast of changing technologies and health information: not many working environment allow you the opportunity or time to do so.

Disability nurses integrate care for people with complex health needs Dr Penelope Kearney I met Sam 26 years ago when I was a brand new community nurse in a multidisciplinary developmental disability team (they no longer exist). Sam was his parents’ first baby and just a few days old when I visited him at the hospital.

He was beautiful – fair-haired, relaxed and so peaceful. My body registered his exceptionally low muscle tone as I held him close to me and spoke softly with his mother, Liz: ‘He is a beautiful baby’. She later told me I was the only person who had remarked on her baby’s beauty – it seemed that all others saw was Down Syndrome.

I worked directly with the family until moving into a university position where I hoped to enthuse students about the joys of working with people with disabilities in community and rehabilitation environments.

However, I maintained contact and Liz participated in research that highlighted the ‘joy and sorrow’ of parenting a child with severe disability (Kearney & Griffin, 2001). Liz is a remarkable mother and advocate for her son, and Sam, despite profound cognitive impairment and chronic health conditions, has thrived. He lives next door to Liz with a small team of staff who support his living and work activities. His health is generally good, but he’s been near death a few times with acute respiratory problems that necessitated traumatic hospitalisations. However, he remains relaxed and has a ‘cruisy’ personality valued in his local community.

I am again working with Sam and his team across a range of issues that include healthy lifestyle and advance care planning. I was initially engaged because Sam’s eye contact was poor, he seemed miserable and was losing skills. Sam does not speak, so assessment that depends on his mother’s understanding of her son is complex. He had experienced recent living and family changes with the loss of a treasured mentor. His GP recommended antidepressant medication, but Liz was resisting for a number of valid reasons.

I commenced comprehensive assessment and devised observational studies for staff to complete day and night. Joining dots that related to hypotonia, sleep apnoea (unable to tolerate CPAP), severe pronation, gait problems, and high levels of supported activity, I considered that pain and fatigue were likely contributing to changes in Sam. Liz organised bespoke orthopaedic boots, she requested that the GP trial him on a PPI for probable reflux (never investigated), a physiotherapist adapted his bed, morning rising time was delayed, and his daily activities were reduced.

The response has been exceptional and Sam is not only back to his old self, but is developing new talents.

Liz thanks my specialty nursing knowledge and skills that enabled us to draw together the pieces of Sam’s puzzle, a process she calls the “horizontal integration” of complex needs for people with intellectual disability. Various specialists had considered only separate pieces.

The above story is a simple one and disability nurses deal with greater complexity every day. Many of us love this area of nursing, but are weary of justifying our work, our nursing practice, our contributions, our very existence. I am now in private practice because the NGO health team I worked with was disbanded due to changing ideologies. Despite being primary care nurses par excellence, disability nurses are facing uncertain futures in the struggle to find their place.

Community midwifery – outback style Kristy Newett I am a born and raised Melbourne chick but have called The Kimberley home for many years now. I prefer the rugged life of red dirt, the mighty Fitzroy River and the peacefulness of bush life than city life could ever offer me. I left Melbourne in 2007 to work as a remote Midwife around Australia. I was drawn to The Kimberley after my first stint in Derby over eight years ago and that is where my love for ‘outback midwifery’ began.

Fitzroy Crossing is situated in the heart of The Kimberley, Western Australia, 400 kilometres east of Broome, and 290 kilometres west of Halls Creek.

The Fitzroy Valley extends for a radius of approximately 200 kilometres from Fitzroy Crossing. There are more than 45 Aboriginal Communities in the Valley. The population of the Valley is approximately 4,500 people, of whom 80 per cent are Indigenous.

There are five main Aboriginal language groups, each with their own distinct language and customs.

I am the only Community Midwife in the Valley, hence the women seek me out on discovering their pregnancy. I ride the waves of emotions from the initial positive pregnancy test, performing their dating ultrasound, pumping them with intravenous fluids when they cannot stop vomiting and feel so weak, holding their hand and feeling their pain when I have to confirm they have miscarried, attending their morphology ultrasounds and watching their faces light up as they see their little human they have created grow so much, helping women to be in tune with their unborn babies to cut out the grog, supporting the women in domestic violence relationships or complex social issues, yarning down at the river in my own version of ‘antenatal classes’, watching the women come back from birthing off country and observing them become mothers on a social and professional level. Above all it is the relationships with women I establish and maintain through their pregnancies and into their postnatal period that I absolutely love and this makes me so passionate and dedicated to my role as their Community Midwife

The high risk pregnancies add another dimension to the care that needs to be provided. The women are faced with chronic disease complications that are not always seen in one’s midwifery career. I do not have obstetric DMO’s (district medical officers) on site at our Fitzroy Valley hospital so I do most of my liaising with the O&G (obstetrics and gynaecology) of The Kimberley via phone and email and at her monthly visits.

I have worked in many remote hospital settings but also in metropolitan Melbourne but will never be returning to the bright lights of the city as I love being out in the bush and the professional and personal challenges of community work that is faced every day keeps me on my toes.

Working as a Community Midwife, the biggest reward is that I have formed such strong relationships with the people of this Valley that in turn promotes better health outcomes all round. The number of women presenting in first trimester has dramatically increased and in turn this starts the process early in the pregnancy to manage the complex medical issues which then improves the outcomes for the babies and their early start to life. This was acknowledged state-wide when I won the Excellence in Midwifery award at the WA Nursing and Midwifery Excellence Awards – an achievement that I am also very proud of.