ANMJ February 2015

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A U S T R A L I A N N U R S I N G & M I D W I F E RY J O U R N A L VOLUME 22, NO. 7

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Editorial Lee Thomas, ANMF Federal Secretary Feeling rested and restored after the Christmas break the ANMF is ready for the challenges and opportunities 2015 brings. Unfortunately the beginning of the year has already seen heartbreak and tragedy around the world. Yet from adversity, the human spirit and community comradery has truly shone through; an attribute that can only be described as awe-inspiring. Last month in my home state of South Australia, the Adelaide hills faced devastating bushfires, destroying up to 38 homes and affecting many lives. During this time the community was quick to rally, offering acts of extreme kindness and support such as donations of food, money and shelter to those in need. When 12 people were tragically gunned down in a terrorist attack on Parisian satirical magazine Charlie Hebdo, the community came together in solidarity to condemn the act. An estimated three million people rallied in Paris to protest against the attack and to demonstrate their right to free speech. Similar demonstrations were also held across the world.

In this month’s ANMJ, we have outlined our priorities for the year, which includes: improving conditions and wages for nurses working in aged care; maintaining and strengthening Medicare and our universal health system; adequate staffing levels and skills mix in all healthcare settings; ensuring secure and meaningful employment for our nurse and midwifery graduates and continuing the campaign against the proposed deregulation of university fees. Additionally, the ANMF will fight the cuts to wages, conditions and jobs for nurses and midwives that many of our states and territories are contending with, as outlined in this month’s feature. Before I sign off, I would like to congratulate ANMF (SA Branch) member Nat Cook who has been elected to state government in a by-election held in SA late last year. Nat’s election to the seat has in effect shifted the balance of power, allowing Labor to form a majority government. Nat is a highly experienced and well respected nurse. She also set up the Sammy D Foundation to bring awareness to young people about making safe and positive choices, after her son was tragically killed in a one punch assault at a party six years ago. Nat is a worthy example of a great leader in our community and of our professions. Well done Nat!

Our inherent nature to support one another and stand up for what is right when needed is the basis of our society and shapes and protects the world we live in. This is why I feel passionate to stand up for what I, and many of you, believe in which is an equitable healthcare system for all and a robust nursing and midwifery profession. To this end we will continue to stand up for our rights and the rights of the community throughout 2015.

February 2015 Volume 22, No.7    1

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The Australian Nursing & Midwifery Journal is delivered free monthly to members of ANMF Branches other than New South Wales, Queensland and Western Australia. Subscription rates are available on (03) 9602 8500. Nurses who wish to join the ANMF should contact their state branch. The statements or opinions expressed in the journal reflect the view of the authors and do not represent the official policy of the Australian Nursing & Midwifery Federation unless this is so stated. Although all accepted advertising material is expected to conform to the ANMF’s ethical standards, such acceptance does not imply endorsement. All rights reserved. Material in the Australian Nursing & Midwifery Journal is copyright and may be reprinted only by arrang­ement with the Australian Nursing & Midwifery Federation Federal Office Note: ANMJ is indexed in the CUMULATIVE INDEX to NURSING AND ALLIED HEALTH LITERATURE and the INTERNATIONAL NURSING INDEX ISSN 2202-7114

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2    February 2015 Volume 22, No.7

If you are a financial member of the ANMF, QNU or NSWNMA, you can transfer your membership by phoning your union branch. Don’t take risks with your ANMF membership – transfer to the appropriate branch for total union cover. It is important for members to consider that nurses who do not transfer their membership are probably not covered by professional indemnity insurance.


Total Readership: 143,792* *Based on ANMJ 2014 member survey showing readership pass along rate of 1.46 Source: BCA verified audit, September 2014


Volume 22, No 7.

ANMF PRIORITIES What’s in store for 2015


ANMF Priorities




World 17 Issues – Beyond 55 18 Feature – Australia’s Health cuts 20 Legal 25 Clinical Update – Ageing with HIV 26 Research 30 Professional


Focus – Aged care 32 Calendar 46 Mail 47







Beyond 55

Annie 48



Aged Care

February 2015 Volume 22, No.7    3

ANMF Priorities for 2015 ANMF priorities What’s in store for 2015 During 2014 the federal government and several state and territory governments undertook a massive assault on Australia’s health, education and welfare systems. Commonwealth funding was ripped from public hospitals across the country. The ability to provide quality care with increased workloads puts at risk the quality of care and safety of patients, something nurses and midwives have fought for. The Australian Nursing and Midwifery Federation (ANMF) nationally and through its state and territory branches will continue to fight against the proposed austerity measures in its Healthcare Emergency – Lies, Cuts and Broken Promises campaign. As the largest health union in Australia, the ANMF outlined the union’s priorities for 2015 which include, to: • Maintain and strengthen Medicare and our universal health system. • Make improvements in aged care, in particular staffing and skills mix. • Have safe staffing levels and skills mix in all areas. • Defend the future of our professions. “These priorities are based on feedback from our members,” ANMF Assistant Federal Secretary Annie Butler said. “It’s time to continue the work we started in 2014. We need to save our universal health system; ensure safe and reasonable workloads for nurses and midwives; and defend the future of our professions through affordable degrees and secure jobs for newly graduated nurses and midwives.”

Save Medicare and keep our universal health system After making a pre-election promise of ‘no cuts to health’, the federal government ripped more than one billion dollars from public health funding and continued to attack Australia’s system of universal healthcare. “Before the last election, Mr Abbott made a pledge. No cuts to education. No cuts to health. Well Mr Abbott all I can say to you is that you lied, you lied to me, you lied to the whole electorate and I have the proof,” ANMF Federal Secretary Lee Thomas said. The ANMF called on the ALP, the Greens, PUP and key independent senators to help fight the federal government’s attempt to ‘destroy Medicare by stealth’.

included brutal cuts to healthcare, including the proposed $7 co-payment to see a GP and the co-payment for diagnostic and pathology services and extra charges for pharmaceuticals. The government scrapped the unpopular and much publicised $7 co-payment in December, and announced their ‘Plan B’ for bulk-billing GPs to ‘use their discretion’ to charge an additional $5 consultation fee and cutting $20 from the rebate for short consultations. “While the government has recognised the widespread opposition to its initial $7 co-payment proposal and Australia’s steadfast resistance to any tampering with Medicare, its plans are crystal clear,” Ms Thomas said. The $5 fee would still increase out of pocket costs for patients and signal the end of Medicare, said Ms Thomas. “We are concerned this $5 fee to patients to visit their GP will open the door for higher out of pocket charges in the future, creating a privatised healthcare system like in the United States where you only get care if you can pay for it.” “Whether it’s $7 or $5, so-called optional or not, it’s still a tax on basic GP services, which will erode Australia’s successful system of universal healthcare – it signals the end of Medicare as we know it.” Australia already has one of the highest out of pocket costs ($1,075 per year) for healthcare in the world, ANMF Assistant Federal Secretary Annie Butler said. “It will only get worse if the government destroys our successful system of universal healthcare and pushes more costs on to individual health consumers and their families.

The federal government’s last budget 4    February 2015 Volume 22, No.7

ANMF Priorities for 2015 “In 2015, the government is on notice; the ANMF will be strengthening our resolve to save Medicare, for all Australians.” Ms Butler said she was pleased the new Minister for Health Sussan Ley had listened to concerns by health professionals that the $20 reduction in subsidies paid to GPs for patient consultations of less than 10 minutes would result in the erosion of Australia’s system of universal healthcare. “We are now calling on Minister Ley to consult with the ANMF and other health professionals about how we can work together to protect Medicare and the future sustainability of Australia’s universal healthcare system. We are ready to engage, consult and talk to the Abbott Government on these issues.” Ms Butler said the ANMF has written to the Minister to request a formal meeting on these issues. The ANMF’s national campaign was launched 1 July 2014: Healthcare Emergency - Lies, Cuts and Broken Promises. The federal government launched a devastating assault on Australia’s universal healthcare system. It cut $50 billion in new funding for health over the next decade. Now in 2015 we must fight even harder. The Lies, Cuts and Broken Promises campaign calls nurses, midwives and the community to pledge to take a stand against the federal government’s budget cuts. Supporters are asked to nominate their number one lie, cut or broken promise. Visit

Improvements in aged care Private industry figures show nursing homes more than doubled their profitability on average last year by cutting down on hours of care, particularly from qualified nurses, and other costs per resident.

Ms Butler said coupled with the Abbott government’s withdrawal of the Workforce Compact which allocated $1.2 billion for wages and training for aged care nurses, it was clear profits for providers were being placed above care for the elderly and over the interests of thousands of frontline nurses and care workers across the country. “Alarmingly, recent changes to the federal Aged Care Act could lead to more and more providers being able to replace qualified RNs with care assistants. The ANMF maintains that RNs are essential if the right amount of quality care is to be delivered to elderly nursing home residents.” Ms Thomas said the current aged care workforce needed to triple in size by 2025. “If qualified nurses can’t be recruited into the sector through better wages and conditions, then ultimately, it is older Australians living in nursing homes who will suffer through poorer care outcomes. “There is no doubt the aged care industry is big business. But providers must not be allowed to increase their profits at the expense of patient care.” The ANMF, with the support of our state and territory branches, will continue to pursue solutions to help overcome the workforce crisis in aged care: 1. A registered nurse on site at all stand-alone aged care facilities – 24/7; 2. Minimum staffing levels and skill mix available to ensure adequate care is provided to all residents; 3. An annual review of aged care funding to ensure that wages paid to aged care staff are the same as those in the public health system; 4. A national registration scheme for all assistants in nursing (care workers) who provide nursing care or deliver nursing services; 5. Enhanced transparency and accountability in funding.


February 2015 Volume 22, No.7    5

ANMF Priorities for 2015

Safe staffing and skills mix In 2015, the ANMF will increase its campaign for safe and reasonable workloads for nurses and midwives across the country in acute, community and aged care sectors through mandated staffing and skill mix arrangements, ANMF Assistant Federal Secretary Annie Butler said. International research presented at the Queensland Nurses’ Union’s (QNU, ANMF Queensland Branch) Keeping it Safe symposium last year showed safer nurse staffing levels contributed to a sevenfold difference in patient mortality rates between hospitals. The research of 30 countries by United States’ Center for Health Outcomes and Policy Research conducted by Dr Linda Aiken showed adequate nurse levels and skills mix had a significant impact on patient survival rates, hospital acquired infections and falls. Professor of Nursing at the University of Pennsylvania Dr Aiken estimated 2,000 deaths a year would be prevented in Pennsylvania if the state staffed at the same levels as California which has had mandated nurse to patient ratios since 2004. Since the Symposium the QNU launched their campaign for safe staffing, “Ratios Save Lives” on 21 January 2015. ANMF Federal Secretary Lee Thomas said Australia’s nurses and midwives would bear 6    February 2015 Volume 22, No.7

the brunt of the federal government’s plans to slash $55 billion in state health funding over the next three to four years with an increased load of patients. “It is Australia’s nurses and midwives who are effectively responsible for the day to day operation of the healthcare system who will be the ones who have to cope with the increased load of patients who have delayed seeking care simply because they could not afford it.”

Victorian Premier Daniel Andrews committed to legislate safe patient ratios in the state in his first term in government. The state’s current enterprise agreement requires major metropolitan hospitals to roster ratios of one to four patients during day shifts and one nurse to eight patients during night shifts. ANMF Victorian Branch Secretary Lisa Fitzpatrick said it would be an historic win for nurses and midwives to have safe patient ratios enshrined in legislation and never have to be fought for again. “In 2011-12 our fight for safe patient care took to the streets for eight months as we stood together to ensure Victoria received the level of care they deserve in our public hospitals and aged care facilities.”

Victoria was the first jurisdiction in the world to enact nurse to patient ratios in 2000. The Andrews’ legislation would also prevent nurse substitution by unregistered health assistants.

The NSW Nurses and Midwives’ Association (NSWNMA, ANMF NSW Branch) has reiterated calls for the state government to appropriately fund over-stretched public health services and to implement much needed nurse to patient ratios across the state. The winning of nurse to patient ratios for major metropolitan hospitals in 2010 was a great advance for safe patient care in public hospitals, NSWNMA General Secretary Brett Holmes said. “However, it’s not enough. Both rural and community nurses continue to struggle to keep their patients safe. “We’ve been calling on this government to implement mandated nurse to patient ratios across all public health facilities, particularly in emergency departments, country hospitals and specialty areas, such as paediatrics and neonatal intensive care units.”

ANMF Priorities for 2015

Last year, 205 out of 206 public health system NSWNMA branches voted to pursue the union’s campaign to extend and improve safe nurse to patient ratios. More important to members than a pay rise was the ability to provide safer patient care, Mr Holmes said. “To do that, they need safe, mandated nurse to patient ratios in all our hospitals and community health services. “Nursing care should not be determined by postcodes. Without them, nurses are worked to breaking point and patients suffer from inadequate care.”

Defending the professions The ANMF worked on a range of measures to improve employment opportunities for more than 3,000 Australian nursing and midwifery graduates unable to find permanent jobs. This included the Stop Passing the Buck! Nursing Grads Need Jobs! Australia-wide Facebook campaign; collation of national data on the registered nurse and midwife labour market; and access and analysis with nursing and midwifery regulatory bodies on registered nurse and midwife education, registration and immigration data.

ANMF Federal Secretary Lee Thomas said ongoing lack of employment for graduate nurses remained one of the profession’s biggest workforce issues, with up to 40% of graduate nurses and midwives without permanent employment across all states and territories. An extra 20,000 nurses were desperately needed in aged care alone, she said. “It’s appalling that so many graduates are unable to find work and many feel they have no option than to walk away from their chosen profession.” The December 2014 National Graduate Nurse and Midwife Roundtable, held in Sydney, was convened by the ANMF with nursing leaders and key industry stakeholders. Participants agreed there is a significant problem of underemployment of nurse and midwife graduates, the causes of which are complex and varied. They identified a number of possible causes of the problem, which included: A lack of robust workforce data and planning; inadequate health budget and government structures; and, professionally ingrained cultural beliefs regarding newly qualified nurses and midwives. The ANMF and the working party established out of the Roundtable will focus on addressing these key issues in 2015. “It’s now crucial that we find solutions for Australian graduates and

continue to advocate for funding and structural changes across the industry to secure greater employment opportunities and increase the supply of highly-educated, skilled labour force into the health and aged care sectors,” Ms Thomas said. It was also not enough to find jobs for graduates but to secure meaningful employment, to be able to retain new nurses and midwives, said Ms Thomas. “It’s about defending the professions; we need to find decent jobs for today’s graduates to develop Australia’s future senior nurses and midwives. “We have to continue to fight for the protection of affordable degrees for our professions. “We have more people wanting to study nursing than we have places available, but fees proposed by the government last year will deter many and will simply make nursing impossible for students from lower socioeconomic backgrounds. “We need to be ready. The immediate impact of such radical fee increases on nursing is obvious, but the sinister element lurking in the detail of this Bill is the Abbott Government’s introduction of American-style privatisation of Australia’s universities.” February 2015 Volume 22, No.7    7

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ANMF Assistant Federal Secretary Annie Butler with graduate Ciara Rafferty

Key industry stakeholders

National Graduate Nurse and Midwife Roundtable Key industry stakeholders, including over 30 nursing and midwifery leaders, came together late last year for an unprecedented roundtable discussion on ways of securing employment opportunities for more than 3,000 Australian nursing and midwifery graduates unable to find permanent jobs. The Australian Nursing and Midwifery Federation (ANMF) convened the roundtable due to its concern about the ongoing lack of employment for the graduates. The ANMF said the issue remained one of the profession’s biggest workforce problems, with an estimated 30 – 40% of nurse and midwife graduates, in varying proportions across all states and territories, unable to find permanent employment in their professions over the last three years. The union said over the last decade there had been a significant increase in the number of people completing undergraduate nursing and midwifery courses. This was due to a need to meet an increased demand for nurses and midwives into the future. However the improvement in the numbers of nursing and midwifery graduates had been negated by the lack of employment opportunities for new graduates, a situation that appears set to continue.

and midwives. These include: • The Stop Passing the Buck! Nursing Grads Need Jobs! Australia-wide Facebook campaign; • The identification, sourcing and analysis of national data on the registered nurse and midwife labour market; and, • Engaging with nursing and midwifery regulatory bodies on cooperative arrangements regarding the access and analysis of registered nurse and midwife education, registration and immigration data. The roundtable was a discussion with key stakeholders recognising, with increasing concern, that the situation would only worsen unless people in the position to make real change came together to find solutions to improve employment opportunities for graduates.

The ANMF had clearly stated that this situation was unacceptable. Not only because of the demoralising and devastating effect this has on the graduates unable to find work, but also because of the loss of public investment in the education of qualified nurses and midwives and the loss of the contribution they could make to the health system and the future nursing and midwifery workforce.

The National Graduate Nurse and Midwife Roundtable included representatives of the Council of Chief Nursing and Midwifery Officers, the Nursing and Midwifery Board of Australia, the Council of Deans of Nursing and Midwifery, the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, the Australian College of Midwives, federal politicians, public sector and aged care employers, nurse educators, a number of professional nursing associations and, of course, new graduates themselves.

Due to the critical importance of this issue, the ANMF has been working on a range of measures to improve employment opportunities for newly graduated nurses

The participants worked collaboratively on discussions of the issues, demonstrating their commitment to resolving the problem by dedicating an entire day to the process.

There were featured presentations of varying perspectives on the employment of graduate nurses and midwives from a range of stakeholders, including Ciara Rafferty, a new graduate from NSW, who spoke about her experience practising and working as a first year registered nurse. All participants agreed there was a significant problem of underemployment of nurse and midwife graduates, the causes of which are complex and varied. They identified a number of possible causes of the problem, which included: • A lack of robust workforce data to inform strategic, innovative planning for the nursing and midwifery professions workforce. • A disparity between the number of nurses and midwives graduating and employment opportunities. • Inadequate health budget and government structures enabling a disconnect between federal funding of university places and state funding of public hospitals. • Professionally ingrained cultural beliefs regarding newly qualified nurses and midwives. The Roundtable participants agreed that further work, which focuses on addressing these key issues, was required to resolve the issue of underemployment for graduating nurses and midwives. Thirteen participants committed to be part of a working party to commence this work in the new year and all agreed to reconvene later in 2015 to review progress. February 2015 Volume 22, No.7    9

Clinician Fact Sheet:

Acute Coronary Syndromes The goal of the Acute Coronary Syndromes Clinical Care Standard is to improve the early, accurate diagnosis and management of an acute coronary syndrome to maximise a patient’s chances of recovery, and reduce their risk of a future cardiac event. Clinicians and health services can use this Clinical Care Standard to support the delivery of high quality care.

UNDER THIS CLINICAL CARE STANDARD A patient presenting with acute chest pain or other symptoms suggestive of an acute coronary syndrome receives care guided by a documented chest pain assessment pathway. A patient with acute chest pain or other symptoms suggestive of an acute coronary syndrome receives a 12-lead electrocardiogram (ECG) and the results are analysed by a clinician experienced in interpreting an ECG within 10 minutes of the first emergency clinical contact. A patient with an acute ST-segment-elevation myocardial infarction (STEMI), for whom emergency reperfusion is clinically appropriate, is offered timely percutaneous coronary intervention (PCI) or fibrinolysis in accordance with the time frames recommended in the current National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary Syndromes. In general, primary PCI is recommended if the time from first medical contact to balloon inflation is anticipated to be less than 90 minutes, otherwise the patient is offered fibrinolysis. A patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS) is managed based on a documented, evidence-based assessment of their risk of an adverse event. The role of coronary angiography, with a view to timely and appropriate coronary revascularisation, is discussed with a patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS) who is assessed to be at intermediate or high risk of an adverse cardiac event. Before a patient with an acute coronary syndrome leaves the hospital, they are involved in the development of an individualised care plan. This plan identifies the lifestyle modifications and medicines needed to manage their risk factors, addresses their psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or another secondary prevention program. This plan is provided to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.

More information on the Clinical Care Standards program is available from the Australian Commission on Safety and Quality in Health Care website at

Acute Coronary Syndromes Clinical Care Standard Clinician Fact Sheet, 2014


SA nurse snares election victory for Labor South Australian nurse Nat Cook says she can’t wait until state Parliament resumes this month. The newly-elected candidate in the electorate of Fisher won in a surprise byelection in December which gave Labor the majority to govern the state. Ms Cook snared the votes in a narrow win in her home community of the postcode 5162 where she grew up. “I have lived in the same home for 25 years. Before that I lived at the nurses’ quarters for a short time when training at the Queen Elizabeth Hospital, but I was still at our family home on my days off.” Ms Cook said she only decided to run after long-standing Independent MP Bob Such passed away in October from a brain tumour. “I would never have run while he was in office. I had tremendous respect for Bob. He was a true Independent and extremely good health advocate and very progressive.” Mr Such had won four elections as an independent, having quit the Liberal Party in 2000 . “I am really privileged, I am really lucky,”

Ms Cook said. “You know that to win by such a small margin that every vote counts – I won by nine votes. To have it so tight, you really value the position and I am determined to work hard and prove to the community that I am worthy of their vote.” The win in Fisher gave Labor and Premier Jay Weatherill the 24 House of Assembly seats needed to govern in its own right, after it formed a minority government back in March 2014. Ms Cook, an ANMF member and former worksite rep in the 1990s has been an advocate for her community and set up the Sammy D Foundation with Neil Davis, after their son, Sam, aged 17 and a half, was killed in a one-punch assault in 2008. Mother of Sheree, 29, (Sam deceased, who would be 24), Ty, 13, and Sid, 2, Nat Cook says she looks at the big picture. “I believe in really strong values and that strong and healthy well-informed educated communities make good decisions that are positive and healthy.”

Ms Cook says she envisages this may include decisions for better use of green spaces that would reduce the disease burden in the community and in turn cost less in terms of healthcare in the future. She has already developed a ‘skeleton’ strategic plan to take to the community consultation. “Key areas to focus on are support and access to our great public schools and transport all linking with other local projects which would increase job opportunities in the area,” Ms Cook said. The electorate of Fisher was 10 minutes away from Flinders Medical Centre where she has been for 12 years as an intensive care nurse, including in retrievals, and nurse manager. On the Sammy D website, the Board, staff and volunteers thanked Ms Cook for the “amazing” work she along with Neil Davis had done in establishing, nurturing, growing and leading the Foundation over more than six years. “We will miss her incredible energy, her strength, warmth and humour around the office. We wish her well in her new role as Member for Fisher.” February 2015 Volume 22, No.7    11

News Curriculum in unis needed to protect students from violence Curriculum specific to addressing violence and aggression should be introduced in universities, following research released last month showing an alarming number of Western Australian nursing students subjected to violence on clinical placement. workplace. Students had been punched, slapped, grabbed, bitten and pushed, and some students had sustained an injury from the incident resulting in time off work. In one incident, a patient had attempted to stab a student. About 150 students enrolled in their second and third years of their Bachelor of Nursing degree participated in the study published in Contemporary Nurse. The second year students had their clinical placements in aged care, with the third year students having had placements in aged care, mental health and acute care in WA metropolitan hospitals. Lead researcher Martin Hopkins

More than one third of second year students experienced physical violence in a clinical setting and about half of those students were exposed to more than one incident, in the PhD study from Murdoch University. About 25% of third year students reported physical violence with 40% of those feeling regularly at risk in the

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“What is not shown in the cold, hard stats, which raises the alarm of ‘what is going on here’, is the personal impact on those students. The qualitative data suggests students suffered significant personal, emotional and psychological effects,” Murdoch University PhD student and lead researcher Martin Hopkins said. It is the first ever survey of violence towards nursing students in Australia that recorded both prevalence and type of aggression experienced, Mr Hopkins said.

The majority of violence and aggression had come from patients. Previous research had been done of a similar nature in the United Kingdom 20 years ago, and in Turkey and Italy in the past decade. “Even more importantly, nobody has examined the impact aggression and violence has on nursing students, or how to adequately prepare them,” Mr Hopkins said. The high level of aggression and violence found in aged care was “surprising” and not stereotypical of other areas such as mental health and aged care, Mr Hopkins said. “It could be that with workforce issues, such as low staffing numbers of RNs, student nurses are doing more of the direct care and subjected to that level of aggression and violence.” Addressing violence and aggression towards nurses was a passion of Mr Hopkins. As an emergency department nurse he had been subjected to violence and aggression on a daily basis, he said. Non-physical violence was more of a problem for the students in the study: about 60% of second and third year students experienced abuse from patients, relatives and other healthcare workers. Mr Hopkins said the levels of aggression and violence were serious cause for concern, which could also impact levels of retention in nursing degrees. “Although it was a minority of students who said they considered not continuing their degree, if

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News we lose one student, it’s one too many – we are losing them before we have even generated them.” Zero tolerance to violence was implemented only on a hospital by hospital basis and there were no specific guidelines from government bodies for educational bodies and schools of nursing and health to establish what they should be doing in their curriculum to prepare and protect students, Mr Hopkins said. Murdoch University has now integrated a one-unit two hour tutorial into their curriculum specific to addressing violence and aggression with further follow-up sessions. “From the research we know we can make a difference. We are not going to eradicate the problem but what we can do is to build resilience and coping in our students. Our students now are scaffolded from year one, first semester, in preparation for their first clinical placement,” Mr Hopkins said. “There is a real need for aggression and violence education to be integrated into the nursing curriculum so that students are adequately prepared for clinical settings.”

Reference “Prevalence and characteristics of aggression and violence experienced by Western Australian nursing students during clinical practice,” Contemporary Nurse, 2014: 49(113-121).

Scope of practice and cancer care A professional framework that addresses changes in the scope of nursing practice when caring for cancer patients is needed, according to Sandy McKiernan President of the Cancer Nurses Society of Australia (CNSA). Speaking at the World Cancer Congress held in Melbourne late last year, Ms McKiernan said workforce challenges seemed to be driving changes in the scope of nursing practice, particularly in relation to the role of the enrolled nurse. “In recent times we have seen the expansion of advanced practice roles for enrolled nurses and we are starting to see those nurses working in cancer units. “The questions have been should this happen, and how safe is it along with a range of issues around that. We have many members coming to us saying that this is happening in my unit, my manager says it’s the way it has to be, what should I do?” Ms McKiernan said that although there were processes in place in terms of practice roles for enrolled nurses through the registration process, there was limited opportunities for them to have the same level of education around chemotherapy administration of a registered nurse. Ms McKiernan added this was due to existing chemotherapy administration education programs being specifically

written for registered nurses. “So while it may be in the advanced enrolled nurses’ scope of practice to deliver IV medications, how far does that extend to in chemotherapy?” Employers also needed to be taken to task on the model of care they wish to put in place in their treatment centres, according to Ms McKiernan. “Are they ensuring that there are safety and quality measures being put in around enrolled nurse [drug] administration?” Ms McKiernan said what was needed was a professional framework. “I am happy to say we have started that conversation with some of our education providers. However, on the flip side, our registered nurses still have responsibility of delegation to enrolled nurses and there is a question around do we fully understand what that means.” In order to achieve a framework there needs to be minimum education preparation to develop those capacities, Ms McKiernan said. “It needs to be clearly defined and right now we don’t believe it is.” Ms McKiernan said that an adequate framework to support enrolled and registered nurses was possible, but believed there needed to be a nationally recognised approach on how this was done. “So as to ensure all nurses working in cancer care who are delivering chemotherapy have the same level of expectations for ensuring quality and safety to cancer patients.”

Send Money Online Anytime, Anywhere Instant Cash Pickup Bank Account Mobile Account Door to Door Delivery

Fees from $3.99

Asthma Educator’s Course This 3 day course covers the latest advances in asthma care & provides participants with the knowledge & skills to work effectively with people with asthma to improve their health outcomes. (NB: Optional 4th day on education & presentation skills.) 4 – 6 March 15 – 17 July 11 – 13 November

Respiratory Course This two part, 5 day course is for participants wanting to update & increase their skills & theoretical knowledge in the area of respiratory care & holistic management of the person with respiratory illness. 29 April – 1 May / 27 – 28 May 16 – 18 September / 14 – 15 October

Theory & Practice of Non Invasive Ventilation – Bi-level & CPAP Management This comprehensive & practical day course is for participants wanting an increased understanding of & skills in the management of NIV, Bi-level & CPAP from the ICU to the community carer. 7 August

Managing COPD This 2 day program is for participants wanting to improve their understanding of & update their knowledge in the current treatment & management of COPD. 16 – 17 April 22 – 23 October

Smoking Cessation Course This 2 day, evidence-based course aims to give participants the knowledge & skills to treat & manage nicotine dependency to help people addicted to smoking to quit. 19 – 20 March 23 – 24 July 19 – 20 November

For further information about these & other courses contact the: Lung Health Promotion Centre at The Alfred Phone: (03) 9076 2382 E-mail:

News NMBA update NMBA focus groups on services for nurses and midwives with a health impairment The (Nursing and Midwifery Board of Australia) NMBA, together with (Australian Health Practitioner Regulation Agency) AHPRA, are currently exploring the role of the regulator in the referral, treatment and rehabilitation of nurses and midwives with a health impairment. In mid-February 2015, ACIL Allen Consulting, (on behalf of NMBA and AHPRA), will hold focus groups in Sydney and Adelaide aimed at getting your feedback on this important issue. Please register your interest to participate in these focus groups, by sending an email (indicating your preference of location) to focusgroup@acilallen. There may be an opportunity to participate via teleconference. Please also indicate if this is a preference. More information will be published at in the coming weeks.

Criminal history – your requirement to tell us We would like to remind all nurses and midwives that you have an obligation under the National Law to not only disclose criminal history when applying for registration or to renew registration, but also, within seven days at any time, you are required to provide notice: • if you are charged with an

offence punishable by 12 months imprisonment or more; or • if you are convicted of or the subject of a finding of guilt for an offence punishable by imprisonment. Section 79 of the National Law requires a National Board to check for criminal history before deciding an application for registration. The National Law defines criminal history as: (a) every conviction of the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law; (b) every plea of guilty or finding of guilt by a court of the person for an offence, in a participating jurisdiction

or elsewhere, and whether before or after the commencement of this Law and whether or not a conviction is recorded for the offence; (c) every charge made against the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law While every case is decided on an individual basis, the National Board considers a number of factors when determining how the criminal history may affect your eligibility for registration. The Criminal history registration standard is available under Registration standards on our website

Strengthening international criminal history checks From early 2015, National Boards and AHPRA will implement a new procedure for checking the criminal history of international applicants for registration. The new approach aims to balance protecting the public without delaying the registration process for applicants. For more information, go to the AHPRA website and read the media release.

Survey The Nursing and Midwifery Board of Australia (NMBA) invites you to participate in an online survey as part of a comprehensive review of the understanding and recognition of the NMBA brand and identity. PricewaterhouseCoopers in collaboration with an independent market research company, Colmar Brunton, have been commissioned to conduct this survey to gather feedback and insights to: • get a better understanding of the NMBA’s role as seen by our major stakeholders including nurses, midwives and consumers in general • analyse the significance of NMBA and AHPRA branding and identity (and any possible confusion between the two). We value your participation, so please tell us what you think. Go to: www. to complete the survey.

News National aged care ratings website goes live

Julia Gillard joins beyondblue’s Board

A national website that enables aged care facilities to be reviewed and rated by consumers and healthcare professionals was launched in Melbourne last month.

Australia’s former Prime Minister Julia Gillard, has taken up the position as Director of the Board for beyondblue. The organisation’s chairman Jeff Kennett said Ms Gillard was a great fit for beyondblue. “Julia Gillard will not only bring a great deal of experience to our Board, but importantly the passion for the sector that drove her government to establish the National Disability Scheme, which if professionally and compassionately introduced could be the most important social reform of the century.” Ms Gillard said that as a daughter of a psychiatric nurse, she always understood the need to talk openly about mental health and respond to those in need. “In government I was proud to extend services to help and treat young people battling depression and other conditions. Like Jeff, I believe the NDIS has great potential to assist those in our community who face profound mental health challenges. In my life now I am delighted to be able to continue to make a contribution in an area I feel so passionately about by joining beyondblue.”

The Aged Care Report Card (ACRC) lists aged care facilities Australia wide and is the first ratings website in the industry that allows both consumers and healthcare professionals to share their experiences. ACRC founder and registered nurse Lauren Todorovic said she established ACRC, an independent privately funded company, after she identified an unfilled need in the marketplace. An aged care advocate and ANMF Victorian Branch member, Ms Todorovic said she heard stories of families standing out the front of aged care facilities asking visitors in the car park: “What is this place really like? What is the food like? What is the care like?” The website established a benchmark for excellence through ACRC Quality Index whilst lower rated or poorly rated facilities could work towards lifting customer’s experiences to maintain a high standard of care, Ms Todorovic said.

“A safe environment with quality nursing care is quite simply the primary focus for people entering residential aged care.” This could be overlooked when available information on aged care facilities focused so much on a home’s physical characteristics, pricing, bed availability or extra facilities exclusively, she said. The ANMF Victorian Branch worked with ACRC to develop information that supported some of the website’s seven criteria: staff presence; nursing care; friendliness; quality of food; activities; cleanliness and environment; and management. ANMF Victorian Branch Assistant Secretary Paul Gilbert said the union supported ACRC. “The ACRC tool has the potential to provide real-time information and feedback on levels of quality care, such as the number of staff, the skills and qualifications of staff, resources available and the management culture to name a few.”

Understanding of hospitalisation A simple worded letter that is directed at the patient and given to them prior discharge from hospital can immediately improve their knowledge and understanding of their in-hospital tests and post-discharge recommendations, according to Australian research. The University of Sydney study revealed patients on discharge had very little understanding of the tests that were performed or the recommendations for what they do when they go home. Lack of understanding could lead to health problems including the need for rehopitalisation, the researchers said. As part of the study, a succinct discharge patient letter was formulated, which was well received by participants. The letter covered follow up appointments, medications, and reinforced life style changes. “This is a small change to practice that could make a large difference in patient’s lives, and could prevent subsequent hospital readmissions and their associated costs,” study lead Professor Geoffrey Tofler said. February 2015 Volume 22, No.7    15

News QLD Labor guarantees nurse patient ratios if elected

The development of her entrepreneurial skills emerged while working as a nursing advisor at Sancella Pty Ltd. Then, in 1987, she launched her company, Ausmed Publications Pty Ltd (later to become Ausmed Education Pty Ltd).

Queensland nurses and midwives welcomed the Labor Party’s guarantee to introduce nurse to patient ratios if elected, last month.

Over the years, Cynthea has acquired substantial leadership, management and marketing skills through a combination of on-the-job experience and professional development activities.

Queenslanders went to the polls on 31 January as the ANMJ went to print.

Cynthea forecasts a future where every nurse and midwife is learning online. She states: “Nothing has the power to improve patient care the way education can.”

Queensland Nurses’ Union (QNU) Acting Secretary Des Elder said Queensland Labor leader Annastacia Palaszczuk promised in January to regulate the number of nurses available to patients in public hospitals if the party was elected. Mr Elder said regulated nurse levels would help ensure public patients received the level of care they deserved. “A commitment to install safe nurse to patient ratios provides a ray of sunshine after three bleak years of hospital and health service job cuts in Queensland.” The QNU released figures on widespread cuts across the state last month, from Cape York to the south west of Queensland. “The nurses and midwives who have survived the LNP health cull have told us they are overworked, fearful for patient safety, tired and demoralised,” Mr Elder said. Mr Elder called on all political parties to commit to legislating safe nurse to patient ratios. He said the ALP’s newly announced Nursing Guarantee: patient safety first! policy also included a provision to create a Queensland Bureau of Health Statistics (BHS) to publicly report key indicators of public and private hospitals and health services. The proposed initiative would give Queenslanders greater access to hospital performance statistics, Mr Elder said. “A Queensland Bureau of Health Statistics would effectively allow greater access to hospital performance statistics.”

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Nurse entrepreneur recognised By Bernadette Keane

Cynthea Wellings (pictured), the well-known Director of her own nurse education company, Ausmed Education, has been nominated in the business entrepreneur category of The Australian Financial Review and Westpac 100 Women of Influence Awards. The awards, now in its third year, list the country’s highestachieving women for 2014. The winners have been selected across ten categories. Cynthea has a long-time background as a registered nurse. After graduating as a general nurse at The London Hospital, she gained substantial clinical experience in medical, surgical and emergency departments of teaching hospitals. Following her migration from UK to Australia, she was employed in senior nursing positions in major teaching hospitals in Melbourne. In addition to being a founding member of the Continence Foundation of Australia, Cynthea co-authored two publications: Urinary Continence and Nursing Diagnosis Explained. For four years she held the dual roles of Clinical Nurse Consultant and Continence Service Coordinator while working at the Royal District Nursing Service. During this time Cynthea was also a sessional lecturer in gerontology nursing.

On occasions, Cynthea’s achievements have been acknowledged and rewarded. A specific example is an impressive AusTrade grant, in recognition of the company’s export endeavours. Her commitment to nurse education is evident in the quality and accessibility of Ausmed’s education services, AusmedOnline. After almost 30 years of successfully providing Continuing Professional Development education at a regional and state level throughout Australia, under Cynthea’s leadership, Ausmed aims to become the world-wide leading platform for professional nurse and midwifery education. Having achieved national and international recognition for the Ausmed Education services, Cynthea is a role model for those nurses who make a lateral leap into nurse practitioner/consultant/entrepreneur roles in private practice. This ‘road less travelled’ has the capacity to bring enormous professional satisfaction and success to those nurses who take the entrepreneurial risk.



Nurses supporting nurses Australian nurses now have the opportunity to support African nurses to provide care in Kenya, thanks to the not-for-profit aid organisation World Youth International (WYI).

A donation of around $400 pays a nurse’s wage for one month which ensures nursing care is provided to people living in Odede, one of the poorest communities in Kenya. The Odede Community Health Centre, where the nurses work, was opened in March 2013 and since then has seen and treated over 6,000 patients and has delivered over 250 babies. According to the centre the demand on services is growing every week. In addition to providing general nursing care, the nurses run an HIV/AIDS support program, reproductive and maternal health services, immunisations, community outreach and public health campaigns. The Australian organisation WYI runs and financially support the centre. The organisation’s Chairperson Mark Veitch said the health centre had made a significant difference to the people living in the area. “The centre has not only provided crucial healthcare to the people, but also jobs to

Rotating night shift increases risk of disease An international study has confirmed working night shift can be hazardous to your health. The study found women working rotating night shifts for five or more years appeared to have an increase (19%) in cardiovascular disease (CVD) and those working more than 15 years or more of rotating night shift work appeared to have an increase (25%) in lung cancer mortality. The results add to prior evidence of a potentially detrimental effect on rotating night shift work on health and longevity. The international team studied almost 75,000 registered US nurses, analysing 22 years of follow up information.

Cancer mapped out globally

the community,” he said. According to Mr Veitch WYI had established a seven year strategy to assist the health centre becoming self-sufficient. “The long term success of the health centre depends on its sustainability, but currently we need to provide financial support and clinical expertise to ensure this happens.” Mr Veitch said supporting the nurses by providing their wages was a significant way to ensure they are paid adequately as well as safeguarding the healthcare programs that they run. “We want to ensure the nurses are supported not only educationally but financially. Donating towards a nurse’s wage will make a major difference in their lives and the lives of so many others living in the community.” For more information about the Odede Community Health Centre or to donate to a nurses wage go to:

The study was one of the largest prospective cohort studies worldwide, according to study lead Harvard Medical School’s Associate Professor Eva Schernhammer. “A single occupation (nursing) provides more internal validity than a range of different occupational groups, where the association between shift work and disease outcome could be confounded by occupational differences. “These results add to prior evidence of a potentially detrimental relation of rotating night shift work and health longevity… To derive practical implications of shift workers and their health, the role of duration and intensity of rotating night shift work and the interplay of shift schedules and individual traits (eg. chronotype) warrant further exploration.”

A new global cancer atlas that highlights the complex nature of the global cancer landscape was launched at the recent World Cancer Congress, held in Melbourne. The atlas, which was created by researchers from around the world, also provides strategies to help governments determine what actions they must take to better control cancer. Some of the strategies identified include early detection of cancer, improved awareness among the general public and healthcare providers of early cancer symptoms/signs and vaccine availability for cervical cancer and Hepatitis B. According to the atlas the number of new cancer cases worldwide is predicted to increase from 14 million in 2012 to almost 22 million in 2030 due to population growth and ageing alone. The atlas states Australia and New Zealand have far the highest prevalence of melanoma than any other country; while India, China and other East and Central Asian countries account for nearly half of the world’s new cancer cases and deaths. Lung cancer was reported as the leading cause of new cases and deaths among men, whereas breast cancer was the leading cause of new cases and deaths among women. The atlas also includes the latest evidence from cancer research, including that being overweight is linked with increased risk of cancer reoccurrence and decreased cancer survival. The resource is a publication of the American Cancer Society (ACS) in partnership with the International Agency for Research on Cancer (IARC) and the Union for Cancer Control (UICC).

February 2015 Volume 22, No.7    17

Issues - Beyond 55 Retirement is a dream at 55, but not a reality. Can nurses work until 70?

By Sonia Allen, Catherine Earl and Philip Taylor Sonia Allen

Labour force participation is considered a critical element of productive ageing with a political consensus emerging around the need to prolong working lives. In response, Australian employers have begun developing strategies to attract and retain older workers and meet the needs of an ageing workforce (Brooke & Taylor 2005).

Their approaches clearly vary in their efficacy as barriers to mature age employment in Australia persist (NSPAC 2012). Schofield (et al 2013) proffers the view that extending working lives not only benefits the national economy but also the individual whose retirement savings are maximised when they remain in the workforce until they are aged 65 years or older. But is it realistic to expect everyone to work for longer? Extending working lives for some may be a choice, however, for others it may simply not be feasible. Nursing is a case in point. Physical capacity may not allow for extending a nurse’s working life. The rhetoric of assistive aids to ensure occupational health and safety (OH&S) compliance does not alleviate standing for long hours in theatre during an operation, nor transferring a patient from an ambulance trolley to an Accident & Emergency bed, nor covering shift at short notice, nor working double shifts. Each of these factors, and many more, impact greatly on the health and wellbeing of older nurses. Currently, the older worker is surrounded by a plethora of professionals from Centrelink, banking, legal, medical and other areas to discuss their retirement plans; however, the most innovative component of the retirement question is a new initiative developed by Federation University Australia called the Australian Retirement Research Institute (ARRI). ARRI is concerned with enabling the

18    February 2015 Volume 22, No.7

best possible later life transitions for all Australians, contributing to national economic performance and reducing inequalities in retirement and when working longer. Through a range of projects now underway it is seeking to understand if and under what circumstances longer working lives can be made a reality. References Brooke, L. and Taylor, P. (2005). Older workers and employment: Managing age relations. Ageing & Society, 25:415–429. NSPAC. (2012). Barriers to mature age employment: Final report of the consultative forum on mature age participation. Canberra: Department of Education, Employment and Workplace Relations. Schofield, D., Callander, E., Kelly, S. and Shrestha, R. (2013). A widening gap: The financial benefits of delaying retirement. Melbourne: NSPAC.

Dr Sonia Allen, RN, RM, PhD, MACS, GradDip.HlthSC. BHSM, GCPHE, FACHSM, FARRI, Lecturer, Researcher, School of Nursing, Midwifery & Healthcare, Federation University Australia, Victoria Dr Catherine Earl, BA, GradDipEd, PhD, Research Fellow, Australian Retirement Research Institute, Federation Business School, Federation University Australia, Victoria Professor Philip Taylor, Professor of Human Resource Management, Director, Australian Retirement Research Institute, Federation Business School, Federation University Australia, Victoria

Workforce shortages and retention of older nurses

By Christine Duffield, Elizabeth Graham, Judith Donoghue, Rhonda Griffiths, Jen Bichel-Findlay and Sofia Dimitrelis Persistent shortages of nurses internationally, particularly those with many years of experience, have focused on the need to retain older nurses. The potential loss of corporate knowledge and human capital cannot be understated. An Australian study has identified factors motivating older nurses (>45 years) to leave the workforce prior to retirement or pension age. These included financial (40.1%), health (17.4%) and social (13.3%) considerations (Duffield et al 2014). Importantly, the authors found that for older nurses who choose to remain in the workforce, satisfying work, flexible working hours, social interaction, and no financial disadvantage were motivators (Graham et al 2014). The need for income was the main reason for staying (43%) (Graham et al 2014). In Australia the retirement age (age to access government pension) is currently 65 years increasing to 67 years by 2023 (DoHS 2014), whilst superannuation (self-funded employment savings) can be accessed at “preservation age” or at 55 years for those born before 1 July 1960 (ATO 2014). The Australian government has proposed increasing the national retirement age to 70 years by 2035 (NCoA 2014) amidst growing concern about the financial burden of the baby boomer generation reaching retirement. While very satisfying, nursing work is physically and mentally demanding and there is growing evidence that as nurses become older they self-select positions out of the acute hospital system into community settings (Norman et al 2005). Retention of older nurses in acute hospital settings will require employers to consider strategies which may reduce the workload while compensating them for their experience and knowledge.


Midwifery, Edith Cowan University, Joondalup, Perth, WA Elizabeth Graham,* MMgt, DN, RN, Doctoral Candidate, Centre for Health Services Management, University of Technology, Sydney * Author now deceased

Judith Donoghue, Phd, DNE, BA (Hons), Emerita Professor, Centre for Health Services Management, University of Technology, Sydney References Australian Taxation Office (ATO). 2014. Accessing your super. Australian Government, Australia. Available at: (accessed 13/11/14). Department of Human Services (DoHS). 2014. Age Pension. Australian Government, Australia. Available at: centrelink/age-pension (accessed 13/11/14). Duffield, C., Graham, E., Donoghue, J., Griffiths, R., BichelFindlay, J., Dimitrelis, S. 2014. Why older nurses leave the workforce and the implications of them staying. Journal of Clinical Nursing. IN PRESS (Accepted 19 October 2014). Graham, E., Donoghue, J., Duffield, C., Griffiths, R., Bichel-Findlay, J., Dimitrelis, S. 2014. Why Do Older Registered Nurses Keep Working? Journal of Nursing Administration. IN PRESS (Accepted 31 October 2014).

National Commission of Audit (NCoA). 2014. 7.1 Age Pension, Recommendation 14: Superannuation Preservation Age. Australian Government, Australia. Available at: (accessed 13/11/14). Norman, L.D., Donelan, K., Buerhaus, P.I., Willis, G., Williams, M., Ulrich, B., Dittus, R. 2005. The older nurse in the workplace: does age matter? Nursing economic$, 23(6), 282-9.

Christine Duffield, PhD, RN, BScN, MHP, Director, Centre for Health Services Management, University of Technology, Sydney. Professor, Clinical Nursing and Midwifery Research Centre, School of Nursing and

Rhonda Griffiths, PhD, RN, CM, BEd(Nurs), MSc(Hons), Professor, School of Nursing, Family and Community Health, University of Western Sydney Jen Bichel-Findlay, RN, HScD, MN, MPH, GDipN, BAppSc, DipAppSc, Deputy Director, Centre for Health Services Management, University of Technology, Sydney Sofia Dimitrelis, MPhil, MPharm, BMedSci, Project Coordinator, Centre for Health Services Management, University of Technology, Sydney



20    February 2015 Volume 22, No.7


Feature Job losses, unemployed graduates, cuts to wages and conditions, and attacks on industrial relations. The austerity measures being rolled out in Coalition-held jurisdictions across Australia have come at a cost to our health system, writes Karen Keast. Enrolled nurse Daniel Slavin is one of the lucky ones. In Queensland, where almost 2,000 nurses and midwives have lost their jobs in the past two years, Daniel has regular work as part of the casual nursing pool at the state-of-the-art Gold Coast University Hospital. Despite this, Daniel is considering following in the footsteps of some of his nursing colleagues and pursuing other career pathways.

shift has to work five shifts to get 30 hours and someone like myself, I generally work nights, I work three 10-hour nights. Whereas before we might have got anywhere between 32 to 40 hours a week, every week, now most people are scratching to make 24 to 30 hours so everybody is short.” Daniel says. The hours are not the only changes. The casual pool is no longer booked a month in advance. Instead, nurses are booked just 48 hours ahead of each shift. “It creates a lot of uncertainty and insecurity in the workplace,” Daniel says. “That filters down to wards because they never know whether they’ve got enough staff the shift before.” As chairman of the QNU local branch steering committee at the hospital, Daniel is one of a few nurses and midwives Australia-wide not afraid to publicly voice concerns at the impact of cost-cutting. He says morale is at an all-time low, and many nurses and midwives are afraid to speak out .“There’s no thinking on your feet allowed, everyone is working by the rules and nobody steps outside the rules because there’s so much jumping up and down going on from executive levels,” Daniel says. “There’s lots of people doing good work and lots of people doing exceptional work but the individuals can’t make up for all the institutional failures.”

The bottom line

QLD ENROLLED NURSE DANIEL SLAVIN “There’s a service that needs to be provided, not a business that needs to be maintained”

Daniel, a nurse of 12 years, says budget cutbacks at the hospital have left him feeling frustrated and disillusioned. “There’s a service that needs to be provided, not a business that needs to be maintained. It doesn’t need to run at a profit - it needs to run efficiently and with due regard for patient safety and workplace safety.” Daniel used to work 32 hours a week and receive overtime for any extra hours. But under budgetary measures introduced over a year ago, a cap has been put at 32 hours with agency staff called in, who often travel from Brisbane, to make up the staffing shortfall. “Under the new arrangements, they have changed the day and afternoon shifts to six hours and the night shift to 10 hours. As a general rule, anyone working a day or afternoon

The Abbott Government’s first federal budget delivered a major blow to health, from a $50 billion shortfall in hospital funding for the states and territories to the much-maligned $7 Medicare co-payment for GP visits, out-of-hospital pathology and diagnostic imaging services, and a rise in the price of prescriptions. The government has since handballed the issue of its unpopular GP co-payment directly to GPs. Under new plans, doctors will be forced to consider charging a $5 fee for consultations with nonconcessional patients in a bid to recoup a $5 cut to the Medicare rebate. Australian Nursing and Midwifery Federation (ANMF) Federal Secretary Lee Thomas says the move will still increase patients’ out-ofpocket costs, and she fears it will also signal the end of Medicare. Ms Thomas says the government’s plan to introduce a tax for basic GP services undermines the nation’s universal healthcare system and paves the way for a privatised healthcare system similar to the system now operating in the United States. With the proceeds set to be poured


“I think it’s a package of austerity measures that Australia has never really seen before.” into the Medical Research Future Fund, Ms Thomas says the co-payment will not be used to retire debt or to fund Medicare.“We know that some people already put off going to the doctor until it’s too late and then, of course, they end up in the emergency department and that puts the pressure on our already stretched emergency departments. “We know that significant numbers of people go to the doctor and then never get their prescriptions filled because they can’t afford it. This is before the introduction of a fee to see doctors. So what is the point of all this? There’s no point.” Ms Thomas says the government’s proposed deregulation of university fees and concerns that the cost of a nursing degree could skyrocket to about $70,000 will also hurt the future of the workforce. “There are very few people in the community that won’t be touched by one or more of the austerity measures arising out of the federal budget. I think it’s a package of austerity measures that Australia has never really seen before.”

Queensland - The axe falls Queensland Nurses’ Union (QNU, ANMF Queensland Branch) Secretary Beth Mohle never thought nurses and midwives would be worried about keeping their jobs. “For the first time ever we’ve had members who are fearful of their job security,” she says. “It’s destroying morale, that’s for sure.” With the Liberal National Party elected to power in 2012, the ‘Sunshine State’ has experienced some of the most debilitating cuts to health in the nation. February 2015 Volume 22, No.7    21

Feature nurses and midwives have shown resilience in the face of adversity.” Ms Mohle says giving up is not an option. She wants members to get angry, stand up and fight for their rights. “I think it really is a battle for the integrity of nursing and midwifery. We’ve just got to keep fighting really and have hope.”

ANMF Tasmanian Branch Secretary Neroli Ellis says the union put forward 60 solutions to assist the government to save funds in its health budget. But Ms Ellis says rather than introduce the cost-saving measures, the government seems intent on slashing services and positions. “I’ve never seen demand so high and we have reduced primary healthcare considerably, our GP services are very limited after hours, so all roads lead to emergency unfortunately.

Tasmania - Deep cuts QNU SECRETARY BETH MOHLE “There is an agenda here to drive down wages and conditions, that is what it’s all about”

Since then, more than 1,900 full-time equivalent nursing and midwifery positions have been cut while there are also high numbers of new nursing and midwifery graduates unable to secure employment. Ms Mohle says the government is forging ahead with its privatisation agenda and has introduced significant changes to industrial relations, slashing rights and conditions, and attempting to silence unions. She says nurses and midwives are concerned about workloads and quality of care, and the rising cost of living. “There is an agenda here to drive down wages and conditions, that is what it’s all about,” Ms Mohle says. “We cost them too much. They want to actually drive down the cost of having to deliver health services and we all know the largest cost in healthcare delivery is the wages cost because it’s a staff intensive industry.”

Savage cuts to health are taking a toll on Tasmanian nurses and midwives. In the aftermath of significant state budget cuts in 2011, fewer nurses and midwives have been employed in the public sector with some moving interstate and overseas for work. Hundreds of nursing graduates have also been unable to secure positions. The end result has been more work for fewer nurses and midwives, with many working double shifts, including up to 500 double shifts counted in one month alone, to ensure safe patient care. It is not the only battle nurses and midwives have had on their hands. With the Liberal Hodgman Government elected in 2014, the Tasmanian Branch fought legislation aiming to outlaw reasonable protest action, which proposed penalties such as $10,000 on-the-spot fines and three-month mandatory jail terms, for members who disrupt workplaces.

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“We’ve cut back on child and health services, we’ve cut back on mental health services - so really we are seeing almost the perfect storm, which is really quite frightening going forward.” Tasmania is home to some of the worst health indicators in Australia and despite increasing demands on the state’s health system, the government plans to cull about 1,200 full-time public service jobs.

Ms Mohle says nurses and midwives, like Daniel Slavin, and spanning both the public and private sectors are worried about the quality of care they are able to provide as “dollar-driven healthcare rules supreme”. With an election on the cards in early 2015, the government extended public sector nurses and midwives’ three-year enterprise bargaining agreement, which was set to be renegotiated in March, until later this year - administratively enforcing a lower than inflation pay rise of 2.2%. “Enterprise bargaining negotiations for nurses is about more than the pay and the conditions, it’s about things like quality of care and workloads,” Ms Mohle says. “Our members have effectively been denied the ability to negotiate about that for another 12 months, the government has just pushed it back.” Queensland

TAS REGISTERED NURSE EMILY SHEPHERD “I don’t think we have started to see the real impacts of what all of these measures will mean for the Tasmanian health system and obviously that’s a huge concern as well - the unknown.”

Ms Ellis fears frontline positions are no longer safe. “At the moment there is no way you could remove a single nursing position because we are working unsustainable numbers of double shifts - there’s simply not enough nurses and midwives employed in our public sector in the health system.” ANMF TAS BRANCH SECRETARY NEROLI ELLIS “At the moment there is no way you could remove a single nursing position because we are working unsustainable numbers of double shifts...”

The branch also worked alongside other unions to successfully defeat legislation designed to freeze public sector wages and reduce the powers of the independent Industrial Commission.

A new two-year public sector enterprise agreement was registered before Christmas and the branch plans to continue to provide strategies to reduce system inefficiencies. Registered nurse Emily Shepherd, who is also president of the branch, says Tasmania is yet to recover from the exodus of nurses and midwives, in search of work.

Feature A nurse unit manager at Launceston General Hospital, Emily says the proposed deregulation of university fees could deter people from pursuing a career in nursing and midwifery, further hampering the state’s dwindling workforce.“The deregulation of universities is a huge concern for nurses and midwives in Tasmania, and what that will mean for access to the tertiary education sector for a lot of people, especially in rural and remote areas. Already we are seeing a lack of nurses and midwives in Tasmania, and wanting to stay in Tasmania.” In addition, nurses and midwives are anxious about looming health job cuts and their ability to provide safe patient care. “The thought of losing all of those positions out of the health system is causing a lot of concern for nurses and midwives in Tasmania,” Emily says. “I don’t think we have started to see the real impacts of what all of these measures will mean for the Tasmanian health system and obviously that’s a huge concern as well the unknown.”

NSW - Attacks on industrial relations With nurse to patient ratios in place in major metropolitan hospitals, the New South Wales nursing workforce has been largely cushioned from the state’s public sector job cuts. New South Wales Nurses and Midwives’ Association (NSWNMA, ANMF NSW Branch) General Secretary Brett Holmes says instead the state has witnessed a stream of “stealthful attacks”, particularly on the industrial relations front. Current laws block bargaining on wages and conditions, effectively preventing award negotiations, while the Industrial Relations Commission has been diminished under the Coalition government. Mr Holmes says the state award has been renewed on 12-monthly cycles since 2012, with the government unwilling to negotiate on wage improvements without members trading off their existing conditions. Consequently, nurses and midwives have been left with a modest 2.27% pay increase. “I’ve been at the union for more than 24 years and 16 of those were under Labor governments where there were some pretty tough times and some pretty strong battles,” Mr Holmes says. “But there was always the reality of some level of fairness

Mr Holmes says the small levy, of about five cents for every $100 traded on banks and other financial institutions, will work to counter government plans to privatise public hospitals and essential health services, along with any moves to dismantle Medicare. “It is a viable alternative to the GST which impacts the hardest on low income and middle income people.”

NSWNMA GENERAL SECRETARY BRETT HOLMES “This is certainly a new era in New South Wales where nurses and other public sector workers have had rights taken away and replaced with bloody-minded determinations from the government deciding what the outcome should be.”

and being able to resolve disputes with the independent umpire. “Having the independent umpire neutered from being able to make any real decisions about wages and conditions is very unique and extraordinary. “This is certainly a new era in New South Wales where nurses and other public sector workers have had rights taken away and replaced with bloody-minded determinations from the government deciding what the outcome should be.” The branch is campaigning for tax reform at a national level with the introduction of a ‘Robin Hood tax’, also known as a Financial Transactions Tax (FTT), to financially support Australia’s universal healthcare system.

Registered nurse and midwife O’Bray Smith says the impact of cuts to the public sector, especially across the health system, has spurred her to run as the Labor candidate for Oatley in the March state election. The Baird Government’s unwillingness to negotiate on improving and extending nurse to patient ratios and its privatisation push are major concerns, O’Bray says. “We have got the public hospital in Manly that used to be a fully-funded public hospital but now it’s going to have a public-private partnership. “We know that there’s been hospitals in New South Wales before, that have been privatised and then the government has had to buy them back in poor condition and at a great cost to the public health system.”

Northern Territory Uncertainty reigns After witnessing the impact of austerity measures in other states, ANMF Northern Territory Branch Secretary Yvonne Falckh is concerned at what lies ahead. Ms Falckh says services and jobs have not been cut in the Territory…yet. “The Country Liberal Party that we have in power at the moment are a force to themselves - they do what they like,” she says. “The government may decide to come in and do something to the health service, without bothering to consult with anybody - you will wake up in the morning and find that they’ve passed something because they’ve got the majority, and that things have changed.” Last year, the federal government revealed plans to enable employers to hire overseas nurses on salaries of up to 10 % below the usual rates established for 457 skilled worker visas, to help ease skill shortages in areas such as Darwin.

NSW REGISTERED NURSE AND MIDWIFE O’BRAY SMITH “We know that there’s been hospitals in New South Wales before, that have been privatised and then the government has had to buy them back in poor condition and at a great cost to the public health system.”

Ms Falckh fears the move to employ more overseas nurses could come at the expense of home grown nursing graduates. “You can go to some workplaces in the Northern Territory and the bulk of the workforce are overseas nurses. I would hate to think that employers, not February 2015 Volume 22, No.7    23

Feature Shirel, who is also the branch president, says the 40-year-old Royal Darwin Hospital was built based on a Canadian design and features snow shields on its windows despite the Territory’s searing heat. “It’s just not adequate and they keep patching it up. We need a new hospital but there’s no money to build one.”

Victoria - New hope

ANMF NT BRANCH SECRETARY YVONNE FALCKH “The government may decide to come in and do something to the health service, without bothering to consult with anybody...”

necessarily just public but in the private and especially in the aged care sector, could latch onto that opportunity and use overseas nurses at a lesser rate to increase their own profits.” Shirel Nomoa, an enrolled nurse of 46 years, says recruiting and retaining nurses in the Territory is an ongoing issue but one that could be improved if the government spent more money on infrastructure and services.

The Andrews’ Labor Government, elected to power in November, has promised to enshrine nurse to patient ratios in legislation and pledged to allow private eligible midwives, equipped with a collaborative arrangement, access to public hospitals to provide birthing services. It’s a far cry from the scenes of nurses and midwives rallying and taking action as part of a bitter nine-month-long industrial relations dispute with the previous Coalition Government in 2011-12.

VIC REGISTERED NURSE TARA NIPE “There are just some things we shouldn’t be looking at to generate a profit from and looking after our aged population is part of that.”

“They certainly voted at the ballot box for change.” Registered nurse Tara Nipe says Victorian hospitals and health services struggled with dollar-driven pressures and a privatisation push under the recently ousted government. ANMF VIC BRANCH SECRETARY LISA FITZPATRICK “There was this inertia by the Napthine Government and people desperately wanted action and wanted to see there was something being done.


24    February 2015 Volume 22, No.7

“There was this inertia by the Napthine Government and people desperately wanted action and wanted to see there was something being done.

After a challenging four years of cutbacks, Victorian nurses and midwives now stand on the threshold of a new era.

“It’s a problem everywhere else, they are cutting everything and privatising everything and just doing horrible things but it doesn’t seem to be that they can do too many horrible things with health here because it’s already in a horrible situation,” she says. “Building a new hospital is what needs to happen.”

“We need a new hospital but there’s no money to build one.”

have got long memories.” Ms Fitzpatrick says the state’s nurses and midwives have been baring the brunt of federal cutbacks impacting on state budgets along with a blowout in the elective surgery waiting list, inaction over a sharp increase in reported workplace violence, a failure to deliver 800 beds, and funding slashed for graduate nursing positions.

ANMF Victorian Branch Secretary Lisa Fitzpatrick says it was a “spiteful” negotiation process. “The government sought to reduce the number of qualified nurses and midwives on each shift by substituting them with health assistants and they sought to introduce split shifts,” she says. “Our public sector enterprise agreement is up for negotiation again in April, 2016 - and our public sector nurses

Tara, who has spent 25 years nursing at The Alfred Hospital and is also a workplace delegate, says the former Coalition Government moved to privatise hundreds of public aged care beds. “There are just some things we shouldn’t be looking at to generate a profit from and looking after our aged population is part of that. Privatising all of these aged care beds when we’ve got an ageing population how does that make any sense at all? “There is a focus with the government, at both a (now former) state and federal level, of looking at what appears to be profitable in the short term rather than having any awareness of how much more expensive that is in the long term.”

Legal Poor communication leads to poor outcomes Linda Starr

Much can be learnt from coronial inquest findings given that the Coroner’s role effectively has a function in regulating the conduct and activities of people in our society (McIlwraith & Madden 2014). The Coroner in each jurisdiction has power through Coroner’s court legislation, albeit there are variations within individual jurisdictions on the breadth of their powers. However, coronial jurisdiction is enlivened in all cases where the death occurs as an unexpected outcome of healthcare. It is at these times where health professionals involved in the care of the deceased may well become actively engaged in a coronial hearing as in the case of the Inquest into the death of Judith McNaught in 2012. In this case, the deceased, Mrs McNaught, was a fit 69 year old woman when she went into hospital for a laparoscopic cholecystectomy. Unfortunately a postoperative bile leak caused peritonitis and she passed away five days later. The cause of death was septic shock as a result of biliary peritonitis. In all, the Coroner identified four broad issues at the inquest one of which was whether the postoperative care provided to the deceased was appropriate. Poor communication and poor documentation significantly underpinned the lack of appropriate and timely intervention and care of the deceased. On this point the Coroner noticed a significant failure of her MO in his documentation and communication skills right from the first postop day, when he decided that she was not fit for discharge as planned, and should be kept in for at least another day. He failed to make any note of this or his rationale for the decision in her records. Had this been done it is arguable the events that followed would not have escalated to the point that the deceased could not be saved. At the very least it was argued that if this information had been recorded it was likely that the deceased would not have been transferred from the surgical unit (SU) to the rehabilitation unit (RU) where she would not be observed as frequently as she should have been. On the second post-operative day the SU MO was requested to come and re-examine the deceased after the RU staff noted some deterioration in her health. Whilst he did this, it was not an immediate response to this urgent request creating a further delay in any possible intervention. In evidence it

was clear that the MO had identified three potential provisional diagnoses, however, he failed to communicate these to the team and failed to record these in her notes. He also failed to note his intentions of returning her to theatre later that day. In fact, there was no record made of the discussions and outcomes of the conversations between the MO in the RU and the SU once the deterioration was noted. The adequacy of the documentation in the nursing notes was also criticised; these were poorly completed, particularly with regard to the need for frequent observations after she arrived at the RU – something that is not routinely done in that unit. The Coroner also determined that the poor record keeping in the RU directly contributed to the MEWS score of 3 to be missed. Consequently a MO was not called which was procedurally required in those circumstances. A further missed chance for review and another delay. Inadequate communication between the surgical team was starkly evident. The Coroner found that the MO’s failure to communicate his provisional diagnosis, future management and intervention meant that no one in the team knew what he was thinking. As such there was no communal awareness that the complication of sepsis was being considered, adversely affecting the ongoing management and observation of the deceased. Furthermore, miscommunication regarding the triple antibiotics that should have been given prior to the surgery was seen to be a critical omission, given the expert evidence noting that there was a direct correlation between commencing these drugs in a timely manner and survivability in these cases. A further issue in this case was the practice at the time, where decisions as to which patients would be transferred from the SU to the RU was made independently by nursing staff without medical consultation. The decision to transfer the deceased was made due to the need for a surgical bed to be released for an acute patient. Both the SU MO and the RN in the RU gave evidence that they did not think this patient was an appropriate patient for the RU. On this point the Coroner concluded that a much

more stringent process for transferring patients from SU’s to RU’s needs to be in place, including a requirement for medical consultation. It was determined that bed shortages whilst a very real concern to hospitals should not be the driver in decision making to transfer patients to a lower dependency unit. It was clear that by the time this case was heard, there had been some significant changes in practice and procedure at the hospital. However, the Coroner noted with concern that surgical patients were still being transferred to the RU and the nursing staff continued to be concerned around these procedures. He further noted that several of the MO’s in this case did not appear to have shown any ‘objective signs of self-searching reflection’ that would have reassured the public that their conduct in a future similar case would be different. Given the evidence heard at the inquest raised concerns about the practice of these MO’s and their management of the deceased’s post-operative care a decision was made to refer the matter to the Australian Health Practitioner Regulation Agency where their professional peers could give consideration to the standard of their practice. This case once again demonstrates how crucial good communication skills in both verbal and written form are to the overall wellbeing of those in our care. References McIlwraith J & Madden B. 2014. 6th ed. Health Care and the Law. Thomas Reuters Law Book Co. Australia Inquest into the Death of Judith McNaught 2012 (Qld).

An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia February 2015 Volume 22, No.7    25

Clinical update Ageing with HIV

Emily Wheeler and Karen Seager Over the last 35 years, HIV has been transformed from what was once a fatal illness to a chronic condition that people can manage. By 2020, 50% of all people living with HIV in Australia will be over 50. Improved antiretroviral (ARV) medications mean people living with HIV can expect to have the same lifespan as people who do not have HIV. As individuals with HIV are living longer and reaching old age, they are now accessing aged care services and requiring nursing support for their increasingly complex comorbidities. This clinical update on HIV and ageing discusses the role of nurses and aged care workers in caring for older people with HIV in the community setting. Fear of ageing and aged care Many people fear getting old and facing the possibility of needing aged care whether they have HIV or not. People living with HIV have expressed added fears directly related to HIV infection. “I am scared of being gay and isolated in aged care and I’m scared of being HIV positive in aged care.” (Lillicrap, 2014) Older gay men in particular may be worried about having to hide their sexuality in order to gain access to aged care at all. Will they be doubly judged – first for being gay and second for having HIV? Will those with same sex partners be allowed to enter the same facility and continue their relationship emotionally and sexually? Will they still be able to access treatment and care for HIV as well as other conditions of the ageing process? What choices will there be in the type of aged care available? “[I] don’t want to be isolated in an aged gay ghetto, but neither do [I] want to be a marginalised individual whose life and loves are regarded too risky to talk about.” 26    February 2015 Volume 22, No.7

Who has HIV infection? • The number of people over 65 living

with HIV grew 10-fold between 1996 and 2006 (UNSW 2014). • By 2020, 50% of all people living with HIV in Australia will be over 50 (Slavin & Ogier 2011). • In 2013 13% of new HIV diagnoses were in people aged 50-59; 5.9% were aged over 60 (Kirby Institute 2014). The most common way of spreading HIV in Australia is through sexual contact between men. From 2008 to 2012, 67% of new HIV diagnoses were in men who have sex with men (MSM) (Kirby Institute 2013). In the same period, 25% of new HIV diagnoses were in the heterosexual population; 2% of cases were diagnosed in people who inject drugs; and the cause of infection was uncertain in 6% of new HIV diagnoses (Kirby Institute 2013).

Treatment and antiretroviral (ARVs) medication The aim of taking ARVs is to decrease the HIV viral load, to limit the damage to the immune system and allow the immune system to restore itself. Ideally the viral load should be undetectable. HIV is treated by combining different classes of drugs (usually with three or more drugs), each one blocking different parts of the HIV virus life cycle and stopping the virus from multiplying: • Entry inhibitors work by stopping HIV getting into the CD4 cell; • Nucleoside/nucleotide reverse transcriptase (NRTIs) and ‘non-nucleoside reverse transcriptase inhibitors’ (NNRTIs) drugs stop HIV changing from a single strand of RNA into a double strand of DNA; • Integrase inhibitors block HIV from being combined into the cell’s DNA; • Protease inhibitors work at the last stage of the HIV life cycle, blocking new HIV from being cut into the right size proteins to be assembled into the final form for release from the infected CD4 cell.

Adherence to treatment and side effects Once treatment has commenced, it is usually lifelong. People living with HIV who need long term aged care will usually continue with their HIV treatment and may also be taking multiple non-HIV-related medications. Continuing to take ARVs as prescribed will prevent HIV progression. Most people with HIV are stable on their ARV treatment and the new generations of medications cause significantly fewer

side effects. However, common mild side effects include nausea, diarrhoea or insomnia and long term side effects may include osteopenia and kidney problems. Over time some people may alter their ARV regime as newer treatments are developed or as they experience side effects. *As with all medications, side effects may make it difficult for the individual to continue to adhere to the treatment, however the nurse is able to support the client to regularly take their HIV treatment as prescribed. If they suspect the client is not adhering to any treatment regime (not just for HIV) or notices changes in the client’s behaviour or health which could be due to side effects (eg. reduced appetite, vomiting), the nurse should discuss this with the prescribing physician.

Resistance to ARVs If a person often misses a dose, stops taking ARVs for a few days or has multiple breaks off treatment, the virus has a chance to mutate, which may lead to drug resistance, requiring the regime to be altered. *Nurses can encourage people with HIV who are on ARVs to take them as prescribed. People living with HIV need to take their medications at least 95% of the time, equivalent to missing one dose per month.

ARVs and drug interactions The combination of HIV infection, ageing and co-morbidities results in the need for multiple medications. When a new medicine is needed, the doctor must make sure that any drug they prescribe can be taken safely with all other drugs the patient may be on. *Nurses should discuss, with the treating physician, any changes they notice in their client’s behaviour after a new medication is started as it may be a sign of a drug-drug interaction.

Prescribing ARVs/Pharmacy dispensing Treatment with ARVs is usually organised through a specialist service. All ARVs are controlled by the federal government in a scheme called Section 100. Only specially trained doctors (some hospital based specialists, sexual health physicians and some GPs) can prescribe them. ARVs are usually only dispensed by a hospital pharmacy, two months at a time with one repeat prescription, although after 1 July 2015 some community pharmacies will

Clinical update begin dispensing ARVs. As a result, it may be difficult for some people to access HIV services and they may need to travel long distances to see a doctor with specialist knowledge of HIV and collect their medication. As the person ages, this may become more difficult or even impossible.

HIV: The Facts Table 1: The Facts about HIV

Frequency of infection

At the end of 2013, there were about 26,800 people in Australia living with diagnosed HIV infection (Kirby Institute 2014).


There is no vaccine for HIV. HIV infection cannot be cleared by the body and infection is for life.

How it is spread

HIV is transmitted through blood-to-blood contact, unprotected sexual contact and from mother to baby during pregnancy or childbirth.

Signs and symptoms

Early signs and symptoms may include: • flu-like illness • rash • fever HIV damages the immune system and if left untreated, can progress to acquired immune deficiency syndrome (AIDS). More advanced disease symptoms may include opportunistic infections, cancer and weight loss.


Antiretroviral treatment (ART) is available for HIV infection. Treatment does not cure HIV infection, but it stops the virus reproducing and minimises damage to the immune system and progression to AIDS.

HIV and ageing For most people, HIV infection is now a chronic condition that can be managed over a long time, due to improved ARV medication. As a result: • People living with HIV can expect to have the same life span as people who do not have HIV; • Many people taking ARVs for a long time do not die from causes linked to the HIV virus; • HIV infection can cause severe damage to the immune system. For some people, this may result in much earlier cardiovascular, renal, cerebrovascular and bone disease. Many people with HIV are starting to suffer from age-related illnesses and frailty. Frailty can occur much earlier in people with HIV infection, especially if they have advanced disease. As with the elderly, frailty can result in an increased risk of falls, hospitalisation, disability and death. People in aged care will experience a number of symptoms due to both HIV and ageing eg. fatigue, weight changes, memory loss, depression and malnutrition. There are a number of conditions that make up the syndromes of ageing: • Falls and gait disturbance; • Declining cognition; • Incontinence; • Altered mood; • Altered organ reserve; • Sarcopenia; • Polypharmacy. People living with HIV have an increased risk of developing co-morbidities. They may also develop them at a younger age than the general population. Long term use of ARVs can cause a number of these co-morbidities and this is known as ARV toxicity (see Figure 1).

Medical management Complex care needs Most people with HIV admitted to residential aged care facilities will also have a number of non-HIV medical conditions eg. dementia, diabetes, heart disease, chronic lung disease, osteoporosis and

What is the risk of getting HIV infection? Type of contact

Level of risk

Sexual contact Unprotected anal (receptive)

Very high

Unprotected anal (insertive)


Unprotected vaginal


Unprotected oral (cunnilingus and fellatio, receptive and insertive)

Very low

Mother to child (perinatal) No intervention


With intervention


Occupational exposure (needlestick)


Sharing injecting equipment among people who inject drugs

Very high

Unsterile tattooing and piercing


Unsterile medical and other procedures


Some evidence of higher risk for male-to-female than female-to-male transmission b Proven interventions include antiretroviral therapy, caesarean section and avoidance of breastfeeding. a

February 2015 Volume 22, No.7    27

Clinical update Figure 1: ARV Toxicity

ARV Toxicity



Cardiovascular disease Renal disease Liver disease Osteopenia Sarcopenia

Cardiovascular disease Renal disease Liver disease Osteopenia Sarcopenia

Cancer Cognitive decline / dementia Mitochondrial damage Depression Social isolation

HIV & Ageing = Increased co-morbidities

Cancer Cognitive decline / dementia Mitochondrial damage Depression Social isolation


possibly cancer. It is still unclear whether people living with HIV experience these co-morbidities related to their age at higher rates and earlier than the general population. It is also unclear why non-AIDS co-morbidities such as diabetes, high blood pressure, heart disease and cancer more often affect people living with HIV. Although there are no clear answers as to what causes premature ageing of people living with HIV, there are a number of factors that may contribute as shown in Figure 2. People with HIV in residential or community aged care services therefore, may have complex care needs. Care delivery should include, but not be limited to: • a Shared Care Plan, coordinated by a case manager to bring together all support people such as the GP, specialists, other clinicians, support agencies, family and carers • ongoing review of medical needs; • support of the person to take their medication correctly; • looking out for drug interactions; • help with access to specialist services when necessary; • access to legal advice such as: – guardianship – advance directives – end of life care. All HIV care providers need to address the multiple co-morbidities that are already common in the ageing population and will now be seen in people living long term with HIV. The person’s GP can manage nonHIV-related medical illnesses.

Mental health issues NORMAL AGEING (Average age in many clinics now around 50)

DRUG TOXICITY (For example tenofovir and renal disease)


LIFESTYLE RISKS (Smoking, drug and alcohol abuse)

Persistant immune dysfunction and inflammation

A recent report shows that older people living with HIV are five times more likely to suffer with depression than people of the same age without HIV. The risk of suicide increases with age and HIV, so it is important to be aware of people in care expressing comments relating to hopelessness, despair or suggestive of self-harm. In addition, older people with HIV are more likely to experience stigma, rejection and abandonment amplifying anxiety, isolation and drug and alcohol dependence. Many older people with HIV are members of minority groups (eg. gay men, transgender, people who inject drugs) and may experience additional stigma, isolation and discrimination.

Cardiovascular disease Deeks, S.G et al. BMJ 2009;338:a3172

28    February 2015 Volume 22, No.7

The risk of cardiovascular disease increases with age, and includes both coronary heart disease and cerebrovascular disease. People with HIV are at higher risk than

Clinical update those without HIV, even after controlling for traditional cardiovascular risk factors. Smoking, high blood pressure and diabetes are all associated with the risk of death during treatment for HIV infection.

Osteopenia/osteoporosis In people with HIV infection, the use of ARVs increases the risk of osteopenia and osteoporosis. Falls resulting in hip and wrist fractures are the most common injuries associated with ageing and osteoporosis. Some women with HIV may experience a premature menopause which will increase their risk, at a younger age, for osteopenia or osteoporosis.

Neurocognitive abnormalities The ability to memorise information and learn new skills can be exaggerated by HIV infection through HIV associated neurological disorder (HAND). Up to 40% of people with HIV will experience HAND, however, early intervention may improve signs and symptoms. In addition some people living with HIV may develop other dementias such as Alzheimer’s disease or vascular dementia. *Nurses often have a close relationship with their clients and are ideally placed to notice changes in their client’s mental, neurocognitive and physical health. Nurses caring for older people with HIV should facilitate health assessments and consider referral to appropriate specialist services where needed.

Stigma and discrimination HIV is an infection that many people have fears, prejudices or negative attitudes about. People do not always recognise their own behaviour as discriminatory. Some common examples of discriminatory behaviour towards people with HIV are: • not making eye contact; • speaking sharply or abruptly; • using different infection control precautions depending on known or suspected HIV status; • physical abuse; • refusing care or providing substandard care, eg. not spending enough time on their needs; • blaming the person for their HIV status; • avoiding touching people living with HIV or only touching when wearing disposable gloves; • making assumptions about risk behaviours (eg. sexuality, injecting drugs, unsafe sex practices) based on the patient’s HIV status; • disclosing the person’s HIV status without their consent.

Legal rights and responsibilities – Disclosure There are very few situations where, by law, someone must disclose their HIV status. A person with HIV using aged care services is not required to tell their health professionals about their HIV status. Therefore, as in any health service, nurses may not be aware they are providing services in residential or community care to a client with HIV. Both state and federal privacy laws, impose confidentiality on people working in healthcare services, requiring that health professionals must not collect information that is unnecessary or intrusive and must not disclose information without the consent of the person concerned.

age than the general population. Long term use of ARVs can cause a number of these co-morbidities. The normal ageing process, lifestyle risks, ARV toxicity and persistent immune dysfunction and inflammation all contribute to premature ageing in people with HIV. Adding to the complex care needs are mental health issues, cardiovascular disease, osteopenia/osteoporosis and neurocognitive abnormalities; all higher risk factors for those living with HIV. Nurses caring for older people with HIV in the community should be aware of the impact of HIV on ageing and their clients’ physical, mental and neurocognitive health. Collaboration with the interdisciplinary team is essential to ensure clients remain well.

The health worker may disclose information if it is directly necessary for the treatment or care of that person eg. the disclosure of medications necessary for the treatment and care of the client where the client is transferred to hospital. However, the nurse should not disclose the client’s HIV status to a paramedic when the ambulance was used just as a form of transport. Standard precautions are the minimum requirements for infection control and ensure a high level of protection against all bloodborne viruses and other infections. These standard precautions should be taken by all people who have contact with blood, body fluids, broken skin, and eye, nose or mouth surfaces, regardless of whether the client has HIV. Standard infection control precautions must be used when dealing with all blood and body fluids. This must be kept in mind when deciding whether disclosure is necessary. Following infectioncontrol procedures will help protect health professionals from occupational exposure to all blood-borne viruses (and other infectious diseases) not just HIV. There is no reason to treat a client differently because of known or suspected HIV infection.

This clinical update was adapted from the latest addition to the ASHM profession based booklet series; Aged Care Workers and HIV and Ageing. With clinical information written primarily by Dr Virginia Furner (Albion Centre, Sydney), the development of the resource was overseen by a reference group. The ASHM resource, originally intended for Aged Care Workers, will be useful for nurses and can be ordered or downloaded free from:

* Nurses may need to challenge their own beliefs and attitudes towards such issues as sex and sexuality (including same sex relationships, transgender and intersex people), injecting drug use, fears of and knowledge of HIV in order to provide the best possible care for people with HIV.

The Kirby Institute (2013). The University of New South Wales, Sydney, NSW, HIV, viral hepatitis and sexually transmissible infections Australia Annual Surveillance Report 2013. The Kirby Institute, UNSW, Sydney.

ASHM is the peak Australasian organisation supporting HIV, viral hepatitis and sexual health workforce Reference: Lillicrap,J. (2014) What’s Next: Thoughts and Fears of moving into Aged Care with HIV: QPP Alive Autumn Slavin S., Ogier A (2011) HIV and Ageing: Research findings, personal perspectives, clinical complications and future planning. Accessed on 2 June 2014 at: and%20Ageing.pdf The Kirby Institute (2014)., HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2014. The University of New South Wales, Sydney, NSW, The Kirby Institute, UNSW, Sydney.

UNSW, Mapping HIV outcomes: geographical and clinical forecasts of numbers of people living with HIV in Australia. Accessed 2 June 2014 at: http://www. FinalModHIVoutcomesAusRep.pdf

Conclusion Many people with HIV are starting to suffer from age-related illnesses and frailty. People will experience a number of symptoms due to both HIV and ageing eg. fatigue, weight changes, memory loss, depression and malnutrition, and are at a greater risk of developing co-morbidities at a younger

Emily Wheeler, is the Nursing Program, National Policy and Education Division Manager, ASHM Karen Seager is the National Policy and Education Division Senior Project Officer, ASHM February 2015 Volume 22, No.7    29

Research Incidental exercises could save lives Incidental physical activity such as walking to catch the train to work or cycling to the shops could improve people’s health saving up to $12.2 million in the health sector and $22.9 million lost in production, a Melbourne study has revealed.

Nurses’ role essential at end-of-life Nurses play a much greater role in decisions surrounding treatment of terminally ill patients than previously thought, a University of Queensland (UQ) study has found. Research lead Associate Professor Alex Broom said dying patients would often turn to nurses for support. “Nurses spend so much time with the patients that they are often in a better position than doctors to know how patients are really coping with often highly toxic, technically life prolonging treatments.” The study found patients would often put on a brave face when their doctor was present and then asked the nurse to tell the doctor they had enough, Dr Broom said. “This can put the nurses in a difficult position professionally, placing them as the mediator between doctor, patient and often-panicked family members.”

Heart condition twice as common in Indigenous Australians Aboriginal and Torres Strait Islander people are twice more likely to suffer from a serious heart rhythm disorder than non-Indigenous people research shows. The study from the University of Adelaide based its findings on data of more than 200,000 people managed at the Royal Adelaide Hospital over a 10-year period in South Australia. The study was the first of its kind to determine the prevalence of atrial fibrillation among Indigenous Australians. 30    February 2015 Volume 22, No.7

A major problem for nurses was some doctors avoided difficult conversations, while others were rushed or blunt, leaving the nurse to explain the situation and provide emotional support to patients and their families, Dr Broom said. Nurses in the study emphasised the emotional toll of caring for patients and families at the end-of-life, the need to balance caring with protecting themselves from burnout, and the fact that there was very limited debriefing or counselling provided. While the nurses discussed the rewards of being involved in the transition to the end-of-life care, they emphasised the mounting pressures on the nursing professions and how this could compromise their capacity to support patients nearing end-of-life.

Study lead Dr Christopher Wong said the findings also showed Indigenous Australians diagnosed with atrial fibrillation were significantly younger, with an average age of 55 years compared with 75 years for non-Indigenous Australians. “We confirmed the results of previous studies showing that Indigenous Australians develop other cardiovascular diseases and at a younger age. Our study now shows, however, that atrial fibrillation (AF) can be added to the list of conditions contributing to the greater burden of death and disease being experienced by Indigenous Australians.” In addition Dr Wong said the study

The study, conducted through Deakin University Population of Health, analysed the daily travel patterns and incidental physical activity, such as time spent walking to get to transport, of over 29,000 people in Melbourne. People in the inner city were found to be more than six times more likely to get sufficient physical activity from travel compared with people living in the outer suburbs. The results of the study revealed hundreds of lives and millions of health sector dollars could be saved from the minutes of incidental exercise associated with active transport. Research lead for the study Dr Margaret Bevis said giving people a choice whether they took public transport, walk, cycle or drive had major impacts on health outcomes, both on an individual level and for the whole population. “The World Health Organization declared physical activity a “best buy” in 2012 when it comes to disease prevention, because 30 minutes exercise daily significantly improves outcomes in so many diseases and reduces premature death rates by 20-22%. “Making active transport an easy option would go a long way to turning the tide on Australia’s rapidly rising levels of diabetes and other health issues such as depression and dementia.”

identified Indigenous people with AF had significantly larger diameters in the left atrium of the heart, and greater rates of dysfunction in the left ventricle. “These differences in cardiac structure and function may in-part explain the excessive prevalence of AF seen in younger Indigenous people which is likely to be contributing in life expectancy between Indigenous and non-Indigenous Australians.” Dr Wong said based on the study results it needed to be determined whether strategies to prevent and manage atrial fibrillation could help reduce the burden of the condition seen in Indigenous Australians.

Professional ANMF Setting the Standard

Julianne Bryce, Elizabeth Foley and Julie Reeves, Federal Professional Officers A warm welcome to Julie Reeves, a much needed addition to the Professional Team. Julie has come to the ANMF Federal Office from her role as Senior Policy Officer at AHPRA. Already in the last four months, her clinical, education, policy and regulation background has proven a fabulous asset to the work of the Federation. Julie arrived just in time to assist us with completing the 18 month review project of the ANF Competency Standards for Nurses in General Practice. The new standards, funded by the Australian Government, are now titled National Practice Standards for Nurses in General Practice and were finalised in December before they were submitted to the Department of Health. These standards are of great importance as the number of nurses choosing to work in primary healthcare, and particularly general practice, is continuing to grow. In the last 10 years, numbers of nurses in general practice have doubled, with now nearly 12,000 nurses working in this setting and over 63% of practices employing at least one nurse. It is essential that we clearly articulate what constitutes best practice for registered nurses and enrolled nurses involved in and being attracted to this increasingly popular area of practice.

ANMF NAtioNAl PrActice StANdArdS for NurSeS iN GeNerAl PrActice

THE PRACTICE STANDARDS FOR NURSES IN GENERAL PRACTICE over view All Australian nurses must meet the national registration standards defined by the NMBA(1, 3), as well as the range of professional codes, standards and guidelines relevant to nursing practice and nursing in general practice. These ANMF ‘National Practice Standards for Nurses in general practice’, build on the NMBA foundational documents to be included in the professional practice framework for nurses working within the Australian general practice setting.

Australian Nursing and Midwifery Federation Standards funded by the Australian Government Department of Health

The Core Professional Standards for the registered nurse and enrolled nurse in this document reflect the Bachelor of Nursing and the Diploma of Nursing as the minimum education qualifications for nurses respectively(1, 3). Therefore, the registered nurse and enrolled nurse standards describe the minimum level at which a registered nurse or enrolled nurse would be expected to practice. It is recognised that many registered nurses in general practice are working at, or have the capacity to work at, a higher level than the minimum standard for registered nurses. To this end, the registered nurse (advanced practice) performance indicators build upon the knowledge and skills of the minimum standard for registered nurses to provide both a measure of higher level practice and also a framework to guide professional development. It is anticipated that most experienced registered nurses will meet a combination of registered nurse and registered nurse (advanced practice) indicators across standards based on their individual nursing experience, continuing professional development and post-graduate education. Registered nurse (advanced practice) performance indicators that are not yet met will assist the registered nurse in identifying potential areas for future continuing professional development and/or post-graduate education.


Enrolled nurses seeking to practice beyond the scope of the performance indicators are encouraged to seek professional development opportunities to facilitate their transition to formal university education. Without the completion of formal tertiary studies to achieve a Bachelor of Nursing (or equivalent) the enrolled nurses’ practice is limited to their educational preparation in accordance with their registration to practice as an enrolled nurse with the NMBA.

ANMF National Practice Standards for Nurses in General Practice

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The project was completed in collaboration with our research partner the University of Wollongong, led by Dr Elizabeth Halcomb, Professor of Primary Health Care Nursing, and ably assisted by the ANMF Professional Team which also included Christine Ashley, ANMF Project Officer. It was a huge undertaking but we are delighted to have produced a quality document following wide-ranging consultation. Of course, we couldn’t have done any of it without input from the profession. The team here at Federal Office would like to

thank the hundreds of nurses who generously committed their time to participating in the research, reviewing the successive drafts and contributing to the national standards. We also acknowledge the significant contribution of the Project Advisory Group and Reference Group members to the research and development of these standards. To accompany the standards we are revising the Standards toolkit to include a self-assessment tool for use against the standards, a professional development plan and portfolio, sample advertisements, job descriptions and sample interview questions. The new national standards and toolkit will be available on the ANMF Federal Office website within the next few months. These documents will be developed into a free e-book which can be accessed through the Apple i-book app around the middle of the year. Another project we have been working on is the National School Nursing Standards review. In 2009 the Victorian School Nurses ANMF Victorian Branch Special Interest Group published a set of professional practice standards specifically for nurses working within a school setting. ANMF Federal Office was invited to adapt these standards for national applicability. Following consultation, we launched the National School Nursing Professional Practice Standards in 2012, and made them available through our website. These national standards included an opportunity to provide feedback on their applicability for school nurses and school communities. We made a commitment, on release of the document, to commence a review of the standards in 2014. It’s been pleasing to see the number of school nurses who have downloaded and read the standards document. Our professional team is now proceeding to formally review these standards. We have

New ANMF Federal Professional Officer Julie Reeves

invited all school nurses across Australia to contribute your views on the standards. Already we’ve received significant feedback from nurses working in a range of school settings and in different jurisdictions. These comments have highlighted the need for the standards to reflect the variation in school nursing practice and to provide broad guidance for their national applicability. We wish to express our thanks to those who have undertaken extensive work to provide feedback during past months and assure you that all your comments will be considered during this review process. It’s still not too late to contribute, feedback remains open until 13 February 2015. In addition to developing and revising standards for nursing and midwifery practice, the ANMF Professional Team contribute to work led by the Australian Nursing and Midwifery Accreditation Council (ANMAC) and the Nursing and Midwifery Board of Australia (NMBA) on both education and entry to practice standards. Keep an eye out for the work ANMAC have just completed on the revision of the midwife accreditation standards, the re-entry to the register and entry programs for internationally qualified (EPIQ) registered nurse accreditation standards, and the nurse practitioner accreditation standards. The NMBA will soon be releasing the revised enrolled nurse standards for practice. Finally, just a reminder that the public consultation phase of the NMBA’s review of the registered nurse standards, which started midway through last year, will be commencing shortly. We’ll keep you posted on all standards under review so you can take the opportunity to contribute your views. We are looking forward to continuing to work with our members in all the states and territories in 2015. February 2015 Volume 22, No.7    31

Focus - Aged Care Robin Digby with an older person

Engaging with people with dementia in subacute care By Robin Digby, Allison Williams and Susan Lee People with dementia can find hospital admission frightening and intimidating due to the unfamiliar environment, faces and routines (Hermann, Muck, and Nehen 2014). The resultant anxiety can lead to disturbed behaviour including wandering, aggression, falls, injuries, deconditioning and a longer length of stay (Galvin et al 2010). In sub-acute care older patients may spend three to four weeks or longer in rehabilitation or waiting for placement in residential care. Guardianship hearings which impact on discharge planning may take six to eight weeks before they are resolved. Many of the patients complain of boredom and restlessness. It is common in residential facilities that diversional therapy is either run by qualified staff or volunteers, who may organise group games and activities such as reminiscence or singing. Despite this many sub-acute care facilities have little or no diversional therapy and the patients spend the majority of their time sitting by their beds waiting for the next meal to arrive. Preliminary results of a recent (unpublished) study by the authors, identified that many people with 32    February 2015 Volume 22, No.7

dementia showed heightened anxiety about their discharge with some reporting no understanding of the reason for their admission or discharge plans. This anxiety coupled with boredom can trigger behavioural manifestations especially wandering and aggression. Nurses report that they are too busy to engage the patients in activities and do not have the resources. Some facilities use what is known as ‘specials’ who are junior or minimally trained staff employed to supervise the disturbed patient who is in danger of absconding, falling or causing harm to themselves or others. However not only is this rarely afforded, the effectiveness of this strategy is questioned as the staff used often have negligible understanding of dementia and frequently shadow the patient rather than interacting with them. For a person who is spending several weeks in a facility this is significant. A personcentred environment provides comfort, occupation and inclusion for the patients, not an exclusive focus on biophysiological concerns (Penrod et al 2007). There is a view that personhood is constructed through interaction with others (O’Connor et al 2007), and that an inappropriate nursepatient relationship may contribute to the deterioration of a person with dementia (Kitwood 1990). It is therefore important that

nurses engage with patients with dementia in their care at every opportunity, and that health services recognise that diversional therapy has a vital contribution to make to the care of people in sub-acute facilities. References Galvin, J, B Kuntemeier, N Al-Hammadi, J Germino, M Murphy-White, and J McGillick. (2010). Dementiafriendly hospitals: care not crisis. Alzheimer Disease and Associated Disorders no. 24 (4):372-379. Hermann, D. M., S. Muck, and H. G. Nehen. (2014). Supporting dementia patients in hospital environments: health-related risks, needs and dedicated structures for patient care. European Journal of Neurology: n/a-n/a. doi: 10.1111/ene.12530. Kitwood, T (1990). The dialectics of dementia: With particular reference to Alzheimer’s disease. Ageing and Society no. 10 (02):177-196. doi: 10.1017/ S0144686X00008060. O’Connor, D , A Phinney, A Smith, J Small, B Purves, J Perry, E Drance, M Donnelly, H Chaudhury, and L Beattie. (2007). Personhood in dementia care: Developing a research agenda for broadening the vision. Dementia no. 6 (1):121-142. Penrod, J, F Yu, A Kolanowski, D Fick, and et al. (2007). Reframing person-centered nursing care for persons with dementia. Research and Theory for Nursing Practice no. 21 (1):57-72. doi: 10.1111/j.15475069.2005.00025_1.x2005-06193-00210.1111/j.15475069.2005.00025_1.x.

Robin Digby is PhD candidate; Associate Professor Allison Williams and Dr Susan Lee are all located at Monash University School of Nursing and Midwifery in Victoria

Focus - Aged Care Huyse, and Sollner 2011).

Social boundaries

Although nearly one-third of older people with diabetes are cognitively impaired, their restriction in social integration and networks are leading to social dysfunction. Isolation and loneliness are common in older age when the patient is living alone as a result of separation, divorce or death of the spouse which further suppresses self-management abilities and support networks (Wild et al 2011).

Economic boundaries

Challenges in self-care in older adults with diabetes

By Grazyna Stankiewicz Diabetes as a chronic condition requires continuing medical care, education, and attentive patient self-management to prevent acute complications and to reduce the risk of long-term complications (Shehatah, Rabie and Al-Shahry 2010). Up to 98% of diabetes care plans are self-administered and the patient’s family and/or carer should be included to support the patient when ability to self-care is significantly reduced, according to Feil, Zhu and Sultzer (2012). Self-care challenges in the elderly with diabetes are multidimensional, including physical, mental, social and economic boundaries (Edward, Rasmussen and Munro 2010, Trubaluk-Liskiewicz and Kobusiewicz 2000).

Physical boundaries

An elderly patient with diabetes Type 2 is more likely to be overweight or obese which restricts the ability to selfmanage. For example feet care can be difficult because of the limited access to them. The age-related changes in the musculoskeletal system further decrease the patient’s ability to self-care and can follow a significant reduction in manual

skills related to neuropathy in elderly age which also restricts the patient’s capability for hands on tasks (Trubaluk-Liskiewicz and Kobusiewicz 2000). Additionally, vision impairment due to diabetic retinopathy in combination with elderly age makes self-assessment and self-care challenging. A gradual decrease in peripheral sensation due to diabetic neuropathy makes the patient vulnerable to the physical injuries without notification. Hearing impairment, common in elderly, can affect patient balance, perception and understanding of an educational content related to self-care (Trubaluk-Liskiewicz and Kobusiewicz 2000).

Psychological boundaries Older patients with Type 2 diabetes are more than twice as likely as elderly without diabetes to have depressive disorders (Shehatah et al 2010). Diabetes and depression can negatively affect quality of life, increase functional disability, the ability to self-care and reduce life expectancy (Edward et al 2010). Elderly patients who suffer from depression and alienation have their own daily routine and any changes to their life can cause difficulties in adjusting to. Depression also has a significant impact in further decreasing patient motivation to self-care and their ability to cope. The level of the patient’s education and potential memory problems they may incur further limit the perception of learned content. Additionally, recalling learned tasks can be problematic. Concentration difficulties and tiredness further diminishes ability to self-care (Wild, Lechner, Herzog, Maatouk, Wesche, Raum, Muller, Brenner, Slaets,

Elderly age patients are more likely to be on a pension or on retirement, which makes affordability of recommended diabetic diet, footwear, health checkups, dental care and/or additional medications difficult (Trubaluk-Liskiewicz and Kobusiewicz 2000).


An increasing prevalence of multiple health conditions in older age, including diabetes, the high prevalence of physical and mental disorders, and social and economic boundaries can make continuity of selfcare challenging and should be routinely assessed and supported in communities. References Edward, K., Rasmussen, B., and Munro, I. (2010): Nursing care of clients treated with atypical antipsychotics who have a risk of developing metabolic instability and/or Type 2 Diabetes. Archives of Psychiatric Nursing, Vol. 24, No.1. Feil, DG. Zhu, CW., & Sultzer, DL. (2012). The relationship between cognitive impairment and diabetes self-management in population-based community sample of older adults with type 2 diabetes. Journal of Behavioral Medicine, 35: 190-199 Shehatah, A., Rabie, MA. & Al-Shahry, A. (2010). Prevalence and correlates of depressive disorders in elderly with type 2 diabetes in primary health care settings. Journal of Affective Disorders, 123: 197-201 Trubaluk-Liskiewicz G. & Kobusiewicz W.: Zasady pielegnacji stop dla chorych z choroba niedokrwienna konczyn dolnych i cukrzyca (The Feet Care for Patients with Diabetes and Ischemic Feet Disease). Pod red. Andrzeja Nowakowskiego. Scholl Polska. Lublin 2000 [B.Wydaw.]. Wild, B., Lechner, S., Herzog, W., Maatouk, I., Wesche, D., Raum, E., Muller, H., Brenner, H., Slaets, J., Huyse, F. & Sollner, W. (2011). Reliable intergrative assessment of health care needs in elderly persons: The INTERMED for the Elderly (IM-E). Journal of Psychosomatic Research, 70: 169-178

Grazyna Stankiewicz is in the School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences at Monash University in Victoria February 2015 Volume 22, No.7    33

Focus - Aged Care Malnutrition and depression in older adults: Are these health issues too hard to tackle?

By Min-Lin (Winnie) Wu, Mary Courtney and Liz Isenring Malnutrition and depression are two major health concerns in older adults, and they are usually unrecognised and thus untreated.

quality of life (Engel et al 2011), and more importantly this is more the case in older adults who are at risk of hospital readmission.

In Australia, about 10 to 30% of older adults are at risk of malnutrition in the community setting, and the prevalence is even higher (40-70%) in the residential aged care setting (Dietitians Association of Australia 2009). Similarly, an estimated 8.2% of Australians aged 60 and older suffer from depressive symptoms (Pirkis et al 2009) in the community setting. Both malnutrition and depression have significant adverse effects on an individual’s wellbeing and

A study was conducted to assess the relationships between malnutrition and depression among older adults who were at risk of hospital re-admission in an acute tertiary hospital. The Malnutrition Screening Tool (MST) was used to detect the risk of malnutrition, and the Subjective Global Assessment (SGA) was employed to assess the nutrition status. Depression was measured using the Geriatric Depression Scale (GDS). One hundred and fifty participants were assessed and 43 (27.7%) showed depressive symptoms. Among these 43 participants, 13 participants (30.2%) were malnourished. Results of


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Focus - Aged Care

this study highlighted that there was a statistically significant relationship between malnutrition and depression that could not be ignored. The key implication for nurses is that although the malnutrition screening is conducted routinely, nurses should be vigilant in assessing depressive symptoms. It might be useful and beneficial to screen for depressive symptoms routinely using the 5-item Geriatric Depression Scale in clinical practice.


References Dietitians Association of Australia. 2009. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutrition & Dietetics, 66 (s3): S1-S34.

Dr Min-Lin (Winnie), Wu PhD, Lecturer, School of Nursing, Midwifery & Paramedicine, Australian Catholic University in Qld

Engel, J.H., Siewerdt. F., Jackson. R., Akobundu. U., Wait. C & Sahyoun. N. 2011. Hardiness, depression, and emotional well-being and their association with appetite in older adults. Journal of the American Geriatrics Society. 59 (3): 482–48.

Professor Mary D Courtney PhD, National Head of School, School of Nursing, Midwifery & Paramedicine. Australian Catholic University in Qld

Jane Pirkisa,J.,Pfaffb, J.,Williamsona, M.,Tysonb, O.,Stocksc, N., Goldneyd, R., Drapere, B., Snowdonf, J., et al., 2009. The community prevalence of depression in older Australians. Journal of Affective Disorders. 115 (1-2): 54-61.

Professor Liz Isenring PhD, Professor, Head of Program, Faculty of Health Sciences and Medicine, Bond University in Qld

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Focus - Aged Care

Partnership for educating new graduates working in aged care

By Fernanda Lais Fengler, Georgina Willetts, Kerry Hood, Robyn Cant and Wendy Cross Australia is facing the necessity of improving and increasing aged care facilities due to the forecasted exponential population increase (Lewin et al 2014). Over the next 40 years Australia is predicted to increase and to develop the Australian Aged Care system (Ageing 2012). Staffing of aged care facilities with appropriate nursing professionals is an ongoing challenge. Therefore the development of appropriate programs to attract appropriate aged care staff 36    February 2015 Volume 22, No.7

will be pivotal to ensure standards are maintained and improved over the coming generations. The Monash University Nursing Academy offers in collaboration with other providers an Aged Care Graduate Nurse Program (ACGNP) for registered nurses (RNs). This 12 month program has been ‘run’ on three occasions, 92 RNs have completed the course. The purpose of this program is to prepare newly graduated RNs to work with older adults. This program is the result of collaboration between the university and industry and course/workplace retention rates have been excellent. The course is being evaluated by researchers from Monash University. While a larger evaluation of the program involves the collection of qualitative and quantitative data, this year a Brazilian nursing student, Fernanda Lais Fengler, has been studying some of the qualitative data, gained from focus group interviews with graduate nurses who participated in the 2013 offering of the course. Fernanda, who is currently supported through the “Science without Borders” program at Monash University, has enjoyed undertaking the

data analysis. The analysis of the focus group data identified five core themes that encompass both the educational and industry areas. Fernanda said, “the data has demonstrated many positive outcomes of this program; particularly that it is so important that newly graduated RNs are supported and encouraged to work in aged care settings.” A diverse team of nursing researchers (Georgina Willetts, Kerry Hood and Robyn Cant) is undertaking the wider evaluation and they have supervised Fernanda’s research experience. All team members share the view that university and industry collaboration are essential to achieving quality outcomes in aged care, and that this program is a good example of the outcomes gained educating, supporting and retaining RN ‘new grads’ who want to work in aged care as a career choice. Fernanda Lais Fengler, Georgina Willetts, Kerry Hood, Robyn Cant and Wendy Cross are all located in the School of Nursing and Midwifery at Monash University in Victoria

Focus - Aged Care Lily Xiao

Wendy Morey

A partnership approach to evaluating evidence-based practice project in aged care By Lily Xiao and Wendy Morey The project titled ‘Clinical Mentoring: From EvidenceBase to Outcomes for Older People’, is one of the ‘Clinical Leadership Projects’ in round three of ‘Encourage Better Practice in Aged Care’ funded by the Department of Health and Ageing (DoHA 2013). Four aged care organisations including residential and community care settings formed a consortium to implement the project led by Resthaven in South Australia. The aim of the project was to determine the effectiveness of the clinical mentoring model in residential and community aged care services in bringing about workplace and practice change and improving clinical outcomes for older people (DoHA 2013). The project comprises components of pain management, manual handling, dementia care and wound management. The project was strengthened through partnership between the aged care consortium and Flinders University. Using action research to implement evidence based practice has been

recognised as a suitable approach to translate knowledge into a local context via the action cycle (Straus et al 2009). However, this approach has also been criticised as lack of rigor in evaluating changes and failing to measure patient care outcomes (Munten et al 2010, Straus et al 2009). The present project evaluation has addressed these limitations through a number of strategies. First, formative evaluation and summative evaluation were utilised to capture the structure, process and outcomes of the project. Second, multiple sources of evidence via quantitative and qualitative research approaches were collected and carefully analysed in order to reach a comprehensive understanding of changes in practice. Third, residents/client outcomes were carefully evaluated using clinical indicators, interviews and satisfaction surveys. In addition, findings from each time point of evaluation were provided to stakeholders in a timely manner to facilitate critical reflection and opportunity for positive changes. This approach to evaluation also improved engagement of stakeholders in the project, a crucial condition for positive change environments. Findings from this project demonstrate that a clinical mentoring model can be embedded in residential and community aged care services and have demonstrated

a positive impact on practice, staff and residents/clients. The attributes of clinical mentors and site champions identified in this evaluation study will inform the evidence-based practice competencies for clinicians in aged care that might differ from these developed in acute care settings in previous studies (Melnyk et al 2014). Moreover, findings will also contribute to research evidence on structured educational programs and selection criteria for clinical mentors and site champions in aged care. References DoHA (2013) EBPAC Round 3, internet/main/publishing.nsf/Content/ageing-bestpractice-program-third-round.htm Melnyk BM, Gallagher-Ford L, Long LE and Fineout-Overholt E (2014) The Establishment of Evidence-Based Practice Competencies for Practising Registered Nurses and Advanced Practice Nurses in Real-World Clinical Settings: Proficiencies to Improve Healthcare Quality, Reliability, Patient Outcomes, and Costs, Worldviews on Evidence-Based Nursing 11 (1): 5-15. Munten G, van den Bogaard J, Cox K, Garretsen H and Bongers I (2010) Implementation of Evidence-Based Practice in Nursing Using Action Research: A Review, Worldviews on Evidence-Based Nursing 7 (3): 135-157. Straus SE, Kitson A, Harrison MB, Graham ID, Fervers B, Légaré F, Davies B, Edwards N and Majumdar SR 2009. The Knowledge-to-Action Cycle. Knowledge Translation in Health Care. Wiley-Blackwell.

Associate Professor Lily Xiao, RN MNg PhD FACN, School of Nursing and Midwifery, Flinders University South Australia Wendy Morey, RN BN MBus Grad Cert Primary Health Care, Resthaven Inc. South Australia February 2015 Volume 22, No.7    37




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Focus - Aged Care Zoe Sabri with client Ted Knibbs, 94 who requires daily home visits

Passion – the DNA that binds nursing By Zoe Sabri

We take so much for granted. As a child, growing up in postwar Afghanistan, I was brought up in a world of hunger, pain, suffering, illness, and poorhealth. But there were also many positive characteristics of Afghanistan that shone through; laughter, smiles, hard work ethic, determination, hope and love. Moving to Australia as a three-year-old and calling Australia home opened up my future to many possibilities, opportunities and a chance to live the life many have only dreamed of. The common question for students when I was at school was “What do you want to be when you grow up…?” For me the answer wasn’t too hard to find. Through my desires of wanting to help those in need and my love of health, nutrition and fitness, I knew not only in my head, but in my heart, that nursing was for me.

This was also evident to my parents. At just four years of age I used to beg them to buy me the plastic stethoscope from the $2 shop, just so I could listen to my baby sister’s heart. Nursing in Australia has so many elements. Jobs range from education and theatre nursing to specialist nurse practitioner roles and even telehealth. Aged care embraces them all – and what a crucial aspect of nursing it is! RDNS’ chief executive officer Steve Muggleton put it so eloquently recently when he said: “Consider for a moment three inconvenient truths: people are living longer, chronic disease is more challenging than ever and the cost of aged care is stretching public purses to the limits.” It is a privilege to be part of the vanguard charged with tackling the consequences of these inconvenient truths. We are nursing in a world of increasing life expectancy and sustained low fertility following the postwar baby boom. Between 1971 and 2011, the proportion of Australia’s population aged 65 years and over increased to 14%. For those aged 85 years and over it more than tripled, from 0.5% to 1.8% (Australian Bureau of Statistics 2011 census). Through my experience with working in the community as an RDNS district nurse,

I have accumulated many beneficial skills that I will use throughout my nursing career – but an important one has been the ability to communicate with clients from a CALD background (culturally and linguistically diverse). Working in the community has given me the opportunity to form strong nurse-patient relationships by acquiring this skill and continually using this in my work today – and most certainly in years to come. My nursing vision is to see younger generations having the same desire and passion that I feel – to spend each day looking after the elderly by helping to put a smile on their face and share the warmth of love one can feel just by being by their side. I have many clients like Ted Knibbs. He is 94 and has experienced and given so much in the course of his long life. Helping Ted, and people like him, to lead better, more comfortable lives, is what it’s all about. For me nursing is not just a job, it’s a way of life. Moreover, it’s a privilege that we must not take for granted. RDNS nurse Zoe Sabri was named Outstanding Graduate at the 2014 HESTA Australian Nursing Awards. She is based at RDNS Springvale, one of Melbourne’s most culturally diverse communities. February 2015 Volume 22, No.7    39

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Focus - Aged Care The deteriorating diabetic client in residential aged care facilities By Arlene Parry and Sue Fairley

unnecessary hospital admission for the diabetic resident.

Do you have a specialist range of skills in the areas of Mental Health, Justice Health or Alcohol & Drug Services? If you have answered yes to the questions above then we want to hear from you as we are recruiting now. Do you know that Canberra is now rated as the Number 1 City in the world to live? The Canberra community has diverse culture and a population of 379,000 people with all the amenities of a city but without the stress. Now for a little about us; the ACT Health, Division of Mental Health, Justice Health and Alcohol & Drug Services (MHJHADS) delivers a broad range of acute and community services delivered through partnerships with community and other government organisations. There is a major focus on Consumer & Carer participation in all aspects of service planning and delivery. Our innovative Models of Care have been developed utilising a population health framework and are informed through extensive consultation, and designed to embrace best evidence practice to meet National Standards and the principles of Person Centred Care. The range of specialised services includes programs in the following areas; • Child & Adolescent Mental Health Services (CAMHS) • ACT Wide Services • Adult Mental Health Services • Justice Health Services • Alcohol & Drug Services. For more information, please go to and click on: Employment – Current vacancies Contact Officer: Maret Rebane PH: (02) 6207 6279 E: For more information visit

Residential aged care facilities (RACF) provide a nurturing, safe homely environment for the elderly who are no longer able to care for themselves in their own home. Residents in these facilities, receive 24 hour care, treatment and management for a number of complex, chronic health conditions including diabetes. Type 2 diabetes is the most prevalent, and of all the people diagnosed with diabetes, approximately 90% are affected by Type 2 (Diabetes Australia 2013). Hyperosmolar hyperglycaemic state (HHS) is a complication of Type 2 diabetes with symptoms such as dehydration, fever and neurological impairment including coma (Brown & Edwards 2012). Recognition of this condition may pose a particular challenge to staff working in RACF, as blood glucose levels can rise significantly before the condition is identified. HHS is particularly common when there is the presence of an underlying infection such as urinary tract infection (UTI) or chest infection. Blood glucose levels (BGL) rise in response to illness and it is important that once an infection has been identified, the frequency of BGL monitoring increases along with maintenance of hydration (Campbell & Alford 2006). Anecdotal evidence suggests that at times, the condition may be misdiagnosed and mismanaged, leading to unplanned,

The McKellar Guidelines (2014) are evidence based recommendations, which were developed, to provide direction and guidance in the management of diabetes for the older person living in residential or other care facilities, in the absence of guidelines from the Department of Health and Ageing. The objective of the guidelines is to ultimately improve standards of care for this vulnerable population group. The guidelines also highlight that HHS is more common in the elderly living in RACF, with mortality increasing with age. With this in mind, there is a need to provide evidence based, diabetes specific education and training to staff working in RACF, inclusive of the GP who has a core role in the management of diabetes with his/her patients. Education ensures staff are equipped with the necessary knowledge and skills in assessment and recognition of the deteriorating diabetic resident, and the reporting process following identification of HHS. The implementation of sick day management plans for the diabetic resident during episodes of acute infection would also enable early recognition of deterioration, which would ultimately lead to implementation of timely and appropriate, interventions to prevent further deterioration and unplanned admission to the ED. References Campbell, L., Alford, J (2006); Sick day management for patients with diabetes; Australian Family Physician. Vol. 35 (6) Diabetes in Australia; Retrieved 6/11/2014 from www. Dunning, T., Duggan, N., Savage (2014). McKellar Guidelines for Managing Older People with Diabetes in Residential and Other Care Settings (2014). Retrieved 6/11/2014 from

Arlene Parry, RN, Med, Lecturer, School of Nursing and Midwifery, Monash University, Berwick campus in Victoria Sue Fairley is Quality and Projects Coordinator, Catholic Homes

Focus - AgedFocus Care Alcohol and drug screening for older Australians

By Lynette Cusack, Janet Kelly, Jennifer Harland, Linda Gowling, Mette Grønkjær and Nancy Whitaker The effects of alcohol and drugs in Australia and internationally has often been highlighted in relation to young people, but less discussed and assessed in relation to older people. This is surprising considering the significant impacts that drinking alcohol can have. Although older people may not consume alcohol in the same quantities as younger people (ABS 2014), they often drink more regularly, alone or at home with family and friends (Grønkjær et al 2010). A recent Australian study found older people underestimate the quantities they consume (Wilkinson et al 2011) and they may not perceive the impacts in relation to the physiology of ageing, increased use of medications and chronic diseases (ANPHA 2013). Furthermore, there is evidence that physiological effects of alcohol consumption is different for older people due to changes in body composition and metabolism (Peters et al 2008), including less efficient liver enzymes and increased sensitivity of the central nervous system (Blow and Barry 2002 ). There is also increased risk of fractures from falls due to increased frailty and decreased bone density. As people age, their chronic conditions and medication use usually also increases, with potential adverse reactions with alcohol (Aira et al 2005). As the proportion of people in the 65+ age group increases, with many of them continuing to consume alcohol, so too will the impact of alcohol related complications. It is clear that some form of alcohol screening in community settings would be useful to help health professionals accurately identify alcohol consumption in older people and the potential harmful effects. The question is which tool is most appropriate and acceptable to the older population group. The University of

Adelaide, School of Nursing conducted an international integrative clinical, social and health policy literature review to determine what tools are available. The most appropriate appears to be the ASSIST tool (Alcohol, Smoking, Substance Involvement Screening Test) developed by a World Health Organization (WHO) working group consisting of an international collaboration of addiction specialists. This tool was designed to be used in the primary healthcare setting by health professionals and community care workers to screen for risky alcohol and drug use in patients (Humeniuk et al 2008). This tool has not been validated for use with older people. The school is therefore conducting a small project to determine whether the tool is acceptable to older people, and is effective for use in primary care settings. References Aira, M., Hartikainen, S. and Sulkava, R. (2005). Community prevalence of alcohol use and concomitant use of medication: a source of possible risk in the elderly aged 75 and older? International Journal of Geriatric Psychiatry 20(7):680–5. Australian Bureau of Statistics (ABS). (2013). Gender Indicators, Australia, Jan 2013: Alcohol Consumption. Canberra, ACT, accessed 18 November 2014. Lookup/4125.0main+features3310Jan%202013 Australian National Preventive Health Agency (ANPHA). 2013. State of Preventive Health - Report to the Australian Government Minister for Health. Canberra: ANPHA. Blow, F. C. and Barry K. 2002. Use and misuse of alcohol among older women. Alcohol Research and Health. 26(4): 308-315. Grønkjær, M., Vinther-Larsen, M., Curtis, T., Grønbæk, M., and Nørgaard, M. (2010). Alcohol use in Denmark: A descriptive study on drinking contexts. Addiction Research & Theory. 18(3): 359–370. Humeniuk, R., Dennington, V. and Ali, R. (2008). The Effectiveness of a Brief Intervention for Illicit Drugs Linked to the Alcohol, Smoking and Substance

Involvement Screening Test (ASSIST) in Primary Health Care Settings: A Technical Report of Phase III Findings of the WHO ASSIST Randomized Control. Geneva, Switzerland. Peters, R., Peters, J., Warner, J., Beckett, N. and Bulpitt, C. (2008). Alcohol, dementia and cognitive decline in the elderly: a systematic review. Age and Ageing 37(5): 505–12. doi:10.1093/ageing/afn095 Wilkinson, C., Allsop, S. and Chikritzhs, T. (2011). Alcohol pouring practices among 65- to 74-year-olds in Western Australia. Drug and Alcohol Review 30(2): 200–6.

Dr Lynette Cusack , Senior Lecturer, Deputy Head Research, RN, MHA, GradDip (Community Health), DNur, MidCert, School of Nursing, Faculty of Health Sciences, The University of Adelaide SA Dr Janet Kelly, Research Fellow, RN, RM, MN, PhD, School of Nursing, Faculty of Health Sciences, The University of Adelaide SA Jennifer Harland, Clinical Practice Development Co-ordinator, RN, CDAN, MSc, MA, Grad Cert (MH), Grad Cert (ICU), Mental Health Justice Health and Alcohol & Drug Services Health Directorate, WMHU, AC Associate Professor Linda Gowing, DASSA Principal Research Officer Evidence-Based Practice, PhD, Discipline of Pharmacology Medical School, NG13 The University of Adelaide SA Dr Mette Grønkjær, RN, MN, PhD, Clinical Nursing Research Unit, Aalborg Hospital, Northern Region, Denmar Nancy Whitaker, Research Assistant, BPsy, MPsy, School of Nursing, Faculty of Health Sciences, The University of Adelaide SA February 2015 Volume 22, No.7    41

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Focus - Aged Care What do you do well? Positive questions improve life for older people living in residential care

Developing a conceptual understanding of ‘quality continence care’

Working in an aged care facility is both rewarding and challenging, accreditation standards and funding policy direct practice and too often there is a focus on what is wrong rather than what is done well.

Does the practice of promoting the use of continence pads to address incontinence in residential aged care services reflect good or bad care? What do you believe constitutes ‘quality’ continence care for people living in residential aged care services?

By Wendy Penney

In a recent action research project conducted in three residential care facilities in rural Victoria, appreciative inquiry was the chosen pedagogy used to develop action learning workshops for staff. The project was based on the successful My Home Life Program and supported by a Commonwealth rural education grant. Thirty-three participants (nurses, facility managers, care attendants and activity coordinators) were asked to describe what they did well in relation to providing residents with a good quality of life. This unconditional positive question (Ludema, Cooperrider and Barrett 2006) generated rich discussion that resulted in substantial change in practice. Appreciative inquiry is based on the premise that it is better to invite people to collaborate and create a future for themselves by nurturing enthusiasm rather than focusing on negative experiences that can be destructive (Ludema, Cooperrider and Barrett 2006). Sadly, participants initially found it difficult to identify what they did well and several staff commented that they were not accustomed to being asked for positive feedback. In the followup post-workshop evaluation interviews, participants stated they enjoyed the positive approach to learning. “…we were shown a way to put something in a positive statement rather than a negative statement…actually makes you feel a bit better...That empowerment thing where you’re empowering…by being positive...,” (Participant).

By Dr Joan Ostaszkiewicz

The success of the action learning approach in establishing a tool for change was exemplified by this comment: “Action learning acknowledges everybody’s strengths. It accepts we’re not perfect. It accepts that people with a lot of experience may then still struggle to achieve what they’re trying to achieve. But it gives them a framework to work within,” (Participant). Beginning with an unconditional positive question as part of an appreciative inquiry approach can be adapted to suit any situation. Commencing with the question “what do you do well?”, and then followed by the question “what do you want to do to improve?, can generate positive energy and a safe space for reflection as participants reconstruct their working worlds and then take action to incorporate the change they envision. Using appreciative inquiry has the capacity to facilitate practitioners’ sense of empowerment as they transform the environment and in doing so, improve quality of care for residents. Reference Ludema, J., Cooperrider, D., and Barrett, F. (2006). Appreciative Inquiry: the power of the unconditional positive question. In Reason, P., and Bradbury, H,. Handbook of Action Research., London: Sage.

Wendy Penney is currently Head of School, Nursing Midwifery and Healthcare at Federation University Australia, Victoria and she is happy to share her experiences of conducting appreciative inquiry based workshops in aged care settings

Apology In ANMJ’s Education article on “Understanding Crohn’s Disease” (Dec/ Jan 2014) the author refers to irritable bowel disease instead of inflammatory bowel disease as a condition that manifests itself as Crohn’s disease. ANMF Federal Office education team wish to apologise for the error.

These are important questions that warrant further investigation. A new study undertaken by researchers at Deakin University will provide much-needed information about consumers’ expectations and preferences for personal care related to bladder and bowel function for people admitted to residential aged care facilities. Researcher, Dr Joan Ostaszkiewicz, claims many residents experience difficulties with bladder and bowel control that is usually managed with pads. However, is this the best way to deal with incontinence? According to international guidelines, decisions about managing incontinence in residential aged care facilities should be based first and foremost on knowledge of each resident’s individual preferences, however little is known about what is an acceptable burden or risk of treatment in people with limited prognosis for cognition or survival. Researchers from Deakin University are conducting a confidential survey with: (i) people living in residential aged care facilities, (ii) next of kin family members, (iii) residential aged care staff and service providers, and (iv) continence practitioners to explore their opinions about what constitutes ‘quality continence care’. If you have an opinion about the best ways to provide quality continence care in residential aged care facilities that you would like to share, please contact: Dr Joan Ostaszkiewicz on (03) 9244 5099 or email au for a 40-60 minute phone interview. February 2015 Volume 22, No.7    43

Focus - Aged Care Rapid Access Service

challenges of working with a variety of care and service providers (families, carers and GPs). Experience indicates that the theorypractice gap, presents one of the biggest challenges necessitating not only awareness of person-centred care, best practice guidelines combined with a knowledge of contemporary clinical evidence but, then balancing this, within the pragmatic confines of the residential aged care sector – one that is ever mindful of staffing levels, staff training needs, financial limits and resident’s individualised care priorities.

By Leigh Hayne and Magda Simon Rapid Access Service (RAS) aims to provide a responsive (within 24 hours) in-reach service focusing on early intervention, hospital avoidance and staff education for people living in residential care facilities (RCF’s) aged 65 or older (45 or older for Aboriginal people). RAS is staffed by two Associate Clinical Service Coordinators and is overseen by a Clinical Service Coordinator – supported by Psychiatry and, Allied Health Services from the broader multi-disciplinary mental health team. The RAS sits within the Southern Adelaide Local Health Network, which is part of SA Health and has strong links with The Repatriation General Hospital (Ward 18) in particular. It forms part of the Older Person’s Mental Health Team in the south of Adelaide; based at Springbank House. RAS aims to reduce the rate of transfer to the ED for residents with recognised or probable psychiatric illness and or, a diagnosed dementia with complex, severe and persistent responsive behaviours. This is achieved through timely assessment within the RCF setting, with subsequent short term intervention (on average five days) of ongoing support and education for the staff in the RCF. The education upskills staff, by working in partnership, to recognise and respond to psychiatric illness and dementia, and thereby improving the quality of life for residents. Seventy percent of the time RAS focuses on RCF staff education and on building their capacity (ensuring consistency of information delivered while utilising small group work and feedback loops) to actively and positively respond to the changing care needs of residents. The initiative is unique in that it is the only public sector health service in South Australia to provide a rapid response in-reach service

to RCFs that is clinician led, with the primary objective being to reduce or avoid preventable ED transfers. A reduction in ED transfers has been borne out by an increase in RCF staff capacity to identify delirium as a cause for changes in presentation and the establishment of positive working relationships with RCFs and General Practitioners (GP’s) in the region. The success of the service is premised on the active and collaborative partnership and, subsequent positive working relationship built between RAS and RCF staff. Significant resources have been allocated to education. This remains the focus of the RAS (generally, studies indicated that initial education is a positive intervention but, when discontinued, loses effect within six to 12 months).

At the time of piloting this service, 50 residential care facilities were located within the service boundary with a potential service population of approximately 5,150 residents. Outcome data indicates that of the total referrals made to RAS (69 in total during the nine month pilot) transfers to the Emergency Department (ED) were avoided 88% of the time. In 2015 the RAS continues with an expanded focus on providing services to residents living with identified psychiatric illness (in acute or crisis situations); akin to a nurse liaison service.

As a mental health nurse working in this area, Leigh has been able to undertake further study and in 2013, completed a Bachelor of Science with Honours in Dementia Studies, delivered by the Bradford University in the UK. This area of study linked directly with her role in RAS and, has subsequently impacted positively on daily clinical practice through an increased awareness of the importance of non-pharmacological interventions, in helping to assess and identify unmet need in people living with dementia and in improving understanding of the potential barriers to change within organisations.

Leigh Hayne is a Mental Health Nurse from the UK with 20 years’ experience – largely in older person’s mental health; both inpatient and community. She has been working in the Older Person’s Mental Health Service in Adelaide since arriving in South Australia – and for the last three years in the Rapid Access Service. Magda Simon is a Registered Nurse with experience in both the metropolitan and rural-remote sectors in acute and community care. Currently she is employed in a mental health nursing workforce development role in South Australia.

As clinicians we are familiar with constraints in the residential sector; the responsibilities of the registered nurse and the potential

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Focus - Aged Care

Aged mental health – innovation in developing a specialist workforce By Lina Wilson

Aged mental health has never been a popular career choice for nurses. Consequently the aged mental healthcare setting has struggled to recruit specialist trained nurses to care for ageing clients who experience mental illness. In the absence of specialist trained staff with mental health qualifications, staff vacancies were filled with general staff to work within these facilities – it was a case of “fill the vacancies” with whomever we can attract. As a result of this method of recruitment; gaps were identified in the provision of mental health focused preceptorship and mentoring to our graduate nurses who were placed within the aged mental health sector of our service. St Vincent’s mental health has a robust Graduate Nurse Program which is conducted in conjunction with a number of other services which make up the NEVIL training Cluster (Austin Health, Goulburn Valley Health, Eastern Health and Albury Wodonga Health).

Problems arose when graduates began reporting a lack of support from the clinical areas when trying to complete their practical competencies. Graduates reported that among the staff groups at some of the facilities only one or sometimes two registered nurses with mental health specialist training were available to assess their clinical competency. In an effort to remedy this issue a Transition to Mental Health Nursing curriculum was developed in collaboration with RMIT (Bundoora campus). This 12 month program was designed for registered nurses working in our aged mental health facilities (two residential Psychogeriatric Nursing Homes and one Acute Aged Mental Health Admission Unit) who did not have post graduate qualifications in mental health nursing. The program was delivered over a 12 month period from June 2013 to July 2014 and included three modules of study which would then articulate into the Post Graduate program at RMIT with the overall aim to increase the specialist nursing workforce at these facilities. Ultimately this would improve the care provided to residents at these facilities and it would improve the education of graduate nurses who are placed in these specialist clinical areas.

We recruited 13 nurses from aged mental health to undertake this program. The outcome from this innovative training program was that nine of the participants completed the academic components of the program and qualified for credit points to complete a Post Graduate Diploma in Mental Health Nursing through RMIT. We lost two nurses along the way to other services and of the three remaining nurses two felt they were too close to retirement age to consider further study a viable option and one felt her English would not be good enough to complete a tertiary qualification. At the time of writing this extract four of the nurses have enrolled for study in 2015. Lina Wilson is Clinical Nurse Educator - Mental Health at St Vincent’s in Melbourne.

This is a photo of the group celebration on completion of their program- in the photo from left to right: Back row: Yin Wang (RN), Jo Wasley (clinical Nurse Consultant), Anna Love (Director of Nursing – Mental Health), Lina Wilson (clinical Nurse Educator) Front Row: Yi Song (RN), Estella Salcedo (RN), Annie Tunstead (RN), Cathy Kershaw (RN). Missing on the day: Amanda O’Donnell, Jianan Bi, Maria Wates, Phyllis Lui, Yedda Yu, Ruby Sotero February 2015 Volume 22, No.7    45

Calendar FEBRUARY Ovarian Cancer Awareness month 1–28 February www.womenscancerfoundation. Inaugural International Conference on Migration, Social Disadvantage and Health Toward developing national and international priorities for migration, health and social wellbeing 11–13 February Rydges on Swanston, Melbourne. Lung Health Promotion Centre at The Alfred 12–13 February Spirometry Principles & Practice P: (03) 9076 2382 E: We Can Walk it Out 15 February Join the Women’s Cancer Foundation – Ovarian Cancer Institute during National Ovarian Cancer Awareness month and help turn The Tan teal for Ovarian Cancer research and awareness. www.2015wecanwalkitout. The person centred approach to healthy weight management. If not dieting, then what?® 27–28 February 2015 – Melbourne 13–14 March 2015 - Brisbane 20–21 March 2015 - Sydney

MARCH Inaugural Student Recruitment and Retention Forum 2–3 March Sydney Harbour Marriott, Sydney. With Australian Higher Education becoming more and more competitive and the Federal government proposing the deregulation of university fees, student recruitment and retention has become increasingly important in the area of higher education. This conference will examine the latest strategies to attract students to universities and more importantly prevent student attrition from occurring. http://www.informa. Lung Health Promotion Centre at The Alfred 4–6 March Asthma Educator’s Course 19–20 March 2015 Smoking Cessation Course P: (03) 9076 2382 E:

Diabetes study day with Kathy Mills, RN, MEd, Dip Business, Credentialled Diabetes Educator. This study day for enrolled and registered nurses covers contemporary and evidence based research on dietary, exercise, psychological and pharmacological management of diabetes mellitus. 6 March from 9am-4pm Inner East Melbourne Medicare Local, 6 Lakeside Drive, Burwood East. Free parking. Morning tea, lunch and notes are provided. This study day is eligible for 6 hours professional education. Early bird special (pay by 20 February) is $220. Full registration fee: $250. All queries to Kathy via email only at 19th National Otorhinolaryngology Head & Neck Nurses meeting and ASHONS 65th scientific meeting Excellence and innovation 7–9 March Australian Technology Park, Sydney NSW. national_conference.html International Women’s Day 8 March World Kidney Day (Australia) 12 March Florence Nightingale Foundation Annual Conference 12–13 March Queen Elizabeth II Conference Centre, London. www.fnfalumni. org/event-1717850 Australian Pain Society 35th Annual Scientific Meeting Managing Pain: from Mechanism to Policy 15–18 March Brisbane Convention Centre, Qld. aps2015 Sustainable Healthcare Transformation International Conference on Health System Innovation 18–20 March Hotel Grand Chancellor, Hobart. www.healthcaretransformation. National Close the Gap Day 20 March closethegapcampaign Health & Environmental Sustainability Conference 20 March Melbourne Town Hall. Learn from Victorian nurses and midwives leading the way towards sustainable healthcare. Explore how climate

46    February 2015 Volume 22, No.7

change is impacting our emergency services and their response to natural disasters. Create achievable and practical action plans to take back to your workplace. Earn up to eight hours CPD. www.anmfvic.asn. au/events-and-conferences APNA Continuing Education Workshops for Nurses in Primary Care 27–28 March 2015 – Melbourne 1–2 May 2015 – Perth 29–30 May 2015 – Adelaide educationworkshops

APRIL Lung Health Promotion Centre at The Alfred 16–17 April Managing COPD 20–21 April Spirometry Principles & Practice 29 April–27/28 May Respiratory Course (Mod A &B) 29 April–1 May Respiratory Course (Module A) P: (03) 9076 2382 E:

MAY Lung Health Promotion Centre at The Alfred 7 May Respiratory Update 27–28 May Respiratory Course (Module B) P: (03) 9076 2382 E: Nurses & Midwives Wellness Conference Create your healthy footprint 8 May Melbourne Convention & Exhibition Centre. Learn how to manage stress and anxiety, conflict and negative relationships. Be opened up to new ways to build resilience, improve motivation and increase your energy levels. Earn up to eight hours CPD. 2nd Australian & New Zealand Eating Disorders & Obesity Conference 18–19 May Outrigger, Surfers Paradise, Qld.

JULY VPNG (Victorian Perioperative Nurses’ Group) State Conference Strategies for Success: Safety and Quality in Perioperative Care 30–31 July Pullman in Albert Park, Melbourne.

Adelaide Children’s Hospital, Group 175, 40-year reunion 8 February at 12md. Contact Wendy Norris (nee Hornabrook) E: wwnorris56@ or search for ACH 175 on facebook and message St John’s Hospital Hobart, All Trainees Reunion 8 February Site 9 Waterworks Reserve, 11am-4pm. Contact Alison Salisbury (PTS 1985) M: 0401 589 299 E: Memorial Hospital North Adelaide reunion for those who worked there between 1974 to 1978 14 February Contact Helen Hookings (nee Murchland) E: M: 0427 833 725 or Jan Huckel E: janh55@bigpond. com M: 0458 253 427 or E: memorial_reunion74@ Geelong Hospital Nurses League 81st Annual reunion and AGM 21 March 2015 If you have a connection to the Geelong Hospital (Barwon Health), are a past trainee or current employee and are interested in attending this reunion, please contact Bev Lodge P: (03) 5243 7794 or E: Alfred Hospital Melbourne, Group 2/75 40-year reunion 13 June Royal Yacht Club of Victoria, Williamstown. Contact Fiona Williams E: or Denise Peterson (nee Letcher), snail mail: 3 Sienna Close, Strathfieldsaye, Vic. 3551

Email if you would like to place a reunion notice

Mail Change of attitude to males involvement in childbirth I’m writing in response to Professor Sheryl de Lacey’s article, “Recruiting men to research” about reproduction in October’s Focus section of the ANMJ. Childbirth is still considered a female dominated area where men do their bit, then the women take over for 40 weeks. Often you hear comments like, “men have their five minutes of pleasure then the women do the rest”. I was a midwife for 10-15 years on and off and feel there is a lot more room for changes in attitudes regarding men’s role in reproduction. My knowledge was often questioned about breastfeeding by mothers because I was male. Yet female midwives’ knowledge was never questioned because they were female irrespective of whether they had breast fed or were failed breastfeeders themselves or had children of their own. Greg Trent RN; RM

Letter of the month The winner of the ANMJ best letter competition receives a $50 Coles Myer voucher. If you would like to submit a letter to the ANMJ email Letters may be edited for clarity and space.

Good work ANMJ! I just wanted to let you know that I’m really enjoying the ANMJ lately. The diverse types of articles you publish provides something for everyone in all specialities and at all levels.

In addition, articles like the ones you publish in the Wellbeing section give handy hints on tackling workplace stress and how to look after yourself, which can be applicable to everyone.

Personally, I particularly enjoy reading the education section and clinical update, as often it is relevant to my practice and helps me to expand my knowledge base. I also find the focus section a good source of information about what is going on in the different specialities. The legal and ethical points of view from experts in their fields are always good reads too.

Furthermore, now that you have improved the layout, and increased the size of the lettering, the journal makes for easy reading on tired old eyes like mine.

B Smith, RN Victoria

Can feeling good strengthen relationships? I appreciate the synopsis of Seligman’s “Positive Psychology” in the article “Personal Development is Professional Development” by Janette Cooper in the November issue of the ANMJ. However I feel it is an approach that could cause more harm than good. I am not a Buddhist, but I have just recently stumbled across the Buddhist concept of “shenpa”, and it is opening up a vast new world for me in my outlook and my practice. In contradiction to the article, I think that “feeling good” and focussing on “doing things that make us feel good so that we experience more positive emotion”, does not necessarily strengthen our relationships. On the contrary, it can lead to indifference to another’s suffering, or even intolerance of another’s failings. Cooper explains that we have a natural tendency to focus on the negative, but we can learn to see through a “positive lens”. But that can also be regarded as a form of self-surgery, whereby you cut off and jettison the negative part. It leads to a brittle view: ‘engagement’ becomes a matter of being “more productive, competent and confident”. Relationships become an ‘I champion you and you champion me’ affair. ‘Meaning’ turns into a search for “like-minded people”. Regarding ‘accomplishment’, there is a bottom line: “to identify our ambitions and our strengths in order to reach our goals”. I am sorry to say, but this unrelenting focus on the positive makes me feel sick! Pema Chodron writes in Taking the Leap about shenpa: “Here’s how shenpa shows up in everyday experiences. Somebody says a harsh word and something in you tightens: instantly

Keep those articles coming and the good work ANMJ team!

you’re hooked. That tightness quickly spirals into blaming the person or denigrating yourself. The chain reaction of speaking or acting or obsessing happens fast. Maybe, if you have strong addictions, you go right for your addiction to cover over the uncomfortable feelings. This is very personal. What was said gets to you - it triggers you. It might not bother someone else at all, but we’re talking about what touches your sore place - that sore place of shenpa”. Ever dealt with a “bad” patient? Sounds familiar? But whenever there is discomfort or even vague insecurity, shenpa can kick in. She says if we catch it when it first arises, “it’s very workable… we have the possibility of becoming curious about this urge to do the habitual thing…”. That curiosity allows us to get in touch with our understanding of what is happening. Rather than rejecting it as problematic, over time it allows us to learn to access to our “natural intelligence”, our compassion for ourselves and others, eventually becoming a stronger force than the shenpa. What I like about the shenpa idea is that it amplifies the intensely personal aspect of experience rather than categorising it as negative (throw out) or good (keep). It also encourages us to stay with our discomfort, and so gradually come to have some appreciation of the discomfort of others. For me, that is where the meaning of relationships begins. It is starting from that discomfort that I find often we can both begin to feel better - both patient, and nurse. In fact, I feel rather than becoming wily with shenpa what is more fruitful is finding how to live with the shenpa of ourselves, and others. Niko Leka, EN NSW February 2015 Volume 22, No.7    47

Annie Annie Butler, Assistant Federal Secretary

Now that we have said farewell to 2014 and gradually extracted ourselves from our Christmas breaks and summer playtime, or for some, summer anguish with scorching temperatures and menacing fires, and seen the kids back to school, it is time to face 2015 in earnest. For the Australian Nursing and Midwifery Federation (ANMF), with our priorities renewed based on feedback from our members, it is time to continue the work we started in 2014. It is time to continue the campaign to save our health system, to ensure safe and reasonable workloads for nurses and midwives, and to defend the future of our professions through affordable degrees and secure jobs for newly graduated nurses and midwives. And, in so doing, to contribute to achieving a better society for all. In 2014 the Australian government sought to make a series of wide ranging policy changes which would have a deep effect on the way we live, challenging the very nature of what we have long regarded as the normal Australian way of life. The federal government, with its first budget as its key weapon and ably assisted by the governments of most states and territories, launched an assault on our health system, our education system, and our welfare system. It threatened the most basic rights of our community, especially those of the poor, the vulnerable, the disadvantaged, and the frail and elderly. It also, in my view and the view of many nurses and midwives, 48    February 2015 Volume 22, No.7

sought to systematically destroy everything that decent Australians value.

quality public services for all; that this is actually why we elect them.

Nurses and midwives immediately realised the terrible consequences the budget would have for our health system and for the care that they would be able to deliver. As the government ripped commonwealth funding from state and territory hospitals, they knew their capacity to provide quality care in the public health system would be seriously compromised, risking the safety of their patients and increasing their workloads. So, nurses and midwives decided to take a stand to save our health system and maintain the standards we take pride in. The ANMF launched a national campaign against the government’s budget of lies, cuts and broken promises and our branches launched campaigns to save their states’ health systems and keep them public.

We realised that in a country as prosperous as ours we have options, we don’t have to compromise. We can actually have whatever health system and education system we choose to have; that it’s up to us to decide what sorts of systems we want, what services we want to provide and to whom.

As we did, groups all around us stood up for what they believe in as well. Multiple campaigns harnessing the dismay of the people and expressing their opposition to the government and the new Senate began. Unsurprisingly, given the extraordinary range of the government’s assault, the Budget announced in May 2014 had the unique effect of achieving something that has rarely been done before. It managed to unite groups all across Australia. It united Australia’s health experts and health groups in opposing the introduction of a US-style ‘user pays’ model for our country’s health care. Thousands joined Bust the Budget rallies and demonstrations, Save Medicare groups and alliances, the March in Australia movement, and those pursuing tax justice. An explosion of digital and social media campaigns such as those run by Getup were unleashed. These campaigns continued to grow throughout the year and to unify not just the health workforce but the Australian community, its pensioners and its disadvantaged. The government had hoped to divide and conquer us but their tactics had just the opposite effect; they united us. We came together to stand up for what we value most as Australians. While this response took the government by surprise and left them fragmented, it galvanised Australians’ expectations of their governments. We realised that we expect governments to use our taxes to provide

We realised that our decisions to pool our funds to share resources and distribute services on the basis of need, as we did with Medicare, has been highly successful and has been consistent with the Australian ethic of a ‘fair go’ for all. We realised that this is what makes us Australian and why thousands of others, who are less fortunate, want to come here. It makes us proud, it makes us unique, and it makes us a community where we care for each other. Whether you’re rich or poor, employed or unemployed, old or young, marginalised, homeless or just down on your luck – the Australian way has been to lend a helping hand to you when you need it. We realised that we must fight for these values, and now in 2015 we must fight even harder for them. In 2015, we are putting the government on notice: the ANMF and its state and territory branches will continue to work with other unions, with community groups, with church groups and with thousands of ordinary Australians to stand up for what we value and a return to a fairer society. We will strengthen our resolve to save Medicare and to keep our health system public. We will increase our campaign for safe and reasonable workloads for nurses and midwives across the country in acute, community and aged care sectors through mandated staffing and skill mix arrangements. We will defend the future of our professions by ensuring that nursing and midwifery degrees remain affordable. And, we will continue our work to ensure that nursing and midwifery graduates secure meaningful jobs. We will not accept any further lies, cuts or broken promises, for the sake of all Australians.

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