ANMJ Feb 2017

V O LU M E 2 4 , N O. 7 F E B R U A RY 2 0 1 7

Off t he

BEATEN TRACK THE RISE OF REMOTE AREA NURSING

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CONTENTS

18

REGULARS

02 DIRECTORY 03 EDITORIAL 04 NEWS 10 WORKING LIFE

SKIN INTEGRITY PORTFOLIO HOLDERS ARE GOLDEN

11 WORLD

ANMF PARTICIPATES IN INTERNATIONAL NURSING SYMPOSIUM ON SHIFT WORK

12 ANMF PRIORITIES 2017 KEY ISSUES FACING HEALTHCARE

16 PROFESSIONAL

SAFETY AND SECURITY IS EVERYONE’S BUSINESS

18 OFF THE BEATEN TRACK

THE RISE OF REMOTE AREA NURSING

24 ISSUES

RELIABLE ALLERGY RESOURCES

25 LEGAL

MERCILESS VERSUS MERCY KILLING?

26 VIEWPOINT

05

ANMF LIBRARIES AT YOUR SERVICE

27 REFLECTIONS

DEALING WITH DEATH

28 VIEWPOINT

BUILDING AN INDIGENOUS HEALTH WORKFORCE

29 ISSUES

THE VICTORIAN NEW HEALTH COMPLAINTS ACT 2016 – WHAT ARE THE CHANGES?

30 CLINICAL UPDATE

ASSISTED FERTILITY TREATMENT AND THE QUALITY OF INFORMED CONSENT

32 RESEARCH 33 FOCUS

30

AGED CARE

43 MAIL 46 CALENDAR 48 MAREE

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February 2017 Volume 24, No. 7 1

Canberra

3/28 Eyre Street, Kingston ACT 2604 Phone (02) 6232 6533 Fax (02) 6232 6610 Email anmfcanberra@anmf.org.au

Cover image: Remote Area Nurse Robyn Hill Photo: Elise Derwin

Editorial

Melbourne & ANMJ

Level 1, 365 Queen Street, Melbourne Vic 3000 Phone (03) 9602 8500 Fax (03) 9602 8567 Email anmfmelbourne@anmf.org.au

Federal Secretary Lee Thomas

Assistant Federal Secretary Annie Butler

Editor: Kathryn Anderson Journalist: Natalie Dragon Journalist: Robert Fedele Production Manager: Cathy Fasciale Level 1, 365 Queen Street, Melbourne Vic 3000 Phone (03) 9602 8500 Fax (03) 9602 8567 Email anmj@anmf.org.au

Advertising Heidi Adriaanse E: heidi@anmf.org.au M: 0415 032 151

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Australian Capital Territory Branch Secretary Jenny Miragaya Office address 2/53 Dundas Court, Phillip ACT 2606 Postal address PO Box 4, Woden ACT 2606 Ph: (02) 6282 9455 Fax: (02) 6282 8447 E: anmfact@anmfact.org.au

Northern Territory

South Australia

Victoria

Branch Secretary Yvonne Falckh

Branch Secretary Elizabeth Dabars

Branch Secretary Lisa Fitzpatrick

Office address 16 Caryota Court, Coconut Grove NT 0810 Postal address PO Box 42533, Casuarina NT 0811 Ph: (08) 8920 0700 Fax: (08) 8985 5930 E: info@anmfnt.org.au

Office address 191 Torrens Road, Ridleyton SA 5008 Postal address PO Box 861 Regency Park BC SA 5942 Ph: (08) 8334 1900 Fax: (08) 8334 1901 E: enquiry@anmfsa.org.au

Office address ANMF House, 540 Elizabeth Street, Melbourne Vic 3000 Postal address PO Box 12600 A’Beckett Street Melbourne Vic 8006 Ph: (03) 9275 9333 Fax (03) 9275 9344 Information hotline 1800 133 353 (toll free) E: records@anmfvic.asn.au

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

Moving state? Transfer your ANMF membership 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.

New South Wales

Queensland

Tasmania

Western Australia

Branch Secretary Brett Holmes

Branch Secretary Beth Mohle

Branch Secretary Neroli Ellis

Branch Secretary Mark Olson

Office address 50 O’Dea Avenue, Waterloo NSW 2017 Ph: 1300 367 962 Fax: (02) 9662 1414 E: gensec@nswnma.asn.au

Office address 106 Victoria Street West End Qld 4101 Postal address GPO Box 1289 Brisbane Qld 4001 Phone (07) 3840 1444 Fax (07) 3844 9387 E: qnu@qnu.org.au

Office address 182 Macquarie Street Hobart Tas 7000 Ph: (03) 6223 6777 Fax: (03) 6224 0229 Direct information 1800 001 241 (toll free) E: enquiries@anmftas.org.au

Office address 260 Pier Street, Perth WA 6000 Postal address PO Box 8240 Perth BC WA 6849 Ph: (08) 6218 9444 Fax: (08) 9218 9455 1800 199 145 (toll free) E: anf@anfwa.asn.au

2 February 2017 Volume 24, No. 7

ANMJ IS PRINTED ON A2 GLOSS FINESSE, PEFC ACCREDITED PAPER. THE JOURNAL IS ALSO WRAPPED IN BIOWRAP, A DEGRADABLE WRAP.

134,148

TOTAL READERSHIP

Based on ANMJ 2014 member survey pass on rate Circulation: 91,882 BCA audit, Sept 2016

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EDITORIAL

Editorial Lee Thomas, ANMF Federal Secretary Welcome to the first issue of the ANMJ for 2017.

The ANMJ team have been kept busy over the break planning and organising an exciting and informative schedule of articles for 2017 which we hope you will enjoy.

The ANMF has also formed its national agenda for the next 12 months on issues that are important to all nurses and midwives. And, unlike many other wayward New Year’s resolutions, we will be unswervingly sticking to ours.

Aged care remains on top of the priority list for the union. We will be working on ensuring staffing ratios are mandated in all aged care facilities. We will also continue to fight for closing the wages gap for nurses and aged care workers, and pushing for minimum education and registration for personal care workers and assistants in nursing.

This year the ANMF will intensify its lobbying of the federal government to improve industrial relations laws that allow nursing staff to be properly represented in the workforce. This includes strengthening the safety net for minimum standards and protecting and improving entitlements.

Lobbying the federal government to restore the $57 billion slashed from national health funding and to reverse the crippling freeze on Medicare rebates is also high on the ANMF’s agenda. Equally important will be urging the government to commit to a national strategy on climate change. This is an issue of great concern to our membership not only because of its detrimental impact on the environment but to the health and wellbeing of communities at home and abroad.

Another priority for the ANMF will be continuing our partnership with Go Gentle Australia to appeal for changes in law to support voluntary euthanasia.

THIS YEAR THE ANMF WILL INTENSIFY ITS LOBBYING OF THE FEDERAL GOVERNMENT TO IMPROVE INDUSTRIAL RELATIONS LAWS THAT ALLOW NURSING STAFF TO BE PROPERLY REPRESENTED IN THE WORKFORCE.

More details about ANMF’s agenda for the year ahead can be found on page 12 in this month’s journal.

Talking about 2017, it would be remiss of me not to mention one of our major highlights for the year that we are greatly looking forward to. The ANMF Federal Office will be holding its Biennial National Conference in Tasmania mid-October.

The conference is an opportunity to bring delegates from all over the country together, to review the work of the ANMF, to discuss major issues with leaders in health and social justice, as well as to create plans for the years ahead. While the conference is some time away we are already working on the agenda to ensure it will be an informative and productive event for all involved. More on the conference will be reported in the ANMJ in the upcoming months.

As you can see the ANMF has a challenging but exciting 12 months ahead.

Rest assured we are eager and ready to fight for the rights and conditions of all nurses and midwives as well as protect and improve Australia’s healthcare systems.

Watch this space!

While these priorities currently top the ANMF’s agenda for 2017, we will also be ready to fight beyond these issues as required throughout the year.

@AustralianNursingandMidwiferyFederation

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February 2017 Volume 24, No. 7 3

NEWS UNIVERSITY OF SYDNEY STUDENTS BRIEANNA WATSON AND HOLLY KOVAC

SOUTH AUSTRALIAN NURSES AND MIDWIVES GIVE GREEN LIGHT TO NEW DEAL Public sector nurses and midwives in South Australia have ratified a new Enterprise Bargaining Agreement for the next three years in an encouraging deal that lays the foundation for improved safety and care of patients.

SUPPORT FOR MORE ABORIGINAL STUDENTS Aboriginal and Torres Strait Islander students at the University of Sydney will be offered subsidised accommodation and a mentoring program in a bid to encourage more Indigenous school-leavers to the university.

All commencing fulltime Aboriginal schoolleavers will be offered guaranteed residency in university-owned accommodation in 2017.

The University of Sydney will subsidise the cost of the rent and students will receive a start-up bursary of $1,000 to assist with relocation expenses.

“For many young Aboriginal people, studying at the University of Sydney can seem an impossible dream for a range of reasons – financial, social and geographical,” Deputy Vice-Chancellor Professor Shane Houston said.

University of Sydney Nursing Advisor for Aboriginal and Torres Strait Islander Students and Registered Nurse Dr Jo River said Sydney was an expensive city to live and a deterrent, particularly for Indigenous school-leavers.

“Certainly being away from family is really hard, we have some students from Thursday Island, for even those that live in or just outside Sydney there is difficulty in finding accommodation. They often are trying to 4 February 2017 Volume 24, No. 7

work fulltime and study – if we want them to do well in their studies, we have to address these issues.”

The first year was “really, really tough” for Aboriginal and Torres Strait Islander students who had high competing demands, Dr River said. For many, they were the first person in the family to go to university.

“Students that come here are very committed: they have really thought about and chosen to do nursing, not just landed here – but trying to work and study often becomes just too hard.”

MOBS (Mentoring Our Brothers and Sisters) a structured peer mentoring program will also be available to Indigenous students in 2017.

“FOR MANY YOUNG ABORIGINAL PEOPLE, STUDYING AT THE UNIVERSITY OF SYDNEY CAN SEEM AN IMPOSSIBLE DREAM FOR A RANGE OF REASONS – FINANCIAL, SOCIAL AND GEOGRAPHICAL,” DEPUTY VICE-CHANCELLOR PROFESSOR SHANE HOUSTON SAID.

“The students get to hear how others made it to their third year, what worked for them in those tough times and also institutional knowledge. We have some students that literally did not know the library services were free,” Dr River said.

“We’re treating this first year as a trial and we’re very open to student feedback; we want to ensure the arrangements work for them,” Professor Houston said.

A final vote was held last December, with members resoundingly in favour of the package, which focuses on better staffing levels, job security, conditions and wages. The new agreement comprises a 2.5% wage increase and salary related allowances, safer staffing levels and skills mix, an extension of the personal development allowance, changes to classification structures and job roles, and paid leave for employees experiencing domestic violence.

ANMF (SA Branch) CEO/Secretary Adjunct Associate Professor Elizabeth Dabars said last year’s ballot result demonstrated nurses and midwives working in the public health system were committed to providing the best possible care. “At a time of significant budget pressure and unprecedented change in our health sector, these new conditions give our nurses and midwives in metropolitan and regional areas more certainty and security so they can get on with the job of caring for South Australians in need.”

The ANMF (SA Branch) campaigned tirelessly and worked extensively on negotiating the new agreement, which expires in September, 2019.

Nurses initiated industrial action last September but suspended their actions once a new offer arrived from the state government.

Ms Dabars said the 17,000 strong public sector nursing workforce deserved recognition for their continued efforts.

“Nurses and midwives play a crucial role in creating a health system for the future and they must share in the benefits their work is creating,” Ms Dabars said. “While we still have work to do, the ballot results show us members are supportive of the way forward – a direction at which patients are front and centre.”

anmf.org.au

NEWS

ABORIGINAL NURSE ELDER AWARDED CHURCHILL FELLOWSHIP An Aboriginal elder and nurse, has been awarded a Churchill Fellowship to further her research into Indigenous health.

to find out the relationship between their intergenerational trauma through colonisation and culture and how they have managed to rejuvenate a sense of belonging and identity within their communities, because we know the health disparities are just huge in all Indigenous Nations,” Dr Fergie said.

“I see a need to build relationships between the Indigenous communities I will visit and the Australian Indigenous community. We need to share our cultural ways and learn from each other and by doing so we can overcome the barriers of geographical isolation.”

Australian Catholic University (ACU) lecturer in the School of Nursing, Midwifery and Paramedicine Dr Doseena Fergie was presented with the prestigious Fellowship at a ceremony at Government House in Melbourne last month.

Dr Fergie was admitted to the Victorian Honour Roll for Women for her work in nursing and community health in 2016. She completed her PhD thesis on postnatal depression among Victorian Aboriginal women in October.

Dr Fergie will spend several weeks travelling to Finland, England, Canada, Hawaii and New Zealand in 2017 for the fellowship.

Academia was an important place for the work of advocacy, Dr Fergie said.

“I hope to visit these Indigenous Nations

TASMANIAN NURSES AND MIDWIVES STRIKE NEW EBA AGREEMENT

“If you have a passion for our own people and you’ve seen the needs out there, this The 18-month agreement, settled in January following weeks of stalled negotiations with the state government that triggered industrial action late last year, also features significant improvements to problematic issues surrounding conditions and professional development.

Notably, the package includes doubling the Professional Development Allowance up to $650 a year for full-time staff, a pledge to address career structure by reviewing nursing pathways, and improvements to on call arrangements through better rostering practice and safeguarding extra payment entitlements.

The agreement also sees an increase in maternity leave from 12 to 14 weeks, as well as the introduction of an Associate Nurse Unit Manager (ANUM) across all wards and units for all shifts.

TASMANIAN NURSES TAKING PART IN INDUSTRIAL ACTION LAST YEAR.

A commitment to reviewing the current ratio framework in Tasmania in a bid to streamline the process and effectively improve workloads and patient care is among the highlights of a new Enterprise Agreement signed off on by the Australian Nursing and Midwifery Federation (ANMF Tasmanian Branch). anmf.org.au

Significantly, the state’s current Nursing Hours Per Patient Day (NHPPD) ratios model has been pinpointed for review, to be completed by October later this year.

The current model is considered difficult to understand and monitor on a daily basis and it is hoped the development of a hybrid staffing ratio model will create simplicity.

A survey conducted by the ANMF (Tasmanian Branch) to gauge the views of members revealed workloads, overtime and inadequate staffing as the biggest concerns, with 60% of members saying they did not understand NHPPD staff allocation methodology and instead would prefer a Nurse to Patient ratio model.

DR DOSEENA FERGIE

passion should be expressed in a place of influence.

“It’s really important for us to have Indigenous researchers because we have a different world view to western knowledge.”

Despite positive inroads, Tasmania’s public sector nurses and midwives received only a 2% per pay increase, the below par amount attributed to the government’s ongoing wages policy.

“It’s an 18-month agreement with two limited wage increases, however, the key issue was securing ratios and safe workloads to ensure quality patient care and addressing conditions,” ANMF Secretary Neroli Ellis said.

Ms Ellis assured that the inadequate pay rise would be a key focus of negotiations when talks concerning the next Enterprise Agreement roll around early next year in March. “Certainly the outcome addresses many of the outstanding conditions. For example, on call arrangements have vastly improved, professional development allowances have doubled. So there’s some improvements in the conditions, however, there’s a clear commitment that in the next Enterprise Agreement we will be focusing on salary outcomes to ensure we’re not the lowest paid nurses in the country.”

Ms Ellis praised members for their resolve throughout the process, including industrial action. “Members don’t like taking industrial action, particularly with their current workloads and stressors in the working environment. But I think it was out of pure frustration and resolve. We initially had nothing on the table and had to get a lot of these long-standing conditions improved. We need to maintain relativity with the other states to retain and recruit nurses and midwives.”

February 2017 Volume 24, No. 7 5

NEWS

MENTAL HEALTH NURSE TAKES OUT PRIME MINISTER’S PRIZE KIM RYAN

A leading Australian nurse has taken out the Prime Minister’s first Australian Mental Health Prize.

Chief Executive of the Australian College of Mental Health Nurses (ACMHN) CEO Kim Ryan was named the inaugural winner for 2016.

The outstanding shortlist included founding CEO of beyondblue and current member of the National Mental Health Commission Professor Ian Hickie and mental health and suicide prevention advocate John Mendoza.

“MENTAL HEALTH NURSES ARE OFTEN AT THE FRONTLINE WHEN IT COMES TO WORKING WITH PEOPLE WHO EXPERIENCE MENTAL HEALTH ISSUES IN THE COMMUNITY.” The annual prize will be awarded to an Australian who has made outstanding contributions to either the promotion of mental health or the prevention and treatment of mental illness in areas such as advocacy, research or service provision.

Ms Ryan was recognised for her work as CEO of the ACMHN and her collaboration with others to improve mental health outcomes

AGED CARE RESIDENTS BEAR BRUNT OF FEWER NURSES AND POOR SKILLS MIX A national study into the delivery of residential aged care has revealed gaping holes across the system, including frequent episodes of missed care, due to widespread staffing shortages and an inadequate skills mix in nursing homes.

The Australian Nursing and Midwifery Federation (ANMF) released its National Aged Care Staffing and Skills Mix Project report in December last year which indicated aged care sector organisations faced significant hurdles in attracting and retaining a workforce due to low wages, limited career pathways, and poor management of facilities.

The extensive project, undertaken by the

6 February 2017 Volume 24, No. 7

ANMF Federal Executive in partnership with the ANMF (SA Branch), Flinders University Research Team, and University of South Australia, spoke first-hand to nurses and aged care residents, analysed important care being missed, and looked at the overarching impact of a lack of nurses coupled with poor skills mix.

Key findings from the report uncovered aged care residents receiving almost half the amount of proper care required.

Residents should receive about four hours and 18 minutes of care each day, but just 2.84 hours is currently being provided.

Based on evidence-based minimum care requirement that ensures safe and quality care, the report recommends adopting a staffing methodology for all residential aged care facilities, that is a skills mix requirement of RN 30%, EN 20%, and Personal Care Worker 50%.

Findings from the project’s MISSCARE survey showed just 8.2% of respondents felt staffing was adequate.

The survey also found nursing services and personal care interventions were missed at least some of the time.

Unsurprisingly, inadequate staffing was considered the biggest cause of missed care, followed by workloads.

for Australians. She was the inaugural chair of the Mental Health Professional Association which brings together nurses, GPs, psychologists and psychiatrists.

Chair of the Australian Mental Health Prize Advisory Group Ita Buttrose said Ms Ryan had shown incredible commitment to advancing the profession of mental health nursing and tireless work advocating on behalf of mental health nurses.

“Mental health nurses are often at the frontline when it comes to working with people who experience mental health issues in the community. Kim’s work demonstrates the enormous difference that speciallytrained mental health nurses can make in the recovery of people with mental illness.”

Ms Ryan said it was her vision for all Australian nurses and midwives to be better prepared to recognise their important role in supporting people to achieve better physical, mental and emotional wellbeing. “Mental health is not just the domain of mental health nurses. We are experiencing increasing rates of mental illness, chronic disease and co-occurring physical and mental health conditions, so it’s absolutely crucial that all health professionals take a more holistic and integrated approach, and increase their confidence in being able to help.”

The report calls for urgent action in addressing aged care’s shortcomings by investing in the sector and protecting vulnerable elderly Australians.

The ANMF submitted the report to the Chair of the Senate Inquiry into the Aged Care Workforce in the hope the committee will take on board the evidence and recommend the legislation of minimum staffing levels and skills mix across nursing homes.

THE REPORT CALLS FOR URGENT ACTION IN ADDRESSING AGED CARE’S SHORTCOMINGS BY INVESTING IN THE SECTOR AND PROTECTING VULNERABLE ELDERLY AUSTRALIANS.

“The report’s findings reflect feedback from ANMF members working on the ground in aged care and is consistent with the stories from members about the increasing difficulty they experience in providing decent care to residents, many with dementia and other high-complex needs,” ANMF Federal Secretary Lee Thomas said.

anmf.org.au

NEWS

ALARMING DRUG SHORTAGES THREATEN PATIENT SAFETY Australia is facing a critical shortage of important antibiotics that is driving some hospitals to use alternative treatments that could be less effective and expose patients to greater harm, experts claim.

Vancomycin and metronidazole are among the latest antibiotic drugs to gain headlines following worrying shortages that have reportedly led to hospitals rationing the drugs once out of stock. Doctors are also adopting back-up treatments, namely treating patients with broader spectrum antibiotics, which are considered potentially dangerous due to being more toxic and vulnerable to superbugs.

Senior hospital clinicians are calling on state and territory health departments to fix the crisis and restore the supply of essential medications. It is believed Vancomycin, will not be available until sometime this month.

“Disruptions are becoming increasingly common in Australian hospitals and for people who rely on antibiotics that’s a real concern,” Australian National University’s Professor of Microbiology Peter Collignon, warned. “Often treatment is time critical and the use of alternative agents may be associated with poorer effectiveness, increased risk of resistance and/or greater toxicity.”

“DISRUPTIONS ARE BECOMING INCREASINGLY COMMON IN AUSTRALIAN HOSPITALS AND FOR PEOPLE WHO RELY ON ANTIBIOTICS THAT’S A REAL CONCERN.” Professor Collignon, who is also patron of the Australasian College for Infection Prevention and Control (ACIPC), said governments must take more responsibility in maintaining a sufficient supply.

Professor Allen Cheng, from the Australasian Society for Infectious Diseases (ASID), suggested existing state contracts should include provisions for the continued supply of drugs of clinical importance. “They should also provide notice regarding potential problems and have an obligation to source alternative supplies where they exist.”

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FISH SAUCE KEY IN CAMBODIAN MUMS AND BABIES NUTRITION Fish sauce could provide mothers and young children in Cambodia better nutrition, Australian research has found.

Researchers from the South Australian Health and Medical Research Institute (SAHMRI) and the University of Adelaide have been seeking ways to improve the intake of thiamine of mothers and children between 1-5 years in South East Asia. According to SAHMRI Nutritionist Professor Tim Green, thiamine (Vitamin D) deficiency is still common in Cambodia putting people at risk of developing beriberi which can lead to death within 24 hours in babies if not treated.

Professor Green said that in Australia, nutrients that could be lacking in the diet are sometimes added to foods that are commonly consumed, for example iodine being added to salt and folic acid added to bread flour. “We borrowed this principle, called fortification, and added thiamine to fish sauce, a condiment that is found in nearly every Cambodian kitchen.” The study found that fish sauce was not only well accepted by Cambodian families, but that it improved blood makers of thiamine status.

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NEWS

IMPROVE YOUR CONFIDENCE AND CARE AT THE END OF PATIENTS’ LIVES

By Kate Munro Flinders University has released six free online learning modules to empower nursing professionals to help improve end-of-life care for patients.

Targeted at acute care, but applicable to a wide range of health settings, these peerreviewed and evidence-based eLearning modules help nurses develop confidence in end-of-life care and rate or gauge their current skills.

Kindness, respect and an interest in a patient’s life story are all important factors in end-of-life care and can make a huge difference by giving patients and their families an opportunity to talk and prepare for the end of the patient’s life.

PATIENT PARTICIPATION FOR BETTER OUTCOMES

Clinical staff, patients and their families benefit from the enhanced conversation skills, application of improved clinical skills that recognise end of life issues and the ability to resolve issues that are unique to nursing care at end of life. By completing these modules and implementing the skills, clinical staff can gain confidence in their ability to provide high quality person centred care at end of life.

The End-of-Life Essentials modules place an emphasis on the importance of the health professional’s ability to use tools and triggers to recognise when end of life care planning is essential. Each module will allow reflection on clinical skills and provide opportunities to gauge confidence in your professional practice.

Completing these modules can help nursing professionals negotiate and plan future end of life goals of care for patients and their families.

The responses to this education package have been extremely positive as reflected in the following statement from one of the nurses who has completed the eLearning: ‘Thank you so much for providing nurses with this most valuable education. I’m already using the tools I’ve learned at work and the results are astonishing.’

University in Melbourne.

The study involved 241 patients treated for total knee replacement in acute care orthopaedic wards at the Epworth Hospital.

Primary outcomes showed a reported reduction in pain intensity by day three post-op and a reduction in length of hospital stay by one day.

Alfred Deakin Professor and Chair in Nursing at Epworth Healthcare Professor Mari Boti, pictured, said the results were astounding. “It was quite extraordinary.

In acute care we espouse but we do not know if outcomes will be better with patient participation.”

Previous research hadn’t shown benefit other than increased patient satisfaction and increased patient expectations, she said.

Patient participation in care can lead to better health outcomes and a reduction in hospital stay, preliminary results from a Victorian study show.

Findings from a study of patient participation in pain and symptom management in acute care were presented at a recent Partnering with Consumers symposium hosted by Deakin

8 February 2017 Volume 24, No. 7

KATE MUNRO

The nurse facilitated discussion at the beginning of the shift on how the patient and nurse would meet patient goals together. An iPad was at the bedside throughout duration of hospital stay and patients were self-directed to their care.

Daily goals included: eating one meal out of bed; exercises to prevent blood clots; knee exercises; practising deep breaths; managing pain; and organising discharge.

Better pain management was achieved in the patient participation group (61.4%)

The End-of-Life Essentials project is led by Kim Devery, Head of Discipline and Senior Lecturer, and Associate Professor Jennifer Tieman, Palliative and Support Services at Flinders University.

All six online learning modules are now available: www.caresearch.com.au/ Caresearch/tabid/3866/Default.aspx

compared with the control group (34.1%).

Patients also reported increased satisfaction: 78% of the intervention group reported they would recommend the Epworth to their friends compared with 57% in the control group.

“This was a quite simple intervention where you do not need to do anything for patients to increase their negotiation skills – just give them the opportunity and capability and it had an explicit effect on their outcomes,” Professor Boti said.

Barriers to patient participation included very short duration of interaction with clinicians; a lack of continuity of care; and the capability of patients to interact within the space they have with clinicians and how they are able to negotiate that.

“There is a lack of clarity of the concept of participation at the point of care – they don’t see clinicians for long enough,” Professor Boti said. Research showed 7080% downtime where patients don’t see anybody in hospital and interactions on average lasted 3.8 minutes, she said. “There is very little window for opportunity for building rapport or permission to engage.”

The Epworth study was easily translatable to other settings with further patient benefits, Professor Boti said. “On follow up, the intervention group returned to work earlier.”

anmf.org.au

NEWS

LAST CHANCE TO NOMINATE FOR HESTA AWARDS 2017 Nurses and midwives have only a few weeks left to nominate a colleague for outstanding work in the 2017 HESTA Australian Nursing and Midwifery Awards.

Three winners receive $10,000 towards further education or team development.

The annual awards recognise graduates, individuals and teams for their professionalism, innovation and care across a range of health settings.It is the first time midwifery has featured in the title of HESTA’s awards in its 11 years. HESTA CEO

Debby Blakey said the 2017 awards shone a spotlight on nursing and midwifery as individual professions, acknowledging their work. “We wanted to bring special attention to the important role they [midwives] play.

The inclusion of midwifery recognises the advancement of the sector, differing education requirements and the significant impact both professions have on the lives of Australians.”

Ms Blakey said the awards recognised those whose work went above and beyond to provide exceptional care and support to patients. “They are also an opportunity to highlight innovations that lead to improvements in clinical practice and improved patient care.”

Awards sponsor ME Bank divides the $30,000 prize pool among the three award categories – Nurse or Midwife of the Year, Outstanding Graduate and Team Excellence.

Nominations from colleagues, patients and employers close 24 February. ww.hestawards.com.au

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February 2017 Volume 24, No. 7 9

WORKING LIFE As you can see, this is an extensive and diverse role. Our acute and sub-acute wards are spread over four sites with approximately a 40km distance between them, so there’s a lot of ground for one person to cover. To help manage the workflow, we have appointed Skin Integrity Portfolio Holders for each site/ ward to ensure best practice wound care is achieved and complete timely audits throughout Peninsula Health.

Managing COPD A 2 day course for professionals to improve their understanding & knowledge of current treatments & management of COPD. (14 CPD hrs) 20 – 21 April, 12 – 13 October Spirometry Principles & Practice This extensive 2 day course aims to develop an individual’s knowledge & skills to enable them to perform spirometry to internationally recognised best practice. (14 CPD hrs) 16 – 17 February, 27 – 28 April 5 – 6 June, 14 – 15 August, 23 – 24 October

Skin Integrity Portfolio Holders are clinical care ward nurses (may also be known as link nurse or clinical resource nurse) that volunteer to be a resource person for their staff and regularly have contact with me to ensure issues are highlighted and skills and knowledge is honed. They attend regular Skin Integrity meetings and study days to ensure best practice is delivered.

Asthma Educator’s Course A three day program covering the latest advances in asthma care management & delivery, enabling professionals to work effectively to improve health outcomes. (21 CPD hrs) 1 – 3 March, 19 – 21 July, 1- 3 November Smoking Cessation Course This evidence based program aims to give participants the knowledge & skills to treat & manage nicotine dependency to help people addicted to smoking to quit. (14 CPD hrs) 9 – 10 March, 3 – 4 August, 16 - 17 November Paediatric Respiratory Update For community & hospital based health professionals who want to improve their understanding & update their knowledge in the current assessment & management of asthma & other respiratory illnesses in children. (7 CPD hrs) 26 June Respiratory Course A four day program, split into 2 modules over a week, for those wanting to update & develop their skills & knowledge of respiratory care & the holistic management of respiratory illness. (28 CPD hrs) 1 – 2 May (Module A) / 3 – 4 May (Module B) Asthma Management Update This update is designed for practice, community & hospital based nurses & other health professionals who want to improve their understanding of & update their knowledge in the current management of asthma. (7 CPD hrs) 26 May Respiratory Update This program will give health professionals the opportunity to improve their skills & knowledge in caring for the person with lung disease.

(6 CPD hrs) 28 July

Lung Health Promotion Centre at The Alfred (03) 9076 2382 lunghealth@alfred.org.au www.lunghealth.org.au

SKIN INTEGRITY PORTFOLIO HOLDERS ARE GOLDEN

By Meagan Shannon I have been the Skin Integrity Clinical Nurse Consultant (SICNC) at Peninsula Health for about eight years. In my role, I oversee wound care and pressure prevention measures.

My role involves managing more than 1,700 complex wounds per year within the clinical ward settings as well as a multitude of other tasks including responsibility for the Skin Integrity Steering Committee, wound product reviews and trials, development of wound clinical practice guidelines, liaison with other health professionals such as occupational therapists, podiatrists, consultants, specialist nurses, education, nurse managers and external bodies like Royal District Nursing Service.

I also undertake regular and extensive auditing of wound and pressure documents as well as preparing monthly pressure injury number reports via key performance indicators for both admitted and developed pressure injuries.

A systematic review of all Stage 3 and 4 pressure injuries is undertaken with a multidisciplinary approach, to understand the root cause and possible origin of the pressure injuries to ensure quality standards are met to prevent further occurrences. Significantly, I am responsible for ensuring all our nurses’ wound knowledge is up to date in a variety of settings from ICU, acute, sub-acute, mental health, residential and palliative care settings, to ensure best practice.

10 February 2017 Volume 24, No. 7

They organise or are responsible for: • education in the ward setting to address knowledge gaps both in theory and practice- they also undertake regular eLearning in wound care; • support coordination of wound supply into their wards; • train the trainer support for Negative Pressure Wound Therapy; • report any changes, audit data and issues back to ward/unit and Nurse Manager; • attend educational study days to keep up to date with best practice in wound care; • feedback any changes to staff regarding wound or pressure care documentation, assessments and resource information; • survey or audit completion; • work with me to coordinate and evaluate dressings; • wound products and pressure prevention equipment, and • liaise with multi-professional staff to ensure consistency of wound care.

Our Skin Integrity Portfolio Holders do an excellent job and are golden in maintaining standards of wound and pressure prevention care.

The Skin Integrity Clinical Nurse Consultant is a varied and challenging role that encompasses regular literature review, constant wound product evaluation, widespread staff education, extensive report writing and data collections and collation. The joys of my job are witnessing the dedication of our staff to strive for best practice and the challenges that it can bring.

None of this is achievable without the magnificent and devoted Skin Integrity Portfolio Holders that ensure ongoing and consistent care is delivered to our patients/ clients and the vital support these patients receive in their hospital setting to get them back home and healthy.

Meagan Shannon, RN; Dip. Crit. Care; Dip. Mngmnt; Masters of Nursing, is a Skin Integrity Clinical Nurse Consultant (SICNC) at Peninsula Health, Victoria anmf.org.au

WORLD INTERNATIONAL DELEGATES AT THE FEDERATION OF MEDICAL WORKERS UNIONS’CONFERENCE, TOKYO

ANMF PARTICIPATES IN INTERNATIONAL NURSING SYMPOSIUM ON SHIFT WORK Nick Blake, ANMF Senior Federal Industrial Officer Nurses and other health workers have long understood the often deleterious impacts that shift work can have on sleep, wellbeing and performance at work.

Most nurses and midwives work according to a roster with changing shift patterns and at antisocial periods day and night. Whether at a hospital, aged care or community setting a nurse or midwife will be on hand to ensure care is maintained, invariably working in chaotic settings for employers who operate their business 24 hour a day, seven days a week.

As nurses and midwives are required to be at the frontline of the provision of healthcare they often suffer stress and other ill health effects from working not only long hours but also nonstandard hours.

Their obligations as employees, coupled with their professional commitment to the care and wellbeing of their clients, often results in exploitation including having to shoulder unacceptable workloads, working short staffed, double shifts and excessive overtime. This in turn leads to burnout and entrenched recruitment and retention problems in specific health and aged care settings.

It was against this backdrop that union representatives from Australia, anmf.org.au

France, and South Korea joined with the International Labour Organisation (ILO) and the Japanese Federation of Medical Workers Unions in Tokyo to exchange views and experiences on the challenges of regulating shifts and long hours in nursing.

The symposium noted that, while it was relatively commonplace for countries to adopt regulation to control excessive night shift and cap working hours, in many settings nurses and other healthcare workers were struggling to cope with the excessive demands of employers to undertake long and often unsafe roster arrangements.

The Japanese Federation of Medical Workers Unions provided disturbing examples of the widespread growth in the use of 16 hour consecutive night shifts. The union noted in 2000 around 8% of nurses were required to do double shifts at night and this had increased to over 32% in 2015. Further in 2015, nearly 55% of Japanese nurses in intensive care units were regularly rostered to work 16 hour shifts.

The situation for nurses in South

Korea was arguably even worse than Japan with the country struggling to attract and retain sufficient nurses to staff hospitals. The impact on nurses who remained in the South Korean health system in 2015 was characterised by increased hours of work and workloads and a growth in unregulated and often unskilled labour providing care. In a quite bizarre development the South Korean delegation reported that many employers were now asking nurses to agree on a ‘pregnancy roster’ to manage workforce needs.

While the Japanese and South Korean experiences were amongst the worst examples nearly all speakers gave examples of the creeping reemergence of the deregulation of hours of work. In response to this disturbing trend the Symposium reaffirmed “vital role played by nursing personnel in the improvement and protection of the health and welfare of the population” and called on the ILO , governments and nursing employers to take steps to ensure nurses are adequately protected against working unacceptably long and harmful hours.

February 2017 Volume 24, No. 7 11

PRIORITIES 2017

ANMF PRIORITIES 2017 Without a doubt our professions and our communities are up for some significant challenges in health and aged care during 2017. Based on the issues important to you, the ANMF has set key priorities for the year ahead and will work hard to ensure health equity and fair conditions for all.

ABOVE: ANMF ASSISTANT FEDERAL SECRETARY ANNIE BUTLER (L) AND FEDERAL SECRETARY LEE THOMAS (R) WITH GREENS SENATOR RACHEL SIEWERT BELOW: LEE THOMAS AT THE NATIONAL PRESS CLUB

AGED CARE The ANMF will continue to fight for aged care in 2017. Mandated staffing ratios including at least one registered nurse on duty 24/7 at all facilities with high care residents; closing the wages gap for nurses and care workers; and minimum education and registration for personal care workers and assistants in nursing are key priorities.

The ANMF provided evidence to the Senate Inquiry into the Future of Australia’s Aged Care Sector Workforce last year.

Recommendations from the committee are due in April.

The National Aged Care Staffing and Skills Mix Project report released late last year shows ‘missed care’ is a regular occurrence in residential aged care facilities due to inadequate staffing levels.

Key recommendations included: residents should receive an average four hours and 18 minutes of care per day – compared with the 2.84 hours currently provided; and a skills mix of 30% registered nurses; 20% enrolled nurses; and 50% personal care workers to ensure safe care for residents.

12 February 2017 Volume 24, No. 7

While the proportion of high care residents entering aged care facilities increased to 83% in 2014, the number of RNs decreased to 12% down from 13.2%, ANMF Federal Secretary Lee Thomas said. “It’s a worrying trend that whilst residents are entering in more frail conditions, and in need of complex nursing care, aged care providers are choosing to hire less registered nurses.

“Without legislated requirements in all Australian jurisdictions to mandate a minimum number and type of nursing and care staff, safe and quality care for the elderly cannot be assured.”

The ANMF is currently undertaking an analysis of the funding cuts to aged care, including the axing of $1.8 billion from the Aged Care Funding Instrument (ACFI). Ms Thomas said these cuts had created a crisis in aged care with residents now unable to get basic standards of care.

Adequate remuneration for aged care workers is a key priority for the ANMF. Aged care nurses are paid up to 30% (or up to $300 a week on average) less than their colleagues working in the public health system. The ANMF will continue to campaign for funding specifically targeted to the wages of workers in aged care, Ms Thomas said. “Nurses and care workers in the aged care sector continue to be undervalued and underpaid, with the pay for most aged workers both skilled and semiskilled, not adequately reflecting the nature of the work and the level of responsibility they have in their workplaces.”

“WITHOUT LEGISLATED REQUIREMENTS IN ALL AUSTRALIAN JURISDICTIONS TO MANDATE A MINIMUM NUMBER AND TYPE OF NURSING AND CARE STAFF, SAFE AND QUALITY CARE FOR THE ELDERLY CANNOT BE ASSURED.”

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PRIORITIES 2017

ANMF FEDERAL SECRETARY LEE THOMAS WITH NURSES AT THE SENATE HEARING INTO PAID PARENTAL LEAVE IN CANBERRA

WORKERS’ RIGHTS The ANMF will lobby the government for improvements to industrial relations laws that allow nursing staff to be properly represented in the workforce.

This includes strengthening the safety net for minimum standards and protecting and improving entitlements.

“We will continue to lobby the government to stop any changes in laws to the detriment of nurses and any erosion in their employment rights,” ANMF Senior Federal Industrial Officer Nick Blake said.

Publicly funded paid parental leave (PPL) has been most recently under attack. A new PPL Bill introduced into Parliament in October 2016 saw PPL entitlements capped at 18 weeks.

“The intention of the government is to decrease the ability for women to access both their government and employer EBA schemes. The ANMF will continue to campaign against any decrease in PPL,” Mr Blake said.

anmf.org.au

The Registered Organisations Act changes, passed late last year, put further scrutiny on unions. The Act now includes an expanded set of reporting requirements for unions in addition to increased penalties. Unions have always had significant obligations to be transparent and accountable to members, said Mr Blake. “Improvements to workers’ rights are under attack by a government that wants to weaken the role of unions in workplaces.”

Recent successes of unions including superannuation, government-funded paid parental leave and regulated hours of work are now at risk.

The government announced for a new workforce Inquiry late last year.

The ANMF will also campaign against some healthcare employers pushing for more unskilled cheaper workers, said Mr Blake.

“The ANMF supports an adequately trained and well paid workforce and opposes further dilution of the RN workforce. We need to guard against policy development of further de-skilling of the workforce.”

“THE ANMF SUPPORTS AN ADEQUATELY TRAINED AND WELL PAID WORKFORCE AND OPPOSES FURTHER DILUTION OF THE RN WORKFORCE. WE NEED TO GUARD AGAINST POLICY DEVELOPMENT OF FURTHER DE-SKILLING OF THE WORKFORCE.”

The ANMF will also keep a close watch on penalty rates in 2017, Mr Blake said. “We note the substantial attacks from various quarters on the restaurant, retail and fast food industries. The Fair Work Commission will likely decide soon whether penalty rates are to be reduced in these areas and it is quite likely a bad decision for these workers will result in employers of nurses looking for the same outcome.”

February 2017 Volume 24, No. 7 13

PRIORITIES 2017

MEDIA PERSONALITY ANDREW DENTON WITH LEE THOMAS PROMOTING THE GO GENTLE AUSTRALIA CAMPAIGN

VOLUNTARY EUTHANASIA CAMPAIGN The ANMF will continue in partnership with Go Gentle Australia to appeal for changes in law to support voluntary euthanasia.

Advocacy group Go Gentle Australia does not argue for a ‘right to die’, Founding Director and television and radio personality Andrew Denton said.

“What we do argue for is a right to have a choice about what happens to us at the end of our lives. We see death not as a right, but as a fact at the end of life.”

The Go Gentle Australia campaign was about fairness, dignity and choice, Mr Denton said. ANMF Federal Secretary Lee Thomas said the union committed to the partnership with Go Gentle Australia because of the daily suffering and incurable pain seen by nurses and midwives. “Whether you personally agree with voluntary euthanasia or not, it’s a choice for people who might want to take that choice.

“We are seeking voluntary euthanasia laws that are completely voluntary; help people who face a terrible, lingering death; have strong checks and balances; and have doctors and nursing professionals at the centre of the process.”

14 February 2017 Volume 24, No. 7

Polls consistently show in excess of 75% of Australians support the introduction of VE laws. The South Australian Parliament voted down the Death with Dignity Bill for people to access voluntary assisted dying by just one vote in November last year.

At that same time, the Victorian government accepted a cross-party state committee’s recommendation to legalise assisted dying for people suffering from serious and incurable conditions. The government will introduce legislation into the Parliament for debate in the second half of 2017. MPs will be granted a conscience vote.

“I think if we are ever to see any law reform in this space it would have to be a modest model that has been the subject of good scrutiny that addresses the issues of exploitation, checks and balances and really engages the clinical community,” Victorian Health Minister Jill Hennessey said.

“WE ARE SEEKING VOLUNTARY EUTHANASIA LAWS THAT ARE COMPLETELY VOLUNTARY; HELP PEOPLE WHO FACE A TERRIBLE, LINGERING DEATH; HAVE STRONG CHECKS AND BALANCES; AND HAVE DOCTORS AND NURSING PROFESSIONALS AT THE CENTRE OF THE PROCESS.”

UNIVERSAL HEALTHCARE The ANMF is lobbying the government to put health and aged care at the top of its policy agenda in 2017. This includes the restoration of the $57 billion ripped from national health funding and reversal of the crippling freeze on Medicare rebates.

“Day in, day out, frontline nurses, midwives and assistants in nursing are witnessing growing inequities in health and aged care, which continue to compromise the care they can deliver to their patients,” ANMF Assistant Federal Secretary Annie Butler said.

The government seemed determined to push ahead with dismantling Medicare by freezing rebates for doctors, reducing bulkbilling services and shifting the cost of basic health services on to consumers, Ms Butler said. “Without a doubt, Australia’s public health system continues to be under threat.”

The government must rule out any changes to Medicare, including privatisation.”

In particular in NSW public health services are under threat. The NSW government’s agenda to privatise the state’s public health services was confirmed late last year with further public services transferred to private operators.

“Less than two months ago we were told of this government’s plans to privatise five regional hospitals and now they’re targeting our metro health facilities,” NSWNMA General Secretary Brett Holmes said in December.

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PRIORITIES 2017

NURSES AND MIDWIVES AT THE NSWNMA SHELLHARBOUR RALLY

Evidence showed privatisation of public services, especially in health led to increased inefficiency, Ms Butler said.

“The best way to be responsive to Australia’s health and ageing needs is to ensure fair and equal access to quality health and aged care for all not to outsource these responsibilities to private, for-profit providers.”

Australians had sent a strong message to the government at the polling booths last election about the importance of healthcare and Medicare, Ms Butler said. Post-election polling showed more than 60% considered healthcare must be the number one focus for the new government.

“Voters have shown they want a fair and equitable health system, not one where you can only receive care if you can afford to pay for it.”

Ms Butler said sustainable public health services could be achieved by creating a system which was evidence based and cost effective, including better use of nurses, nurse practitioners and midwives working to their full potential, particularly in prevention and primary healthcare.

“Restoring the billions axed from public health and maintaining Medicare must be its (government’s) key priorities - the privatisation of the country’s health services is not the answer.”

anmf.org.au

AUSTRALIAN DELEGATES AT THE 2016 SOUTH PACIFIC NURSES FORUM IN THE SOLOMON ISLANDS

CLIMATE CHANGE The ANMF is lobbying the federal government to commit to a national strategy on climate change.

The Climate and Health Alliance (CAHA), of which the ANMF is a member, released a ‘National Strategy on Climate Health and Wellbeing for Australia’ discussion paper in June 2016.

A CAHA study last October of health professionals, including nurses and midwives, found 78% considered Australia’s current climate policies inconsistent with its international obligations, including the Paris Agreement. The Australian government only ratified the Paris Agreement late last year.

International journal The Lancet in tracking the progress of the health impacts of climate change revealed they were already being felt and affecting some of the most vulnerable on our planet.

ANMF Federal Professional Officer Elizabeth Foley said the impact was evident in the Solomon Islands which held the South Pacific Nurses Forum in November. “These people are already living with the effects of climate change. Sea waters are rising encroaching on the villages; people are re-building their houses on stilts or completely relocating to higher ground. Man-made islands made hundreds of years ago are disappearing.

These people were not the cause of climate change yet are the ones feeling the effects,” Ms Foley said. “It’s not about a 1.5% or 2% reduction in carbon emissions for these people – they are living the effects of climate change in the moment.”

The mantra was to keep putting in front of government the human face of the health impacts of climate change on communities – both here and in Australia’s neighbouring countries, Ms Foley said. “Any Australian climate change policy has to include our South Pacific neighbours: we have a very real responsibility to look beyond our own borders.”

Australian nurses and midwives were already active in their local areas in reducing the carbon footprint in workplaces, Ms Foley said. “Our members are now looking at the ANMF and other peak bodies to take it to the politicians to do something at a national level.

“Nurses and midwives want the health system to have capacity building to cope with the effects of climate change and capacity building for their communities to be able to manage extreme weather conditions.”

Unions have called for ‘just transition’ to manage the move to a clean energy economy and to support or workers and communities that rely on fossil fuel-related jobs.

“There are too many examples from recent years of economic transition leaving the majority of affected workers out of a job, local businesses left to die, and their towns and communities decimated. We must do better as we face significant change in a number of industries,” ACTU President Ged Kearney said.

A Senate Committee recommended an independent statutory authority to oversee the transition of the energy sector and longterm employment for workers late last year.

February 2017 Volume 24, No. 7 15

PROFESSIONAL

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

Julianne Bryce

Elizabeth Foley

Julie Reeves ANMF Federal Professional Officers

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

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

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

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

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

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

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

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

Reference The Australian Nursing and Midwifery Federation, 2015.

ANMF policy Statement: Occupational Health and Safety

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

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

16 February 2017 Volume 24, No. 7

latter part of 2016.

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

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

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

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

Many respondents felt unsupported and that their concerns went unheard.

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

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

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

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

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

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

FEATURE

REMOTE AREA NURSE ROBYN HILL ON BATHURST ISLAND PHOTO: ELISE DERWIN

FEATURE

OFF THE

BEATEN TRACK THE RISE OF REMOTE AREA NURSING

Remote Area Nurses (RANs) work in far-flung pockets of Australia delivering healthcare to largely disadvantaged communities. Highly skilled, adaptable, and resilient, RANs collectively strive to improve health outcomes for people living remote. As the sector moves forward, ongoing challenges loom large, namely workforce shortage issues, boosting safety, and improving health service provision, writes Robert Fedele.

R

egistered Nurse Robyn Hill was biding time at the John Hunter Hospital in Newcastle, her dream of becoming a Remote Area Nurse firmly tucked away in the back of her mind. Since becoming a nurse she had been spellbound by the idea of travelling to a distant part of Australia to live and work out bush in a challenging environment.

The seed had been planted years earlier when Robyn worked as a jillaroo in South West Queensland during a gap year following high school.

In 2015, Robyn bit the bullet and headed to Alice Springs, to the annual conference held by the Council of Remote Area Nurses of Australia (CRANAplus) in search of kick-starting her ambition.

Through word of mouth and networking, Robyn stumbled across a transition program developed by the Northern Territory Government’s Primary Health Care Branch and Centre for Remote Health (CRH) to fast-track nurses into jobs working remote.

A Registered Nurse for five years, Robyn thought she would need 25 years of nursing experience under her belt before even considering a career as a RAN. But the Transition to Primary Health Care Practice, known as the Primary Health Care Nurse 3 (PHCN3) program, shifted her mentality and at the start of 2016 she embarked on a 12-month

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journey at the Julanimawu Health Centre on Bathurst Island in the Northern Territory, off the northern coast of Australia above Darwin.

The N3 program requires nurses to have at least 3 years’ full-time experience prior to applying because, although the scheme is supported by nurse educators and clinic managers, budding RANs work autonomously and need sound clinical experience and judgment.

“You need to be able to do all sorts of checks from acute clinical work (which we do in the hospitals) but also chronic disease management, midwifery care, child and adolescent health, and sexual health,” Robyn explains of the range of skills. “It was certainly an eye-opener and I took a little while to settle into the environment, particularly the heat up here. Your first couple of days out somewhere so far away from your supports is a little bit nerve-racking. But this particular clinic and this community has been incredibly supportive of me and I felt from day one that I wasn’t alone.”

Dotted with red dirt roads and bordered by crystal blue waters, Bathurst Island paints a striking picture. The Julanimawu clinic is staffed by about a dozen health professionals, including four acute nurses like Robyn, who support a community of 1,800, the population almost entirely Indigenous.

Robyn cites chronic diseases including heart disease, lung disease, diabetes and renal disease, as the most

significant health issues facing locals.

Although she’s only been a RAN for a short time Robyn is revelling in her newfound autonomy and extended scope of practice. “It’s seeing someone after hours in that acute phase and doing all the work yourself. You’re not surrounded by a team of Emergency Department staff in which you’ve got lots of people assisting you and specialists on hand. You’re the one that needs to look at them, get their story, take their observations, listen to their chest, take blood tests and then you consult with doctors in Darwin about further management.”

Late last year, Robyn officially graduated from the transition program and is now a fully-fledged RAN. This year, she will expand her skills by undertaking a Graduate Certificate in Remote Health offered by the Centre for Remote Health and Flinders University, which focuses on boosting education surrounding cultural awareness, Indigenous health, remote advanced nursing practice, and chronic disease and primary healthcare.

At age 31, Robyn belies the sector’s glaringly ageing workforce. Judging from her own experience, she suggests younger nurses could benefit from greater information. “Since I’ve achieved a placement in this course, I want people to understand that they don’t have to wait until they’re 40 or 50 to go out bush,” she says. “I think

February 2017 Volume 24, No. 7 19

FEATURE

RAN ROBYN HILL TREATING PATIENT MARCELLA PORKILLA-FERNANDO AT THE JULANIMAWU HEALTH CENTRE. PHOTO: ELISE DERWIN

people sometimes wait until their families grow up or think of it as a retirement step.

But there are lots of places that are eager to take you and your family. It’s a fantastic learning experience for everyone.”

THE STATE OF PLAY

According to the Australian Institute of Health and Welfare (AIHW), in 2013 29% of the country’s population lived in rural and remote areas, with 1.4% in remote areas and 0.9% in very remote areas. In its 15th biennial health report released in 2016, AIHW states Australians living in rural and remote areas tend to have a lower life-expectancy, higher rates of disease and injury, and poorer access to and use of health services than people living in major cities.

Poorer health outcomes in rural and remote areas may reflect a range of social and other factors that can be detrimental to health, including a level of disadvantage related to education and employment opportunities, income, and access to health services, the report adds.

Troublingly, in 2009-2011, people living in remote and very remote areas had mortality rates 1.4 times higher than people living in major cities, with coronary heart disease the leading cause of death, alongside land transport accidents and diabetes.

Similarly, disease prevalence is greater in rural and remote areas than other parts of Australia, with arthritis, deafness, cancer, and mental health problems all above the norm.

People living rural and remote are also more likely to be overweight or obese, smoke daily, exceed lifetime alcohol risk guidelines, and have lower rates of breast and bowel cancer screening.

20 February 2017 Volume 24, No. 7

The report also points out people living rural and remote may need to travel long distances or even relocate to attend health services or receive specialised treatment.

Ultimately, the report found it difficult to pinpoint the implications of remoteness for health, citing the higher proportion of Indigenous Australians, and gaps in the availability and coverage of health data in rural and remote areas as significant shortcomings.

THE RISE OF REMOTE AREA NURSING

Experienced RAN Christopher Cliffe is the current CEO of CRANAplus, the professional body representing remote health professionals. Every few months Mr Cliffe heads out bush to work remote. One of his posts last year was based at Groote Eylandt and Bickerton Island in East Arnhem Land in the Northern Territory.

“It’s huge personal value to me. It keeps me engaged and keeps me passionate about our industry,” Mr Cliffe says. “It also gives me the opportunity to not just rub shoulders with workforce at conferences and at meetings and things like that, but also at 2 o’clock in the morning on call when you’re dealing with an emergency and you get to see the reality of it. It’s a very levelling playing field and it’s a great way to hone some insight into the complexities of the land.”

Mr Cliffe considers the growth of remote area nursing slow and steady. “We were very much the wild west back in the 90s. There were very little guidelines. The demand was very acute, emergency type care. Much less staff. Much less resources. Much less support or acknowledgment of what we were doing out there. In some ways, it was a bit more

adventurous.”

Today, he says the landscape has undeniably changed, a testament to former trailblazers who elevated remote health into the mainstream and onto the political agenda.

“The amount of education that’s required to maintain your base skill level as a remote area nurse is enormous. Maintaining clinical currency and also the community expectations and demands; the complexity of care has increased dramatically; the demands have increased exponentially.”

CRANAplus’ mission statement spruiks delivering quality healthcare to remote areas of Australia and, fundamentally, improving outcomes.

Still, Mr Cliffe concedes the question he’s probed on the most is why the health gap isn’t improving. “I think often people fail to see the bigger picture. Healthcare is only a percent of the health equation. The social determinants of health are often overlooked.

There’s more overcrowding. There’s more poverty. There’s more social dysfunction and a burden of chronic disease. So even though we’re advancing clinically and as a health service the deterioration of health paradigm in the community is getting worse.”

WORKFORCE SHORTAGE

Remote area nursing is an important, sometimes unheralded, cog in the wider health system. Significant issues facing the sector include workforce recruitment and retention, prevalent safety and security concerns, and the push towards greater professional development.

A survey undertaken by CRANAplus last year found 70% of the workforce is aged 50 years anmf.org.au

FEATURE or older, and that 20% are not expecting to work remote within the next two years.

“Perhaps that’s just the way it’s traditionally been,” Mr Cliffe says. “The quintessential remote area nurse is a 50-year-old woman, post-children, that has gained an amount of clinical expertise and specialties in their urban and rural area and has decided to give back and go on a bit of an adventure.”

“THERE TENDS TO BE A BIT OF AN ATTITUDE THAT TO WORK IN RURAL AND REMOTE HEALTH REGARDLESS OF WHICH PROFESSIONAL GROUP THAT YOU ARE A BIT LOWER DOWN THE PECKING ORDER, YOU COULDN’T CUT IT IN THE CITY SO YOU GO BUSH.” National Rural Health Alliance Chair, Geri Malone PHOTO: NATIONAL PRESS CLUB OF AUSTRALIA

A study released last year by Rural Health Workforce Australia (RHWA) in collaboration with Monash University Department of Rural Health, University of Newcastle Department of Rural Health, and the Centre for Remote Health in Alice Springs, made 11 recommendations aimed at recruiting nurses and allied health professionals by increasing awareness of non-urban practice.

CRANAplus CEO Christopher Cliffe

anmf.org.au

Senior Clinical Psychologist Annmaree Wilson, Bush Support Services

Its key recommendations focused on better promotion and marketing of rural and remote practice, providing and supporting rural practice experiences for students and early career professionals, supporting the transition to rural and remote practice, and developing clear career pathways in rural and remote Australia.

“Sometimes it’s very hard. Some people see the media portray remote Australia as this very dangerous place with people living in poverty and it’s really quite confronting,” Mr Cliffe says. “Absolutely there is poverty out there and there are issues out there but certainly from my experience it’s also been a most wonderful career.”

Mr Cliffe says remote health must overcome considerable challenges. He concedes more GPs are required, but contends a strong remote area nursing workforce coupled with an Aboriginal health workforce is also essential in influencing cultural change throughout communities. “Improving links with education, housing, transport, making sure there’s the infrastructure in place, making sure that there are employment opportunities.”

“THE SOCIAL DETERMINANTS OF HEALTH ARE OFTEN OVERLOOKED. THERE’S MORE OVERCROWDING. THERE’S MORE POVERTY. THERE’S MORE SOCIAL DYSFUNCTION AND A BURDEN OF CHRONIC DISEASE. SO EVEN THOUGH WE’RE ADVANCING CLINICALLY AND AS A HEALTH SERVICE THE DETERIORATION OF HEALTH PARADIGM IN THE COMMUNITY IS GETTING WORSE.”

“IT’S A CHALLENGE SOMETIMES BUT BECAUSE WE’RE SO USED TO IT AND PICKING UP ON THE CLUES AND WORKING WITH SILENCE AND NOT BEING ABLE TO SEE BODY LANGUAGE BUT PICKING UP INFORMATION IN THE VOICE AND THOSE SORT OF THINGS I THINK WE OVERCOME TO A LARGE EXTENT THOSE BARRIERS.”

In addition to fixing investment in health and services, Mr Cliffe believes there should be a greater focus on the speciality of remote area nursing. “My hope for the road ahead is that we as a remote nursing profession can actually unite much more into a clear professional discipline. With that comes the need for all remote nurses to be able to meet the professional standards of remote nursing practice,” he says.

“A LOT OF MONEY IS PROVIDED FOR INDIGENOUS HEALTH. THERE’S NO ONE ANSWER. IT’S JUST A MATTER OF KEEPING ON AND KEEPING ON AND IT’S JUST REALLY HARD TO SEE THE OUTCOMES IN THE SHORT TERM. OUTCOMES ARE ONLY SEEN OVER A LONG PERIOD OF TIME. THE PROBLEM IS THAT GOVERNMENTS ARE ONLY IN FOR A SHORT PERIOD OF TIME SO THEY WANT AN OUTCOME IN THREE YEARS.” Remote Area Nurse Amanda Maher

BUILDING PATHWAYS

Jason Phieler is a rural and isolated practice endorsed registered nurse (RIPERN) working as the Nurse Unit Manager at Lorne Community Hospital.

RIPERN’s undertake additional training to be able to provide a wider range of primary care and emergency services from rural health services to assist local doctors struggling with demand.

February 2017 Volume 24, No. 7 21

FEATURE Jason was one of the first cohorts to undertake the program in Victoria, run by the Department of Human Services (DHS), back in 2009. His extended scope now allows him to administer and supply medications under legislation without a doctor’s order.

Jason says rural nurses were viewed as “generalist specialists” and the scheme has helped facilitate new career paths. “It’s also helped with retention because people also have a greater satisfaction of work with that extended scope of practice.”

As the lines between rural and remote become increasingly blurred, Jason is typical of many nurses who pinch hit between both fields. Jason says rural and remote nurses need to be a jack of all trades. “Working in that type of environment we wear different hats because you don’t have the resources or structure like you would have in a big hospital.”

implementation of ‘Never Alone’ guidelines, mostly due to adequate staffing and proactive clinic managers.

emergency call-outs be accompanied by a second responder, where possible a trusted local community member.

Some 25% of respondents however felt their accommodation was unsafe and that emergency communication was not always functional or utilised, while 60% of RANs said they had never been offered formal workplace orientation.

Other measures to support frontline staff included ramping up mandatory safety guidelines, teaching de-escalation procedures, enforcing minimum orientation requirements, and addressing infrastructure and equipment flaws.

Alarmingly, the study revealed 40% of clinicians had experienced or directly observed episodes of threats, bullying, or assault that had impacted on their personal

SUPPORTING NURSES WORKING REMOTE

CRANAplus’ Bush Support Services aims to bridge the gap by providing a 24/7 confidential telephone counselling service for remote health workers, their families, and friends. Established in 1997, Bush Support Services offers specialised support from a team of trained psychologists

Jason is currently working with CRANAplus as a member of their Rural Leadership Advisory Group, which is aiming to identify the strengths, opportunities and barriers which impact upon rural and remote health professionals, including recruitment, retention, and professional development.

He suggests autonomy, the opportunity for extended scope of practice, and working across diverse areas of health, can help attract a new breed to the sector.

ZERO TOLERANCE

The tragic murder of RAN Gayle Woodford a year ago sparked national interest and triggered revived demands for increased safety for nurses working remote.

In the aftermath, CRANAplus embarked on a wide-ranging study into the problematic issue, launching its Remote Area Workforce Safety and Security Project.

In addition to tackling violence, the study is looking at the prevention of vehicle accidents, the most frequent cause of injury or death for staff working remote, as well as increased risks due to emerging social challenges such as the escalating use of Ice. The 12-month project is aiming to deliver a literature review on the safety and security of the remote health workforce, stimulate national dialogue, and develop practical national guidelines. It has also proposed creating an industry handbook, selfassessment tool, health smart app, and free online learning module.

“WORKING IN THAT TYPE OF ENVIRONMENT WE WEAR DIFFERENT HATS BECAUSE YOU DON’T HAVE THE RESOURCES OR STRUCTURE LIKE YOU WOULD HAVE IN A BIG HOSPITAL.” Remote Area Nurse Jason Phieler

“One of the things that we specifically look for and value in our team is the ability to work on the phone,” Senior Clinical Psychologist Annmaree Wilson says. “It’s a challenge sometimes but because we’re so used to it and picking up on the clues and working with silence and not being able to see body language but picking up information in the voice and those sort of things I think we overcome to a large extent those barriers.”

Today, Bush Support Services helps remote health staff deal with a wide-range of issues including mental health problems, violence, depression, isolation, and workplace bullying.

Ms Wilson says toxic workplace conflict consistently surfaces as the biggest issue.

wellbeing and ability to continue working.

Project Officer Rod Menere labelled safety and security a shared problem that demanded cultural change and leadership from key stakeholders. “There’s some good news and a lot of things we can do but when you read stats like that it’s really disturbing when you consider the impact of the work environment on people.”

Early findings from a project questionnaire completed by more than 70 remote area clinicians revealed mixed results when presented at last year’s CRANAplus conference in Hobart.

In a similar sentiment, the Northern Territory government late last year released its own response to the Gayle Woodford tragedy in a comprehensive review into remote area nurse safety - Remote Area Nurse Safety: On-Call After Hours Security - it hopes will better protect remote primary healthcare staff working across the NT.

Staff from several locations reported improvements in safety and security, with 38% of clinics indicating consistent

Chief among the NT government’s 14 recommendations stood ensuring all remote health professionals attending after-hours

22 February 2017 Volume 24, No. 7

Understandably, the day-to-day environment RANs work in can often lead to higher amounts of stress than that experienced by health professionals working in larger regional and urban areas with access to better support networks.

“People’s normal supports for dealing with the ups and downs of a workplace aren’t always available when people are working rural and remote. There’s that tyranny of distance,” Ms Wilson explains, adding that isolation and loneliness are also common.

Ms Wilson says nothing but experience can prepare a nurse for working remote.

RANs need to possess clinical expertise, be multi-skilled, self-motivated, and resilient, she says. When RANs contact the service they usually chat about issues for an hour and ongoing support is available.

Ms Wilson says psychologists often uncover multiple underlying issues when talking to RANs. “For example, someone might call us because there’s been some sort of event in their workplace. Maybe they’ve been first on the scene at a motor vehicle accident or one of their patients has gotten very ill or has died.”

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FEATURE

RAN ROBYN HILL ON THE JOB WITH COLLEAGUE BRADLEY TIPILOURA. PHOTO: ELISE DERWIN

A RARE BREED

Remote Area Nurse Amanda Maher trained at the Launceston General Hospital in the 80s and in years to come would work across every section from radiology and emergency to surgical and the children’s ward.

The solid grounding held Amanda in good stead when she decided to become a RAN following the heartbreaking death of her youngest child from cancer. “Most people, the reason they go remote is that something happens in their life for them to decide to give up their secure position and to go and do something different.”

Amanda’s first post was in the town of Aurukun in Far North Queensland, just below Cape York. Today she works across various communities within the Cape for Queensland Health.

The fly-in fly-out lifestyle sees her on average spend a month working in each community before returning to Tasmania for a break. The communities are largely Indigenous and the health priorities significant. Chronic disease, including diabetes and rheumatic heart disease, are major issues.

“A lot of money is provided for Indigenous health. There’s no one answer. It’s just a matter of keeping on and keeping on and it’s just really hard to see the outcomes in the short term. Outcomes are only seen over a long period of time. The problem is that governments are only in for a short period of time so they want an outcome in three years.”

After six years as a RAN, Amanda says she couldn’t imagine a more fulfilling job. anmf.org.au

She says the people are open, honest, and grateful. Amanda believes RANs must have the inherent ability to work under pressure, be adaptable, listen, and make timely decisions.

She admits to once working in a single-nurse post on Cape Barren Island in Tasmania, but would never do so again. “It’s dangerous.

There is no back-up and you really are, security wise, not very well off.”

Amanda says being a RAN provides a rare opportunity for a person to extend their skills and make a real impact. But it’s not for everyone. She admits heading home to Tasmania for some respite between stints up north allows her to stay focused and overcome the difficult parts of the job. “I don’t go up there to make friends but you certainly find a lot of like-minded people and have a lot of fun and learn and get in touch with the country.”

THE ROAD AHEAD

Last November, The National Press Club of Australia convened a forum on fixing rural and remote health. It featured speakers, Chair of the National Rural Health Alliance, Geri Malone, CEO of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, Janine Mohamed, and CEO of the Royal Flying Doctor Service, Martin Laverty.

Identifying the widespread inadequacy of health services, Ms Malone said appropriate and affordable healthcare should be a basic human right. “We are not talking about the highly specialised surgical and medical services but primary healthcare services, emergency response including mental

healthcare, and being able to birth and die close to where you live.”

The National Rural Health Alliance, led by Ms Malone, has unveiled five key areas it believes represent the way forward for rural and remote Australia – unlocking the rural and remote economy, incentives to get the right workforce into place, a greater focus on Aboriginal and Torres Strait Islander health, and further support for primary health networks. “We do not have a health worker shortage in this country at the current time, what we have is a distribution problem – we can’t get them out of the cities,” Ms Malone said. “There tends to be a bit of an attitude that to work in rural and remote health regardless of which professional group that you are a bit lower down the pecking order, you couldn’t cut it in the city so you go bush.”

The forum was in part triggered by the imminent appointment of a new independent National Rural Health Commissioner, a government pledge aimed at leading reform and increasing pathways to support highly skilled rural and remote doctors.

Ms Malone said investment in rural and remote health had been historically poor. “Scratch the surface and the actual investment in services be they health, education, communications and business is tokenistic at best.”

She said succeeding in rural and remote practice demanded a special kind of person.

In her view, the way forward calls for local solutions for local issues, and above all, “a fair go for rural and remote health”.

February 2017 Volume 24, No. 7 23

ISSUES

RELIABLE ALLERGY RESOURCES Deryn Thompson Allergic conditions now affect 20% of the Australian population (Mullins et al. 2015). This means that nurses in different clinical practice fields will be involved in caring for patients who may also have an allergic condition.

An allergy is: an exaggerated reaction of a person’s immune system, initiated by immunological mechanisms.

A person reacts to a substance that the body usually considers harmless (World Allergy Organization 2016).

The term ‘allergy’ is commonly confused with ‘intolerance’ by the public and health professionals. An intolerance does not involve the immune system, is not life-threatening and symptoms commonly include bloating, headaches or lethargy (Australian Society of Clinical Immunology & Allergy, [ASCIA] 2016).

Allergies include reactions to foods, medications, insects and conditions such as allergic rhinitis (hay fever), atopic eczema and asthma. Reactions can range from mild, such as hives, itchy eyes and sneezing to lifethreatening anaphylaxis.

Hospital admissions for anaphylaxis have increased five-fold over the past 20 years, with reasons unknown (Mullins et al. 2015). One in seven Australians suffer with allergic rhinitis (Australian Institute of Health and Welfare, [AIHW] 2011). For children, 37% have long-term health conditions, with asthma, eczema, chronic sinusitis and hay fever featured in the top 10 listing (AIHW, 2012). Allergic conditions severely impact the quality of life of those with the condition and their families (Thompson & Thompson, 2014; Mullins et al. 2015).

Nurses need to reflect critically upon their current practice of allergy management strategies, identifying if they need greater knowledge and understanding about allergic conditions, to optimise patient care.

Practice standards require nurses base their practice upon reliable, evidence based information and resources (Nursing & Midwifery Board of Australia, [NMBA] 2016). However, it is often difficult for nurses to know where to access evidence based, current allergy information to begin this reflective process. The plethora of misinformation on the internet, the media and even in seemingly ‘reliable’ sources creates barriers to health professionals accessing evidence based information. It is not 24 February 2017 Volume 24, No. 7

uncommon for nurses to encounter statements such as: • ‘It is ‘natural’ so it cannot hurt me or my baby’.

• ‘My child’s blood test said he was allergic. I am avoiding all the foods the doctor tested for’.

• The doctor prescribed a child’s ‘Epipen’ for my 16 year old who has anaphylaxis’.

• ‘The next allergic reaction will be much more severe so I am scared’.

These answers require evidence based responses. Effective patient education is part of the professional role of nurses and can maximise improved health outcomes and improve quality of life for those with allergic conditions (Thompson & Thompson, 2014). Timelimited medical consultations do not allow general practitioners enough

NURSES NEED TO REFLECT CRITICALLY UPON THEIR CURRENT PRACTICE OF ALLERGY MANAGEMENT STRATEGIES, IDENTIFYING IF THEY NEED GREATER KNOWLEDGE AND UNDERSTANDING ABOUT ALLERGIC CONDITIONS, TO OPTIMISE PATIENT CARE.

time to undertake the detailed explanations and demonstrations required to help maximise patients’ understanding of how and why they undertake treatments (Thompson & Thompson, 2014).

In their daily clinical practice, nurses may be called upon to: • administer immunotherapy injections; • demonstrate how to correctly administer topical nasal sprays; • demonstrate the use of asthma inhaler devices; • check that an anaphylaxis action plan is up-to-date; • demonstrate the use of an automated adrenalin device and, • demonstrate how to apply the correct amounts of moisturising

creams for eczema: 500gms per week for an adult and 250gms per week for a child (British Dermatology Nursing Group, 2012).

Where to access reliable allergy resources

So, where can busy nurses gain reliable, evidence based, allergy related information? Nurses can access free resources at the Australasian Society of Clinical Immunology & Allergy (ASCIA) website www.allergy.org.au Nurses can explore this professionally established and monitored website to gain reliable information and resources including e-training modules. Some examples of commonly utilised resources available on the ASCIA website are: • Food Allergy Clinical Update for health professionals 2016; • allergic rhinitis e-training for health professionals; • anaphylaxis e-training for health professionals; • action plans, treatments plans and checklists (anaphylaxis, travel plans, eczema, rhinitis, subcutaneous immunotherapy); • allergy testing overviews; • unorthodox treatments and testing, and • facts sheets for patients and consumers.

Further professional development for Registered Nurses

Registered Nurses can also undertake the online The Professional Certificate of Allergy Nursing. The course integrates theory and practice, with a one week clinical placement in an allergy service. Information is available at: www.unisa.edu.au/ Health-Sciences/Programs-andCourses/Short-courses/Allergy/ This article has highlighted where nurses can gain knowledge and skills from reliable, evidence based allergy resources. Nurses can be confident that they are providing appropriate information to facilitate patients’ informed decision making (NMBA, 2016).

Deryn Thompson is a Lecturer in the School of Nursing and Midwifery at the University of South Australia and Women’s & Children’s Health Network SA (Eczema Nurse)

References Australian Institute of Health and Welfare.

2011. Allergic rhinitis (‘hay fever’) in Australia.

Cat. no. ACM 23.

Canberra: AIHW. Australian Institute of Health and Welfare.

2012. A picture of Australia’s children 2012. Cat. no. PHE 167.

Canberra: AIHW. British Dermatological Nursing Group.

2012. Best practice in emollient therapy: a statement for healthcare professionals.

Dermatology Nursing.

11(4):S1–S19.

Mullins, R.J., Dear, K.B. and Tang, M.L. 2015.

Time trends in Australian hospital anaphylaxis admissions in 1998-1999 to 2011-2012, The Journal of Allergy and Clinical Immunology, 136(2):367-375.

Nursing and Midwifery Board of Australia.

2016. Registered Nurse Standards for Practice, file:///C:/Users/ deryn/Downloads/ Nursing-and-MidwiferyBoard---Standard--Registered-nursestandards-for-practice--1-June-2016%20(1).PDF accessed: Nov 2016 Thompson, D. and Thompson, M. 2014.

Knowledge, instruction and behavioural change: building a framework for effective eczema education in clinical practice, Journal of Advanced Nursing.

70(11):2483-2494 World Allergy Organization 2016 WAO/EAACI Allergy Definitions www. worldallergy.org/ professional/allergic_ diseases_center/ nomenclature/english. php accessed Nov. 2016

anmf.org.au

LEGAL

MERCILESS VERSUS MERCY KILLING?

Linda Starr

In the current legal and political climate intentionally ending a patient’s life is unlawful euthanasia and assisted suicide continue to be crimes in Australia.

There are however, situations where withholding or withdrawing life sustaining treatment may be lawful, and where the provision of palliative care and the doctrine of double effect will also not attract criminal charges.

In common law and legislation in some states the doctrine of double effect means healthcare professionals are protected from criminal liability when providing reasonable treatment/ palliative care to a patient in good faith even though an incidental effect of this treatment could hasten the patient’s death.

However, three recent cases concerning healthcare professionals and the lethal administration of drugs fall outside this definition and have the potential to damage the public’s trust and confidence in the health professions.

Reference Carter L. 2016. Megan Haines: Ex-nurse sentenced to 36 years in jail for murder of elderly women by insulin overdose. Accessed online: www.abc.net. au/news/2016-12-16/ megan-hainessentenced-for-murderof-two-elderlywomen/8126418 Kenyon G & Smith P. The case for assisted dying – is palliative care failing? Australian Doctor 4 November 2016.

R v Crickitt [2016] NSWSC 1738)

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 anmf.org.au

In December 2016 Dr Brian Crickitt was found guilty of murder in the NSW Supreme Court for killing his wife by injecting her with a lethal dose of fast-acting insulin (R v Crickitt).

Whilst the Crown’s case was built on circumstantial evidence, Hoeben CJ found beyond a reasonable doubt that Crickitt improperly obtained a supply of insulin and administered this to his wife with an intention to cause her death.

Significantly, this evidence included an internet search by Crickitt using the words ‘insulin’ and ‘fatal’ a day before her death and the script for insulin he filled and obtained from the pharmacy.

Hoeben CJ was satisfied that the primary motive for this action was Crickitt’s increasing dislike for his wife and his infatuation for another woman. Although the defence raised the possibility of suicide given the deceased’s history of depression, this was dismissed.

The second case, Megan Haines a former nurse was found guilty of two counts of murder also in the NSW Supreme Court in December 2016.

In this case, the accused gave two elderly nursing home residents a fatal dose of insulin with the intention of causing their death.

in this case was compassion and the doctor’s belief patients should be able to choose how they wish to die.

In November 2016 an investigation began into the conduct of Dr Lancee following her disclosure that she assisted an elderly patient to die which was published in a book `The Damage Done’ (Kenyon & Smith, 2016). Lancee admitted to administering a lethal dose of medication to an 80 year old competent woman, with severe emphysema to hasten her death.

INDEED, THESE TWO CASES HAVE RAISED CONSIDERABLE PUBLIC CONCERN, PARTICULARLY THE LATTER WITH RESPECT TO HOW WELL THE ELDERLY ARE PROTECTED FROM UNSCRUPULOUS INDIVIDUALS IN POSITIONS OF TRUST AND AUTHORITY WHO BLATANTLY ABUSE THAT TRUST.

The court heard that Haines had boasted about how easy it had been to kill someone without being detected by using insulin. The motive for this calculated crime was that the residents several days earlier made a complaint about the standard and quality of the care she delivered.

In sentencing Haines to 36 years of imprisonment Garlin J stated that: “Her conduct was deliberate and calculating. It was a gross breach of trust and a flagrant abuse of her power,” and “She clearly abused that position of trust. I consider this to be a significant aggravating factor.” (Garling J) Indeed, these two cases have raised considerable public concern, particularly the latter with respect to how well the elderly are protected from unscrupulous individuals in positions of trust and authority who blatantly abuse that trust.

The third case yet to be heard in the courts also involves an alleged unlawful killing, however, the motive

This woman had expressed a passionate wish to die and had attempted suicide by tying a plastic bag around her head on three occasions due to her intolerable suffering. In Lancee’s opinion this was a case where the patient’s condition was terminal, she was in severe distress and palliative care was inadequate to deal with her pain and suffering. Over several weeks Lancee attempted to provide the woman with symptomatic treatment without success. During this time the woman was persistent in her wish to die, and the family were supportive of her decision. Then with the family by her side, Lancee administered the drug and “the mother died a beautiful, peaceful death with a smile on her face” (Australian Doctor, 2016).

Is there a difference between these three cases? On the face of it the first two cases describe intentional, calculated and callous acts clearly undermining the public’s trust and confidence in the health professions.

But would the public share the same view of Lancee’s conduct? Clearly, all three acts are unlawful and whilst the first two have been expediently dealt with through the courts, the last case has not.

The South Australian Parliament recently considered a Bill for euthanasia to be lawful – it was defeated. The Victorian Parliament will introduce a euthanasia Bill in 2017 and not surprisingly there is strong support for and against this on legal, ethical and moral grounds amongst the public and health professionals.

These cases highlight the ends on the continuum of what is unlawful and what might be considered the competent adult’s right in end of life care and the need for clear guidelines in the development of such laws to safeguard the rights of patients and healthcare providers.

February 2017 Volume 24, No. 7 25

VIEWPOINT LEGAL

ANMF LIBRARIES AT YOUR SERVICE

By ANMF Federal Librarian Elizabeth Reale Did you know many of the ANMF Branches offer library services to members and ANMF staff?

Libraries are at ANMF Branches in Victoria, New South Wales, South Australia and Queensland and can assist members who are: • students studying at ANMF; • nursing and midwifery students enrolled at other institutions; • nurses, midwives and assistants in nursing (practicing and non-practicing; • ANMF nurse educators, elected officers and professional/industrial staff.

ANMF has an institutional subscription to CINAHL which is available to members for onsite and offsite use in Victoria, NSW, QLD and SA.

ANMF libraries understand how important it is to be equipped with the right information at the right time, by providing dedicated library spaces with a range of print and electronic information resources. All library spaces are well equipped with computers and wifi and are pleasant places to be, providing a conducive environment for individual or group study and research.

How can a librarian help me?

ANMF Libraries can help you with:

CINAHL is a great research tool for undergraduate and postgraduate study and for professional practice and scholarly research. Your librarian can help you search CINAHL and other online information tools in the most effective way.

ANMF libraries are staffed by professionally qualified librarians. Librarians are educated in the university sector to degree-level and above. Our librarians are focussed on the needs of library users. They have an understanding of the information needs of all ANMF library user groups including students, practicing nurses and midwives, ANMF educators and staff.

• strategies to do research for

assignments;

• staying on top of NMBA requirements

for CPD;

• finding answers to clinical enquiries; • accessing quality information resources;

and

• building strong study, research and

What is held in ANMF Libraries?

Other resources include:

• books and e-books, including those

found on course reading lists;

• LibGuides – guides which direct you

to topical resources in nursing and midwifery; • historical collections in nursing and midwifery and ANMF workplace gains; • some ANMF libraries subscribe to the ProQuest Nursing Collection, Joanna Briggs Institute Evidence-Based Practice Database and the Informit Health Collection.

What is CINAHL Plus with Full Text?

CINAHL Plus with Full Text is an online database of peer reviewed journal literature in nursing, midwifery and allied health. The 26 February 2017 Volume 24, No. 7

Nothing pleases a librarian more than helping library users find what they need, when they need it.

What is Information Literacy?

Information literacy is the ability to effectively find your way around the subject area you are exploring, and more broadly, around the information we are all exposed to in our everyday lives. Information literacy is the ability to cast a critical eye over printed and online information, with a view to sorting the information wheat from the information chaff. It’s also the ability to apply knowledge to professional practice.

Information literacy is more than a professional skill, it’s a life skill you can transfer to other areas. It can help you evaluate the information you are reading and arrive at accurate conclusions about its credibility.

information literacy skills.

Each library holds a wealth of collections in nursing and midwifery, including workplace relations, workplace health and safety and legal information, as well as an extensive range of journal titles covering Australian and international nursing and midwifery literature.

The libraries also hold CINAHL Plus with Full Text and have access to other online resources such as Medline and the Cochrane Collaboration of Systematic Reviews.

do your research. The librarian’s role is to help you identify and navigate sources and develop your research skills.

Librarians can: • help you to select and gather the information you need; • assist with strategies for searching journal literature held in databases; • teach you about nursing and midwifery information tools and resources; • teach information literacy skills; • assess information sources for relevance and credibility; • obtain difficult-to-get journal articles.

There is a lot of information out there which lacks credibility. Accurate and well-presented information takes a little more skill to find.

Quality information is:

• authored by someone with relevant STUDENTS AT ANMF (SA BRANCH) LIBRARY

Librarians’ key skills are organising and retrieving information (remember Dewey?); accessing sources of information for credibility, relevance and bias; curating library collections; educating library users about services; teaching information and research skills, and most importantly, assisting library users to find the best information resources for their needs. Librarians are constantly learning about new technologies, which they pass on to library users through classroom and informal education.

Librarians can be the link between you and the information you need. They match your information requirement with available resources, tailored to your purpose. While the aim of ANMF librarians is to unite library users with the right information at the right time, it’s not the librarians’ role to actually

professional credentials;

• comes from an established, respected

source such as an academic journal, official news source, government or organisational website; • is factual and can be attributed to established knowledge sources; • unbiased and not founded in opinion; • timely;

Information lacking credibility is: • authored anonymously or with a pen

name;

• unsubstantiated; • based on opinion rather than fact; • out of date (depending on the context

for which it is being used).

ANMF libraries are provide reliable sources of evidence-based research to support nursing and midwifery study and practice.

To learn more, contact your ANMF Branch. anmf.org.au

REFLECTIONS

DEALING WITH DEATH Amy Benn One inevitable thing we all must address…is death. As soon as we are born, we are dying. Although part of the normal sequence of life, death encompasses grief, and grief is uncomfortable. So naturally death at times is avoided in general conversations, which can create fear surrounding the process.

And so, resting my head at night suddenly became difficult.

Generally speaking, nurses are notoriously altruistic. They give and give and give until everybody else is accounted for, though it may come at a price. Healthcare workers (nurses) possess empathy, meaning we feel what our patients are feeling. We are compassionate as we will habitually do whatever we can to relieve others suffering, whether it be emotional, physical or mental.

As nurses, we go through intense vigorous training and do everything possible to prevent death and clinical deterioration in our patients, and when the time comes, to facilitate a peaceful dying process. Though when I walk onto a shift to take a person and their family through the experience (sometimes who I have never met) there is not much that can prepare me for what is coming.

After that experience, I had what they call a ‘normal reaction to an adverse event’ that explained why I was no longer coping. It was also attributed to a combination of multiple deaths over a short space of time which made it so difficult for me to deal with.

I presume I am speaking on behalf of my profession when I say that if my patient is comfortable, surrounded by their loved ones, and has their wishes met, that it’s a good day. When they are cared for with dignity and respect, I have done my job and can rest my head easy at night.

AFTER THAT EXPERIENCE, I HAD WHAT THEY CALL A ‘NORMAL REACTION TO AN ADVERSE EVENT’ THAT EXPLAINED WHY I WAS NO LONGER COPING. IT WAS ALSO ATTRIBUTED TO A COMBINATION OF MULTIPLE DEATHS OVER A SHORT SPACE OF TIME WHICH MADE IT SO DIFFICULT FOR ME TO DEAL WITH. But sometimes we are not so lucky.

One night I found myself amongst my team in a horrendous prolonged arrest situation, where the patient died.

Amy Benn is a Registered Nurse specialising in intensive care nursing anmf.org.au

can only describe it as being punched in the chest, having her heart ripped out and slashed apart in front of her, and then someone stomping on the remaining pieces.

By my definition it was not dignified.

It was organised, but not peaceful.

It was prolonged but not effective.

We pulled in every resource and ended with a poor result for a young man. There was no way we could have prevented this situation. It was still one of the most unpleasant experiences of my life.

I was standing over this man when his wife walked in. The poor woman’s scream is something I can still feel. I

The accumulated stress significantly outweighed the resilience I had at the time, and I had to ask for professional help.

I am so glad I did. I found out my extremely low mood was ‘normal’ as well as the unexpected intense waves of grief which came over me, where I had no choice but to stop what I was doing, and breathe through each emotion as they eventually passed.

For a short while, I couldn’t bear the thought of going to work ever again.

If my resilience and ability to cope was a pendulum, it did not stand a chance from the emotional stress I endured.

Motivated by my ambition to prevent my career from sabotaging my personal life, it became my mission to draw meaning and equanimity from the experience.

I have a long list of healthy coping strategies that I acquired over the years. I learnt to channel and release my anger and frustration through exercise. I learnt ways to express my feelings through creative outlets. I learnt that being kind to myself was paramount. I sought out particular people to talk to, who could hold a conversation about life and death, and I learnt how to talk about it.

To me, ICU nursing is like a heightened emotional profession.

Along with the lows, come the highs.

The ICU team work relentlessly to acquire skills and provide a service.

Regardless of race, gender, sex, wealth or age everyone is equal

and receives the best possible care.

We not only save lives but provide comfort and reassurance that everything possible is done regardless of the outcome. It is extremely unique in this day and age and personally satisfying.

Although that arrest experience shook me to my core, there are many others whose suffering is relieved. I found satisfaction from slowing down and engaging more with my patients. By not rushing and talking less, listening and asking questions more. By also helping them out the door and on their way again.

By practising my self-care strategies, slowly my stress and resilience pendulum came back into balance and my ability to cope was restored.

I am proud I had the courage to say I was not ok. I am even more grateful for the help and support that I received.

If I could go back now and give myself any advice it would be: Check in with yourself. Ask yourself how you are feeling and how you are coping. A good measure of this is “How much do you have to give today?”

Create opportunities to practice mindfulness in your daily activities.

This may be creating a playlist for your commute to work, taking some nice deep breaths in line at the post office. Connecting with others instead of withdrawing.

Restore your own pendulum. I learnt that nobody will even notice when you are out of balance if you hide it well and don’t speak up. It is your responsibility to show up as your best self. So practice your self-care practices not only to help yourself feel good, but so you can be of best service to others.

February 2017 Volume 24, No. 7 27

VIEWPOINT

Dr Faye McMillan

References

VIEWPOINT AND REFLECTION FOR THE NURSING WORKFORCE Faye McMillan If the Close the Gap Campaign is working to achieve health and life expectation equality, are we creating an ageing health workforce to work with older Aboriginal and Torres Strait Islander people?

Healthy ageing is a desire of all Australians, if this desire becomes a reality for Aboriginal and Torres Strait Islander people, are we educating a health workforce that understands, appreciates and responds to the cultural needs of this population within society. The National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (NATSIHP, 2013-2023 pg 7) emphasises the need for older people to be able to live out their lives as active, healthy, culturally secure and as comfortable as possible.

For this to become a reality there must be a focus on other identified health priorities that places emphasis on care and treatment that is based on the best possible evidence, workforce and service delivery models of care that are free of racism and inequality (Australian Human Rights Commission, 2016). Currently due to the health and life expectancy inequalities experienced by Aborignal and Torres Strait Islander people (Australian Bureau of Statistics, 2013), the inclusion of a healthy ageing agenda for this population is absent due to the lack of data and the lived experiences of older Aboriginal and Torres Strait Islander peoples that informs curricular design and curricular content into nursing programs (Mleck et al. 2017).

It is acknowledged that through the accrediation process of Nursing and 28 February 2017 Volume 24, No. 7

Midwifery programs within Australia by the Australian Nursing & Midwifery Accreditation Council has seen the embedding of Indigenous issues into the curricular (Australian Nursing & Midwifery Accreditation Council, 2016). The curricular provides a context of history and the current impact of Aboriginal and Torres Strait Islander health concerns on current nursing and midwifery practices.

However, healthy ageing for Aborignal and Torres Strait Islander peoples must be addressed as we actively seek through medical and social and emotional wellbeing supports to increase the number of older Aborignal and Torres Strait Islander peoples through the decrease of the life expectancy gap.

Through change in life expectancy, current work practices will need to be addressed.

Aboriginal and Torres Strait Islander peoples currently experience poorer health outcomes and live with chronic and complex conditions. With appropriate care and management, preventable deaths will be reduced and as a result Aboriginal and Torres Strait Islander peoples will live longer. However, as this population ages the impact on the health and human services will increase. The understanding of this workforce as to the needs of old and older Aboriginal and Torres Strait Islander peoples is reduced due to the already

mentioned lack of evidence. As the evidence increases so too must the understanding and engagement of the workforce in this area to not only the health needs, but also the cultural needs of this group to enable them to feel and be culturally secure (NATSIHP, 2013-2023 pg 7). Understanding the cultural and medical needs will need to have synergy to allow older Aboriginal and Torres Strait Islander peoples to engage in their own care with a focus on person centred care as it relates to connection to country/home (McMillan et al. 2010). It is envisaged that through synergistic research that is focused on reducing the impact and prevelance of chronic and complex health needs of Aboriginal and Torres Strait Islander people/families and communities, leading to healthy ageing within communities, therefore creating the need for understanding of living well rather than living to die.

Dr Faye McMillan is a Wiradjuri woman, Faye holds a Doctor of Health Science, Master of Indigenous Health, B.Pharm, Grad Cert Wiradjuri Language, Culture and Heritage and Grad Cert Indig Governance and is the Director of the Djirruwang Program and Discipline lead for the Bachelor of Health Science (Mental Health) - Snr Lecturer in the School of Nursing, Midwifery and Indigenous Health at Charles Sturt University.

Australian Bureau of Statistics. 2013.

Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Canberra: Australian Bureau of Statistics, 2012-13. www. abs.gov.au/ausstats/ abs@.nsf/Lookup/ CD58150AC0A36286CA 257C2F0014591C?open document Accessed: Aug 2016 Australian Government.

2013. National Aboriginal and Torres Strait Islander Health Plan (2013-2023).

Canberra: www.health. gov.au/internet/main/ publishing.nsf/content/ B92E980680486C3BCA 257BF0001BAF01/$File/ health-plan.pdf Accessed: Aug 2016 Australian Human Rights Commission.

2016. Close the Gap: Indigenous Health. Sydney www. humanrights.gov.au/ our-work/aboriginaland-torres-strait-islander -social-justice/projects/ close-gap-indigenoushealthAccessed: Aug 2016 Australian Nursung & Midwifery Accreditation Council 2016. www. anmac.org.au/ Accessed: Oct 2016 McMillan, F., Kampers, D., Traynor, V and Dewing, J. 2010.

Person-centred care as caring for country: an Indigenous Australian experience. Dementia: The International Journal of Social Research and Practice, Vol 9 (2), 163-167. SAGE Publications.

Mleck, S., McMillan, F., & McMillan, R. 2017.

The Experience of Ageing for Indigenous Australian and Mãori peoples. Eds Bernoth, M., & Winkler, D. Healthy Ageing and Aged Care. Oxford University Press: South Melbourne

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ISSUES

THE VICTORIAN NEW HEALTH COMPLAINTS ACT 2016 – WHAT ARE THE CHANGES? Dr Grant Davies, Health Services Commissioner (January 2017) The Health Complaints Act 2016 (Vic) commenced on 1 February 2017, bringing into operation a new office of the Health Complaints Commissioner (HCC). This article outlines the changes nurses and midwives are likely to see under the new Act. An expert review of our old legislation found it did not allow the office to fully meet the needs of the Victorian community. The office undertook to improve efficiency and effectiveness while shifting towards what new legislation might encompass. One such change was a greater focus on informal resolution.

Informal resolution, which can involve advising complainants about raising their complaint with a provider or calling the provider to explore their willingness to negotiate, now constitutes around two-thirds of our resolved matters.

Our early contact with practitioners is in no way designed to pressure them into agreeing with outcomes being sought.

Our voluntary process relies on the parties entering into negotiations willingly. There are strengths in that approach which will remain under the new Act.

The Act includes a broader definition of ‘health service’, in part describing it as an activity performed “to assess, predict, maintain or improve the person’s physical, mental or psychological health or status”.

This is a much broader definition and covers a wide range of non-registered providers we were previously unable to deal with.

In a significant step, the new Act introduces a Code of Conduct for non-registered practitioners or those practicing outside their area of registration. This Code was agreed to by Health Ministers in April of 2014 and Victoria is the first jurisdiction to incorporate it into legislation. This provides the minimum standards non-registered practitioners are required to meet. The HCC will be able to receive complaints about alleged breaches of this code as well as launch investigations and make interim or permanent prohibition orders. This is consistent with other jurisdictions and there is mutual recognition of prohibition orders with New South Wales, Queensland and South Australia. There are substantial penalties for contravention of prohibition orders, including up to two years’ imprisonment.

The new Act requires that complainants try and resolve the matter with health services in the first instance, where appropriate.

This means practitioners continue to play an important role in complaint handling.

Our role is also to support nurses and other frontline staff with advice on how to manage complaints at their service.

THE NEW ACT REQUIRES THAT COMPLAINANTS TRY AND RESOLVE THE MATTER WITH HEALTH SERVICES IN THE FIRST INSTANCE, WHERE APPROPRIATE.

Anyone can make a complaint to the HCC about a health service in Victoria. This has been broadened beyond consumers and their legal representatives to include the ability of carers to make complaints about the treatment they receive. We can also take complaints from third parties including other practitioners, members of the public, media organisations or professional bodies.

Of course, health privacy is an important consideration in third party complaints and how we deal with them will differ from ‘ordinary’ complaints processes.

The new Act envisages a much greater capacity to investigate matters where there’s a risk to the health, safety or welfare of individuals or the public. The HCC will undertake follow up investigations into undertakings made by health services, the Minister will be able to refer matters for investigation and the Commissioner will be able to undertake own motion investigations. Prior to commencing an own motion investigation the Commissioner must

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seek advice from the President of the Health Complaints Commissioner Advisory Council.

The new Act includes powers to undertake hearings and to compel attendance and produce documents. The HCC will also be able to require a response to requests for information within specified timeframes, which should make our processes more efficient.

As part of the new focus on protection of the public, there is scope for the HCC to issue public warning statements about both registered and non-registered practitioners where there is a need to avoid a serious risk to the life, health or safety of individuals or the public.

The office holds an enormous amount of qualitative and quantitative data and will be reviewing complaints data about health services to analyse trends and make recommendations on addressing any issues.

This will be a particularly useful process in light of the Duckett recommendations around quality and safety in Victoria’s health services.

The Duckett review also identified legislative limitations to the way organisations in the health regulatory system share information.

The new Act enables better information sharing between the HCC, AHPRA and the Department of Health and Human Services (DHHS). The HCC will work closely with Safer Care Victoria and a new information agency in the DHHS to further the quality and safety agenda.

Part of that information sharing will include complaints about health services not meeting the legislated complaints handling standards.

These interim standards included in the Act will be replaced by a new set to be developed by the HCC over the next two years.

We share your interest in safe and ethical healthcare and see our role as supporting that through effective and impartial complaints resolution and by taking action regarding unsafe and unethical practitioners. It is an exciting time and the HCC looks forward to working with you in this important work.

February 2017 Volume 24, No. 7 29

CLINICAL UPDATE

cl References Australian Bureau of Statistics. 2008. 4102.0 Australian social trends: How many children have women in Australia had? Commonwealth of Australia, Last Modified 01/01/2008 Accessed 11/09/2009. www.abs. gov.au/ Australian Government Department of Health and Ageing. 2010.

Building a 21st century primary care system, Australia’s First National Primary Health Care System. Commonwealth of Australia.

Commonwealth of Australia. 2010. National Women’s Health Policy.

Canberra: Australian government Department of Health and Ageing.

Eijkemans, M.J.C., Lintsen, A.M.E., Hunault, C.C., Bauwmans, C.A.M., Hakkaart, L., Braat, D.D.M. and Habbema, J.D.F. 2008.

Pregnancy chances on an IVF/ICSI waiting list: A national prospective cohort study. Human Reproduction 23 (7):1627-1632. doi: 10.1093/humrep/ den132.

ASSISTED FERTILITY TREATMENT AND THE QUALITY OF INFORMED CONSENT Kerry Hampton, Jennifer Newton and Danielle Mazza Defining informed consent

Informed consent is a well-accepted cornerstone of ethical practice in all fields of healthcare.

The WHO defines informed consent as follows: Patients have a right to be fully informed about their health status, including the medical facts about their condition; about the proposed medical procedures, together with the potential risks and benefits of each procedure; about alternatives to the procedures, including the effect of non-treatment; and about the diagnosis, prognosis and progress of treatment (The World Health Organization, 1994).

This definition shows that there are several components to gaining informed consent from patients (WHO, 1994). In this article on ethical issues in nursing and midwifery practice, we focus on just one of these components in the health context of infertility; women’s knowledge of alternative treatment options to assisted reproductive technology (ART).

30 February 2017 Volume 24, No. 7

Health literacy and informed decision making

We recently completed a four-year fertility-awareness study, which sought to inform a future primary care model as one way of reducing infertility in general practice (Hampton, 2014).

We found that only 13% of infertile women who attend ART clinics understand the fertile window of the menstrual cycle for correctly timed intercourse. This is despite, 87% actively tried to improve their understanding of this ‘window’ to optimise natural conception in the hope of avoiding costly and invasive ART procedures (Hampton et al.

2013).

Evidence and practice

The most reliable test of a couples’ ability to conceive naturally, is correctly timed intercourse within the fertile window of the menstrual cycle over six or more cycles (Stanford et al. 2002). For the one in six Australian couples who experience trouble conceiving (Loxton and Lucke, 2009) this test remains true whether the fertility problem is of male, female or

combined (male and female) origin (Eijkemans et al. 2008). In developed countries like Australia, delayed childbearing is the single biggest cause of infertility (Australian Bureau of Statistics, 2008). Seminal studies in Ireland and Canada have shown that educating women regarding fertility awareness in order to correctly time intercourse as part of comprehensive care in general practice can substantially mitigate the impact of reduced fecundity that naturally occurs with increasing age (Stanford et al. 2008; Tham et al. 2012).

Despite the fundamental importance of correctly timed intercourse to women’s agency for family planning, Australian studies have consistently shown that women’s understanding of ‘fertile window’ is generally poor across the entire reproductive life course (Hampton et al. 2013; Hampton et al. 2015; Hammarberg et al. 2013).

Bias towards specialist care In Australia, access to ART treatment is mediated first by

Hammarberg, K., Setter, T., Norman, R. J., Holden, C. A., Michelmore, J. and Johnson, L. 2013.

Knowledge about factors that influence fertility among Australians of reproductive age: A population-based survey. Fertility and Sterility 99 (2):502507. doi: 10.1016/j. fertnstert.2012.10.031.

Hampton, K. D. 2014. Informing the development of a new model of care to improve the fertilityawareness of sub-fertile women in primary health care. Monash University Accessed ethesis-20141120-13313 0. http://arrow. monash.edu.au/ hdl/1959.1/1060341 Hampton, K. D. , Mazza, D., and Newton, J.M. 2013. Fertility-awareness knowledge, attitudes and practices of women seeking fertility assistance Journal of Advanced Nursing 69 (5):1076-1084. doi: 10.1111/j.13652648.2012.06095.x.

Hampton, K. D., Newton, J. M., Parker, R., and Mazza, D. 2016.

A qualitative study of the barriers and enablers to fertility-awareness education in general practice Journal of Advanced Nursing Mar 9. doi: 10.1111/ jan.12931. [Epub ahead of print].

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CLINICAL UPDATE

Hampton, K. D., and Mazza, D. 2015.

Fertility-awareness knowledge, attitudes and practices of women attending general practice. Australian Family Physician 44 (11):840-845.

Hoare, K. J., Mills, J. and Francis, K. 2011.

The role of government policy in supporting nurse-led care in general practice in the United Kingdom, New Zealand and Australia: An adapted realist review.

Journal of Advanced Nursing 68 (5):963-980. doi: 10.1111/j.13652648.2011.05870.x.

Loxton, D., and Lucke, J. 2009. Reproductive health: Findings from the Australian longitudinal study on women’s health.

Australian government Department of Health and Ageing.

PREVENTIVE HEALTHCARE IN MANY ASPECTS OF WOMEN’S SEXUAL AND REPRODUCTIVE LIVES IS HIGHLY DEPENDENT ON A CORRECT UNDERSTANDING OF THEIR FERTILE BODY

general practitioners who make referrals to fertility specialists, and second by fertility specialists who then make recommendations for a treatment plan. This systematic approach to accessing ART treatment generally takes around 12 months and is designed to ensure that the treatment plan is both appropriate and appropriately timed (McLachlan, 2005).

Our study of infertile women who attend ART clinics (n = 204) showed that half (50%) had attended two or more GP appointments about trouble conceiving, and more than half (62%) had attended two or more fertility specialist appointments (Hampton et al. 2013). Subsequent interviews with GPs and practice nurses (Hampton et al. 2016) showed that referral pathways from general practice to ART clinics are well-understood and well-utilised by these practitioners.

In contrast to these embedded anmf.org.au

practices towards ART treatment, few infertile women in our study (<5%) had received counselling from a trained teacher in fertility awareness to optimise spontaneous conception (Hampton et al. 2013). These findings suggest there is a systematic bias towards tertiary level fertility care in Australia’s healthcare system (Hampton et al. 2016; Hampton et al. 2013). Similar findings have been reported in the Netherlands (Mourad et al. 2009).

Improving the informed consent process

Preventive healthcare in many aspects of women’s sexual and reproductive lives is highly dependent on a correct understanding of their fertile body (Commonwealth of Australia, 2010).

The National Women’s Health Policy 2010 contends that expanding the role of nurses and midwives in women’s health primary care settings is crucial to increasing women’s access to such preventive health activities (Commonwealth of Australia, 2010).

Nurses and midwives were first employed in general practices in the United Kingdom in the 1980s to instil continuous improvement in healthcare in general practice (Hoare et al. 2011). This practice has subsequently been adopted in numerous countries (Hoare et al.

2011) including Australia where the role of nurses and midwives are being actively promoted to help reduce unnecessary specialist care through improved health literacy (Australian Government Department of Health

and Ageing, 2010). Embedding a nurse/midwife primary care model in fertility awareness in general practice, would potentially increase women’s access to this preventive healthcare activity when first reporting trouble conceiving and before a referral for ART treatment is given (Hampton et al. 2016).

Conclusions

There is no doubt that ART is essential healthcare for infertile couples with proven need. However, consideration needs to be given to informed consent to ART treatment from the perspective of women’s knowledge of fertility awareness as an alternative treatment option. This is just one of several aspects of informed consent to ART treatment that requires further deliberation. A nurse/midwife care model in fertility awareness has the potential to not only assist spontaneous conception in couples who report trouble conceiving, but also improve the process of informed consent to ART treatment in couples who actually need tertiary level care to overcome their fertility problem (Hampton, 2014).

Dr Kerry Hampton is in the Department of General Practice and the School of Nursing & Midwifery Associate Professor Jennifer Newton is in the School of Nursing & Midwifery Professor Danielle Mazza is in the Department of General Practice All are at Monash University

McLachlan, R. I. 2005.

Management of the infertile couple.

Australian Family Physician 34 (3):111-117.

Mourad, S. M., Hermens, R. P. M. G., Cox-Witbraad, R. P. T. M., Grol, R. P.T. M., Nelen, W. L. D. M. and Kremer, J. A. M. 2009.

Information provision in fertility care: A call for improvement. Human Reproduction Advance Access published February 17 1 (1):1-7.

Stanford, J B., Parnell, T. A., and Boyle, P. C. 2008. Outcomes from treatment of infertility with natural procreative technology in an Irish general practice. Journal of the American Board of Family Medicine 21 (5):375-384.

Stanford, J B., White, G. L., and Hatasaka, H. 2002. Timing intercourse to achieve pregnancy: Current evidence. Obstetrics & Gynecology 100 (6):1333-1341.

Tham, E., Schliep, K., and Stanford, J. B. 2012.

Natural procreative technology for infertility and recurrent miscarriage: Outcomes in a Canadian family practice. Canadian Family Physician 58 (May):e267-e274.

The World Health Organization. 1994.

A Declaration on the promotion of patients’ in Europe: Principles of the rights of patients in Europe: A common framework.

Copenhagen, Denmark: WHO Regional Office for Europe.

February 2017 Volume 24, No. 7 31

RESEARCH

ENHANCING STUDENT NURSE PREPARATION FOR PAEDIATRIC PRACTICE Dr Natasha Budd, Associate Professor Patrea Andersen, Ms Penelope Harrison An innovative pilot project at the University of the Sunshine Coast is giving undergraduate students an opportunity to develop their skills in caring for child clients and their families.

The project brings together nursing students and actors to explore the unique needs of children and their families accessing healthcare. Further, the project investigates the ethical and practical issues associated with the employment of children in tertiary training programs to establish a robust and sustainable model for broader application. The experience offered nursing students the opportunity to practice applying knowledge and skills related to working with families, demonstrating developmentally appropriate communication and obtaining consent and assent from children and parents in an acute care setting.

An action research cycle involving two rounds of simulation was employed. Each included a suite of three scenarios where children aged 7-10 and adults performing the role of a family sought care for an injured child. Actor preparation involved a series of preparatory workshops. During this they were given detailed information regarding the learning objectives of the nursing students. These were integrated into an unscripted scenario challenging students to respond to authentically crafted interpersonal communications.

In each cycle students (n=12) were immersed in a replica clinical environment.

Simulations were video recorded and live streamed to other students who were able to observe their peers in action and contribute to scenario debriefing sessions.

Debriefing included a two tier approach where students were able to explore their learning and obtain feedback from actors.

Data was collected from actors and nursing students after each simulation. Actors were interviewed. Nursing students completed a modified Satisfaction with Simulation Experience Scale (Levett-Jones et al. 2011), and ranked the simulation experience in relation to clinical learning, critical thinking and reasoning, reflection and debriefing.

They also participated in an interview.

Results revealed that all students agreed or strongly agreed that the simulation was a valuable learning experience with 91% indicating that the simulation reinforced content learnt in the degree. Ninety nine percent thought the actors’ performance positively influenced learning, felt more prepared for practice, and had developed their confidence working with children and families. Valuable information from children regarding their preparation, the impact of the scenario and support was gathered and will inform development of future simulations.

This pilot project provides valuable insights informing development of a safe workable model that provides students with opportunities to develop skills working with children, prepare for paediatric clinical experience, and for developing policy and process for wider application when working with vulnerable groups in simulation.

Reference Levett-Jones, T., McCoy, M., Lapkin, S., et al., (2011). The development and psychometric testing of the satisfaction with simulation experience scale. Nurse Education Today.

31(7):705-710.

Dr Natasha Budd is a Lecturer in Drama in the Faculty of Communication and Creative Industries at the University of the Sunshine Coast Associate Professor Patrea Andersen is Academic Director for Simulation and Visualisation in the Faculty of Science, Health, Education and Engineering at the University of the Sunshine Coast.

Ms Penelope Harrison is an Associate Lecturer in the Faculty of Science, Health, Education and Engineering at the University of the Sunshine Coast.

32 February 2017 Volume 24, No. 7

WOMEN’S HEALTH IMPROVES WITH AGE All women’s mental health improves steadily throughout their 30’s while their mental health in their early 20’s varies according to life circumstance, research reveals.

According to Professor Christina Lee, Professor of Health Psychology and Associate Dean Research, Faculty of Health and Behavioural Sciences at the University of Queensland, better mental health is associated with women moving into long-term relationships in their midtwenties and having a first baby in their late twenties to early thirties.

Yet the timing was affected by life circumstance, she said. “Women who live in the country, women who have lower education, and women who have some health problems are likely to get married and become mothers earlier than average, and these young women are also likely to have poorer mental health.”

Despite this Professor Lee said overtime the trajectory for almost every group of women is upward. “Whether you have a child at 18 or 25 or 35 years of age, or never, and whether you are in a stable relationship or remain single.

“Women are making responsible and sensible decisions with what they’ve got.

As they move through their twenties and get themselves established and gain confidence in dealing with adult life, the pattern is that mental health does improve for every group of women.”

The research is part of the Australian Longitudinal Study of Women’s Health which is a longitudinal population based survey examining the health of over 58,000 Australian women.

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Aged Care FOCUS and their successes. Everyone is working hard - it’s not from not caring.”

Maggie says it is thinking differently about food that is so important. “Homes where food is not important and not beautiful, we need to change, it’s about deinstitutionalising the food , there is absolutely no need for it.

“It needs new thinking and a new approach with a different mindset. So many things are done the same way because that’s how they’ve always been done.

“Everyone is working hard – you need a catalyst for change. Part of that is having an understanding that lovely simple food full of nutrients that provide pleasure and give protein for energy for those in aged care to be active to undertake physical exercise within their scope.”

The ‘Creating An Appetite For Life’ program will be extended to regional communities in Northern NSW in March this year.

COME TO THE TABLE

MAGGIE BEER WITH RESIDENT.

By Natalie Dragon Renowned celebrity cook Maggie Beer is improving the food experience for everyone as they age.

“It’s been a wild journey,” says Maggie of her foundation set up entirely for aged care more than two years ago.

Her interest in the area sparked when she was awarded Senior Australian of the Year in 2010.

One of her 900 requests at that time included an event with 1,000 CEOs of aged care.

Consequently Maggie became determined to change the culinary experiences of older Australians and spent a couple of years hoping to get the government to do something about it. “They were interested but there was no money. So I decided to set up a foundation was the way to go. And we did exactly that.”

The Maggie Beer Foundation launched in May 2014 aiming to bring national attention to the issue of food in aged care.

“Fresh, seasonal food gives energy and pleasure to those in aged care,” says Maggie. “It’s about not using frozen food, it’s serving soups made from stock made from scratch, having a vegie garden and the processes in place to use herbs from the garden.

“It’s about having real food that is familiar and full of protein necessary for their age.

Many older people don’t have a huge appetite so every bite has to count with the right nutrients and for pleasure – one without the other isn’t any good.”

It’s broader than the food, argues Maggie.

“It’s about being served, the ambience, and anmf.org.au

“WE NEED PROPER PROGRAMS TO SHARE AND MAKE FOOD FOR PEOPLE WITH DYSPHASIA BEAUTIFUL. THAT’S WHY I SAY A COOK OR CHEF IN AN AGED CARE HOME HAS TO REALLY CARE; IT IS HARDER THAN BEING A COOK IN A CAFÉ. THEY HAVE TO LEARN SO MUCH MORE AND THERE’S NO ACCREDITED SYSTEM.” to make it a place of home, a familiar place.”

A former student nurse at Concord Hospital in NSW another life a long time ago, Maggie greatly respects nurses. She wants no nurse to have to mash pureed food together on a plate so it’s unrecognisable.

“We need proper programs to share and make food for people with dysphasia beautiful. That’s why I say a cook or chef in an aged care home has to really care; it is harder than being a cook in a café. They have to learn so much more and there’s no accredited system.”

The Maggie Beer Foundation provides Master Classes for 30 cooks over two to three days. About 100 aged care homes are now involved, says Maggie.

“We share with them what we have learnt, how we know we can make a difference.

We have experts on nutrition and physical exercise, and we listen to their impediments

“My aim is to inspire and challenge chefs and cooks from regional aged care homes to create wholesome, memorable, low cost meals, every day in their kitchens,” says Maggie. People are often working in isolation and need support, she says.

Maggie is a firm believer in creating and sharing good stories to bring about change.

“We share the good stories as much as possible. When we can share with people and give them respect it makes an amazing difference for the people they look after.

“Cooks and chefs go back and convince their CEOs to bring about change. What happens is they are giving back and have good feelings about themselves and their role in this.”

The Maggie Beer Foundation’s logo is the pomegranate, and for good reason.

“When you open it up it’s so full of antioxidants,” says Maggie. “It’s amazing food and grows in South Australia, in the Mediterranean climate and it’s prolific. When you open it up there’s the seeds - for me it’s the seeds of change.”

There is much work to do, says Maggie, including influencing government and CEO’s to spend more money on good food in aged care and less money on expensive supplements when a resident is malnourished. “We want to see a different way of thinking, more awareness and a partner program with aged care homes up and running very soon.

“There are many people doing extraordinarily things in all facets of this wide and complicated field- If we can bring them all together we can really effect change.”

To find out more or to help go to: https://www.maggiebeerfoundation.org. au/programs February 2017 Volume 24, No. 7 33

FOCUS Aged Care

A REVIEW OF AGED CARE PROVISION IN MULTIPURPOSE SERVICES (MPS)

By Judith Anderson, Linda Deravin-Malone and Lyn Croxon The MPS model has been in place for over 20 years in NSW as a way to address the ongoing healthcare needs of small rural communities.

By combining small rural hospitals, aged care and primary health services, the MPS model supports the delivery of aged care services where stand-alone facilities would not be financially viable. Providing aged care services in this manner allows older people to age within their own small communities close to their family and friends, and social networks which is an essential component of social wellbeing (Anderson, 2010; Anderson et al. 2011).

One of the aims of the MPS program was to improve coordination of health and aged care services. This aspect of the program was realised with improved medical services, fewer transport issues and an improved opportunity to age in place (Anderson, 2010; Anderson et al. 2011). The recommendation of placing an accommodation bond on access to Residential Aged Care Facilities (RACF) places a particular strain on the rural elderly as they typically have homes and assets that are of lesser financial value than their city counterparts and generally less accessible income (Productivity Commission, 2011). This has reportedly, in some rural areas, resulted in an increase of funding for MPS to provide new residential places in direct competition with a RACF, with people choosing to wait for admission to an MPS (Keast, 2016; Henderson et al. 2016).

The development of MPS improves the sustainability of the service and the community through providing employment opportunities in these small communities (Anderson & Malone, 2014). However, Henderson et al. (2016) identified funding and staff shortfalls in both residential aged care facilities and also in MPS. In MPS these shortfalls were perceived to be

OUM’s innovative teaching style is fantastic and exciting.

Truly foreword thinking, OUM allows the student to benefit from both local and international resources.

Brandy Wehinger, RN OUM Class of 2015

RESIDENTIAL AGED CARE FACILITIES (RACF) PLACES A PARTICULAR STRAIN ON THE RURAL ELDERLY AS THEY TYPICALLY HAVE HOMES AND ASSETS THAT ARE OF LESSER FINANCIAL VALUE THAN THEIR CITY COUNTERPARTS AND GENERALLY LESS ACCESSIBLE INCOME

related to the prioritisation of work as staff were required to deal with unexpected emergencies and subacute care without additional staff (Henderson et al. 2016; Malone & Anderson, 2014). Although more nurses are employed in MPS they frequently lack specific aged care qualifications (Anderson, 2010; Henderson et al. 2016). Multi-purpose services have more nurses and fewer care staff than residential aged care facilities, but they are perceived to be more focussed on medical aspects of care than social aspects (Henderson et al. 2016). However, quality improvement strategies focussing on resident satisfaction in MPS have been demonstrated to be successful in addressing such issues (Anderson et al. 2008).

Dr Judith Anderson is Senior Lecturer; Linda Deravin-Malone and Lyn Croxon are Lecturers in Nursing. All are at Charles Sturt University in the School of Nursing, Midwifery and Indigenous Health

References Anderson, J. K. 2010. Developing a Collaborative Rural Health Identity: A grounded theory study of the development of multi-purpose services in rural New South Wales. (PhD), Charles Sturt Univeristy, Canberra.

Anderson, J. K., Bonner, A., & Grootjans, J. 2011. Collaboration: developing integration in multi-purpose services in rural New South Wales, Australia.

Rural and Remote Health, 11(1827).

Anderson, J. K., & Malone, L. 2014.

Suitability of the multi purpose service model for rural and remote communities of Australia. Asia Pacific Journal of Health Management, 9(3), 14.

Anderson, J. K., Rae, J. B., Grenade, L. E., & Boldy, D. P. 2008.

Residents’satisfaction with multi-purpose services. Australian Health Review: a publication of the Australian Hospital Association, 32(2), 349-355.

Henderson, J., Willis, E., Xiao, L., Toffoli, L., & Verrall, C. 2016.

Nurses’ perceptions

of the impact of the aged care reform on services for residents in multi-purpose services and residential aged care facilities in rural Australia. Australasian Journal on Ageing. doi:10.1111/ajag.12343 Keast, J. 2016. Rural and remote providers struggling against government services.

Australian Ageing Agenda. 10 Feb. www. australianageingagenda. com.au/2016/02/10/ rural-and-remoteproviders-strugglingagainst-governmentservices/ Malone, L., & Anderson, J. 2014. The right staffing mix for inpatient care in rural multi-purpose service health facilities. Rural and Remote Health, 14(2881).

Productivity Commission. 2011.

Caring for Older Australians. Report No. 53, Final Inquiry Report.

Canberra: Australian government.

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Aged Care FOCUS

A COLLABORATIVE PROJECT

By Eleanor Horton, Anne Livingstone and Elizabeth Dodd The Queensland government Department of Communities, Child Safety and Disability Services has funded Community Resourcing to establish the Community Care Smart Assistive Technology Collaborative (CCSATC) online space.

A Project Expert Reference Committee was appointed bringing together a range of service providers, researchers, carers and clients, academics and interested individuals in the role of Smart Assistive Technology in community service provision. As a Nursing academic, carer and advocate I am privileged to be involved with this collaborative.

The platform contains local, state, national and international linkages and provides a space to collaborate, learn and access resources and expertise in regards to Smart Assistive

Technology. The CCSATC is available for Community Care service providers as well as consumers and carers.

Recent upgrades to the portal allow users to choose which category they fall under to allow them to access relevant information. The platform provides an opportunity for nurses whether they are employed in the acute care sector or the community to be involved in Smart Assistive Technology.

The focus is on local, national and international community care practices and experiences

incorporating Smart Assistive Technology in service provision to ensure participants are able to access leading edge and contemporary information. Any nurses who are working in this space or interested in contributing to the collaborative platform please go online and register at satcommunity.com.au Dr Eleanor Horton is Senior Lecturer in Nursing at the University of the Sunshine Coast and a member of the Smart Assistive Collaborative Anne Livingstone is Lead for Research and Development at Community Resourcing and Chairperson for the Smart Assistive Collaborative Elizabeth Dodd is the Project Lead for the Smart Assistive Collaborative

Dr Patrea Andersen is Associate Professor in Nursing and Academic Director for Simulation and Visualisation

By Patrea Andersen, Eleanor Horton and Karen Ann Clarke

Developed by the University of the Sunshine Coast in conjunction with developers Bondi Labs and industry community care partner Suncare, “Safe Environments” is a competency-based serious game that has been created to address The Australian National Safety Standards.

Using specific client profiles, the app anmf.org.au

Australian Institute of Health and Welfare.

2012. Australia’s health 2012: in brief. Cat. No. AUS 157, Canberra: AIHW Robson, L. S., Stephenson, C. M., Schulte, P. A., Amick III, B. C., Irvin, E. L., Eggerth, D. E., Chan, S., Beleskey, A. R., Wang, A. M., Heidotting, T. L. & Peters, R.H. 2012.

A systematic review of the effectiveness of occupational health and safety training.

Scandinavian Journal of Work, Environment & Health, pp.193-208.

IMPROVING HEALTH AND SAFETY IN AGED CARE USING GAME BASED SIMULATION Australia faces the challenge of supporting a growing ageing population (AIHW, 2012).

Health and safety is paramount in ensuring care is economically sustainable. Nurses involved in healthcare have a responsibility to protect themselves and those being cared for against health and safety risk. Training of the workforce is paramount to reducing the chance of injury (Robson et al. 2012).

References

provides opportunities to improve knowledge and skills in managing environments for people with health concerns related to perception, coordination and movement in facility and in-home care. Immersing players in a virtual 3D environment, the application exposes them to over 100 randomly generated hazards representing 11 hazard categories in a variety of environments. These test ability to identify and categorise hazards, determine risk and make recommendations for risk elimination/ containment and minimisation.

Detailed analytics and feedback provide players with information about the percent of hazards found, correctly categorised hazards, level of risk, likelihood of incident, consequence and correct management.

Used to vitalise content and engage

learner’s critical thinking, the application is designed for tertiary education and community and facility care sectors to educate nurses, health workers, volunteers, family and friends. The application was a finalist in the Australasian Simulation Congress Showcase in October 2016, and will soon be available via Apple’s App Store. It is hoped that this form of interactive media will provide new and engaging ways for learning and have a positive impact on the health and welfare of the community. Research about the success of the application and how learning from simulation based games can translate to health outcomes will commence in early 2017. For further information about the application and trial contact Associate Professor Patrea Andersen at the University of the Sunshine Coast.

Dr Eleanor Horton is a Senior Lecturer in Nursing in the School of Nursing, Midwifery and Paramedicine Ms Karen Ann Clarke is a Lecturer in Nursing in the School of Nursing, Midwifery and Paramedicine All are in the Faculty of Science, Health, Education and Engineering at the University of the Sunshine Coast.

February 2017 Volume 24, No. 7 35

FOCUS Aged Care

References

PARTNERSHIPS FOR LEARNING AND MENTORING IN AGED CARE

By Judith Anderson, Maree Bernoth and Lyn Croxon It is well known that the Australian population is ageing (Australian Bureau of Statistics, 2013). This ageing population has led to an increase in chronic and complex diseases, leading to a range of challenges for healthcare providers (Hunter & Levett-Jones, 2010), yet 75% of residential aged care facilities report skills shortages.

Of those, 60% are shortages of registered nurses (National Institute of Labour Studies, 2012).

Annear et al. (2014) found that student nurses generally have negative opinions about aged care. Abbey et al. (2006) also note the negative opinions of students about aged care, and link these negative opinions to career plans to avoid the industry. However, Koehler et al. (2016) indicates that a positive learning experience is an important indicator in promoting positive perceptions of working with older adults.

Relevant preparation and support of students can lead to enriched learning experiences and positive attitudes towards caring for older people (Koh, 2012). Other research, (King et al. 2013; Zisberg et al. 2014) however has found that despite attitudes and preference for working with older adults improving over time, preference to work in nursing homes was consistently last.

The aim of this project was to facilitate the establishment of an education program delivered on site which was relevant to nursing students and to staff of the residential aged care facility (RACF), and to develop a culture of acceptance of students, mentoring skills for the RACF staff and thereby enhance the attractiveness of the field of aged care as an employment option to nursing students.

Participation by these students was structured into the subject around care of the older person.

36 February 2017 Volume 24, No. 7

Nursing students’ experiences and interactions with residential aged care included on site tutorials. A preceptor program for staff of the RACF was implemented as engaging staff in the teaching of students has been found to improve student knowledge, attitudes and understanding around aged care due to an enriched, supported experience (Lea et al.

2016).

A sustainable partnership was formed between CSU School of Nursing, Midwifery and Indigenous Health and the RACF to support undergraduate students in order to develop a learning community. The feedback from the students revealed that they were able to apply the theory they were learning to real life people and real life situations. It made learning meaningful and the learning objectives became more relevant. The project validated and valued the knowledge and experience of the RACF staff, including them in the teaching team (Bernoth et al. 2015). This is congruent with appreciative inquiry (Cockell & McArthur-Blair, 2012) and authentic partnerships (Dupuis et al. 2012).

Dr Judith Anderson is Senior Lecturer; Dr Maree Bernoth and Lyn Croxon are Lecturers in Nursing. All are in the School of Nursing, Midwifery and Indigenous Health at Charles Sturt University

Abbey, J., Abbey, B., Bridges, P., Elder, R., Lemcke, P., Liddle, J., & Thornton, R. 2006.

Clinical placements in residential aged care facilities: the impact on nursing students’ perception of aged care and the effect on career plans. Australian Journal of Advanced Nursing, 23(4), 14-19.

Annear, M., Lea, E., & Robinson, A. 2014.

Are care workers appropriate mentors for nursing students in residential aged care? BioMed Central Nursing, 13(1), 44. doi: 10.1186/s12912-0140044-8 Australian Bureau of Statistics. 2013.

Population Projections, Australia 2012 (base) to 2101. Retrieved 10/4/15 from www.abs.gov. au/ausstats/abs@.nsf/ Lookup/3222.0main+fe atures32012%20 (base)%20to%202101 Bernoth, M., Lawless, A., Croxon, L., & Anderson, J. 2015. Enabling Community Partnerships for Learning and Mentoring in Aged Care. Wagga: Charles Sturt University.

Cockell, J., & McArthur-Blair, J. 2012.

Appreciative inquiry in higher education: A transformative force: John Wiley & Sons.

Dupuis, S. L., Gillies, J., Carson, J., Whyte, C., Genoe, R., Loiselle, L., & Sadler, L. 2012.

Moving beyond patient and client approaches: Mobilizing ‘authentic partnerships’ in dementia care, support and services. Dementia, 11(4), 427-452. doi: 10.1177/1471301211 421063 Hunter, S., & LevettJones, T. 2010. The practice of nurses working with older people in long term care: an Australian perspective. Journal of Clinical Nursing, 19(3/4), 527-536 510p. doi: 10.1111/j.13652702.2009.02967.x

King, B. J., Roberts, T. J., & Bowers, B. J. 2013. Nursing student attitudes toward and preferences for working with older adults.

Gerontol Geriatr Educ, 34(3), 272-291. doi: 10.1080/02701960.2012 .718012 Koehler, A. R., Davies, S., Smith, L. R., Hooks, T., Schanke, H., Loeffler, A., Ratzlaff, N. 2016. Impact of a stand-alone course in gerontological nursing on undergraduate nursing students’ perceptions of working with older adults: A Quasi-experimental study. Nurse Education Today, 46, 17-23.

Koh, L. C. 2012.

Student attitudes and educational support in caring for older people: a review of literature.

Nurse Educ Pract, 12(1), 16-20. doi: 10.1016/j. nepr.2011.04.007 Lea, E. J., Andrews, S., Stronach, M., Marlow, A., & Robinson, A. L. 2016. Using action research to build mentor capacity to improve orientation and quality of nursing student aged care placements: what to do when the phone rings. Journal of Clinical Nursing.

National Institute of Labour Studies.

2012. The Aged Care Workforce, 2012 - Final Report: Commonwealth Department of Health and Ageing.

Zisberg, A., Topaz, M., & Band-Wintershtein, T. 2014. Cultural-and Educational-Level Differences in Students Knowledge, Attitudes, and Preferences for Working With Older Adults An Israeli Perspective. Journal of Transcultural Nursing, 1043659614526252.

anmf.org.au

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FOCUS Aged Care HOME VISITING NURSE PROVIDES INFORMATION OF HEALTHY DIET AND EXERCISE

COMMUNITY BASED HOME VISITING SERVICE IN KOREA: CITY OF GWANGMYEONG

By Chung-Min Cho, Deborah Parker and Stacy Blyth There has been growing interest in enhancing the quality of life of the economically vulnerable through programs aimed at improving the equality of and accessibility to public health services for these people.

One such program is the nationwide community-based home visiting care service operated by the Korean Ministry of Health and Welfare (KMHW) since 2007. This program targets economically vulnerable elderly. The goal of community-based home visiting care is to prevent complications of chronic diseases and enhance the quality of life of the economically vulnerable, especially the elderly, through managing health risk factors.

Community-based home visiting care services in Korea is provided by 254 community health centres run by local governments. One such centre is operated by Gwangmyeong, a city located near Seoul, which in 2014 had a population of 340,982 living in 18 towns (10.7% of the population is composed by the elderly of 65 years old or older).

There are 18 staff members working at the city’s home visiting the care service centre. On staff are fifteen nurses, a physical therapist, a dental hygienist and a nutritionist. Each nurse has an assigned geographic area and where required the nurse refers patients to the other staff.

38 February 2017 Volume 24, No. 7

THE GOAL OF COMMUNITY-BASED HOME VISITING CARE IS TO PREVENT COMPLICATIONS OF CHRONIC DISEASES AND ENHANCE THE QUALITY OF LIFE OF THE ECONOMICALLY VULNERABLE, ESPECIALLY THE ELDERLY, THROUGH MANAGING HEALTH RISK FACTORS. Services vary depending on the characteristics of each local community, but basic services include the following: regular services (blood pressure, blood glucose and cholesterol monitoring for those with hypertension and diabetes mellitus, physical therapy, joint exercise, oral assessment, registering cancer patients, emotional support), education service (medication error prevention, fall prevention, diet, exercise, stress management, smoking cessation, alcohol consumption restriction,

and prevention of chronic disease complications).

The frequency of visits were categorised according to the participants’ health status and care plans were set accordingly. Each visit provided by each member of the team in addition to the participants’ health status were collected across all the participating community health centres allowing longitudinal evaluations.

In 2014 the Gwangmyeong community-based home visiting care services had 7,261 households registered for the service and number of visits was 23,803. The number of the participants of the service was 10,456.

Conditions participants required care for included hypertension, arthritis, diabetes mellitus, stroke, cancer, psychiatric disorders and dementia. A service unique to the Gwangmyeong community-based home visiting care services is a cognition enhancement program which employs a nurse offering a program incorporating participants’ favourite song and photos from their lives. Evaluation of the cognition enhancement program showed improvement in the participants’ cognitive function and quality of life.

Evaluation of the communitybased home visiting care service in Korea helped to decrease hospital readmission rates of the participants which served as a reduction in healthcare costs for the participants, increased access in public health services for the economically vulnerable, and improved the participants’ quality of life.

Reference Lim, J. Y., Kim, G. M., Kim, E. J., Choi, K. W., Kim, S. S. 2013. The effects of communitybased visiting care on the quality of life.

Western Journal of Nursing Research.

35(10): 1280-1291.

ChungMin Cho is Professor of Nursing School at Sungshin Women’s University in Korea and Visiting Professor in the School of Nursing and Midwifery at Western Sydney University Deborah Parker is Professor of Nursing Aged Care (Dementia) in the Faculty of Health at the University of Technology Sydney Stacy Blyth is Lecturer/ Director Engagement and International in the School of Nursing and Midwifery at Western Sydney University anmf.org.au

Aged Care FOCUS A RESIDENT, SAMPLING SOME OF THE PARTYSTYLE FOOD SERVED DURING ‘HAPPY HOUR’ WITH DONNA WANG IN A RESIDENTIAL AGED CARE FACILITY.

FOOD CHOICES – LETTING AGED CARE RESIDENTS HAVE THEIR CAKE, AND EAT IT AS WELL

By Dong Wang and Amy R Villarosa In residential aged care (RAC), malnutrition and unplanned weight loss among residents is an important quality indicator.

A contributing factor is limited access to food choices in the facility that meet their personal food preferences.

This is also likely to add to their loss of independence and autonomy, which negatively impacts on their quality of life (Abbey et al. 2015).

Hence, in the RAC setting, the aim of nutritional interventions may also have anmf.org.au

to focus on increasing food appeal, to promote the enjoyment of eating.

To provide additional food options to residents, and at the same time, promote social interactions, and create an enjoyable environment conducive to eating, an activity called ‘Happy Hour’ was introduced at our facility. This usually occurs once or twice per week. The objectives of introducing Happy Hour were: • to provide residents more choices through the provision of partystyle food; and • to provide a sense of independence and autonomy, thereby improving their quality of life.

During Happy Hour, residents are served foods that are typically eaten at parties and social events, based on feedback given regarding residents’ individual preferences.

The RAC facility prepares seven to eight choices at each Happy Hour, including a selection of drinks, sweets, fried food and baked goods that cater for both normal diets and diets with special requirements (eg. pureed, diabetic, or culturally specific diets).

Since the introduction of Happy Hour at the facility, staff have observed that residents have become more interested in food, which may explain their maintenance of body weight.

Feedback from the residents also

SINCE THE INTRODUCTION OF HAPPY HOUR AT THE FACILITY, STAFF HAVE OBSERVED THAT RESIDENTS HAVE BECOME MORE INTERESTED IN FOOD, WHICH MAY EXPLAIN THEIR MAINTENANCE OF BODY WEIGHT.

indicated that they enjoyed the social interactions. Allowing residents to have a say in food choices has restored some sense of their autonomy. Although providing a wide range of enjoyable food options at every meal may not be feasible, many RAC facilities have the capacity to provide more food options during their routinely scheduled social activities, as seen with Happy Hour.

The success of this Happy Hour in this setting suggests other RAC facilities may also benefit from including Happy Hour into their own schedules.

Reference Abbey, K. L., Wright, O. R. L. and Capra, S. 2015. Menu planning in residential aged care - The level of choice and quality of planning of meals available to residents. Nutrients.

7(9): 7580-7592.

Dong Wang is Clinical Manager at Opal Specialist Aged Care and a Bachelor of Nursing (Honours) Candidate at Western Sydney University, School of Nursing and Midwifery Amy R Villarosa is at Western Sydney University, School of Nursing and Midwifery

February 2017 Volume 24, No. 7 39

FOCUS Aged Care qualified nurses are not inclined to want to work within this area. Then the future of residential aged care nursing can appear less than ideal.

WHERE HAS THE COMPASSION GONE FROM THE RESIDENTIAL AGED CARE ENVIRONMENT?

By Kim Oliver Would working in residential aged care be your dream job as a newly qualified nurse, probably not, but why not? Montayre (2015) suggests that although nurses don’t like to talk about it, or even less, what the real problem is perceived to be with this practice area, residential aged care nursing is thought to be less exciting, monotonous, and requiring less skill than other areas such as emergency nursing, or medical nursing.

Residential aged care nurses can become disgruntled, not only as a result of the negativity they perceive within themselves, but also from the attitudes of other nurses, which can lead to them becoming less engaged and less compassionate towards their patients and fellow workers. An experienced residential aged care nurse and a director of nursing working in Auckland, Noeline Whitehead said how sad it makes her feel when she hears elderly people say how they fear having to live in a residential aged care facility even though they struggle with loneliness and safety in their own homes (Manchester, 2013).

Montayre (2015) says that this could have been initiated right back at the beginning of the nurses training when they were a student nurse on their practicum placements, whereby they may have witnessed a lack of compassionate behaviour towards patients in the residential aged care environment, as a result of the staff perceiving they were unable to move to a more acute sector, or being trapped within this setting. As a student nurse this lack of motivation could drive this negative spiral, 40 February 2017 Volume 24, No. 7

AS A NURSING PROFESSION WE NEED TO WORK TOGETHER TO STOP THIS NEGATIVITY, TO ACKNOWLEDGE THAT RESIDENTIAL AGED CARE IS A VALUABLE SPECIALITY, NURTURING COMPASSIONATE BEHAVIOURS (NICHOLSON, 2015) TO ASSIST A GENERATION IN THEIR YEARS OF NEED. motivating them to stay away from residential aged care, rather than returning following graduation.

Furthermore, considering that the average age of the nursing staff working within the residential aged care environment in Australia is 48 years of age, Montague et al.

(2015), the stress caused from the ever increasing staff shortages as a result of the retirement of the baby boomers, heavy workloads and poor pay, as well as the fact that newly

As a nursing profession we need to work together to stop this negativity, to acknowledge that residential aged care is a valuable speciality, nurturing compassionate behaviours (Nicholson, 2015) to assist a generation in their years of need. This patient group are the people who have given us the opportunities we have today, and they deserve nothing less than quality healthcare delivery, from compassionate, motivated nurses, who want to be working and practicing in this specialised area.

Lea et al. (2016) says by working on engaging in two-way communication with student nurses, to ensure a positive learning environment, enabling them to see the diversity, and skills needed to practice in this ever changing and challenging environment, can positively influence their perception of returning to work within the residential aged care environment. Furthermore, setting benchmarks, relating to minimum standards of care to assist with this increased focus, and standardising practices across all residential aged care organisations regardless of geographical location can assist with this increased positive awareness and appreciation. As well as focusing on initiatives to attract newly qualified nurses into this practice area, exploring what attributes nurses who chose to practice within the residential aged care environment hold, also needs further exploration, as many nurses enjoy and thrive in this practice area.

Cope et al. (2016) suggest to alleviate the stress from the residential aged care environment, nurses need to develop a resilience to enable them to adapt and to remain positive amongst the stressors of their work environment. Moreover, nurse leaders are encouraged to implement educational programs, which focus on resiliency training to assist with staff retention, job satisfaction and personal wellbeing of the residential aged care nurses. Only then will the compassion be nurtured and returned to this area of practice, and one of our most vulnerable patient groups. After all, isn’t that why we all went into nursing, because we are compassionate people, who care about our patients, who want to help them, and give them good quality care when they need us, the most?

Kim Oliver is a Lecturer in the School of Nursing and Midwifery at Edith Cowan University in WA

References Cope, V. C., Jones, B., & Hendricks, J. 2016. Residential aged care nurses: portraits of resilience.

Contemporary Nurse, 1-26. doi:10.1080/10376 178.2016.1246950 Lea, E., Robinson, A., Mason, R., & Eccleston, C. 2016.

Aspects of nursing student placements associated with perceived likelihood of working in residential aged care. Journal of Clinical Nursing, 25(5/6), 715-724. doi:10.1111/ jocn.13018 Manchester, A. 2013.

Valuing aged care and its nurses. Kai Tiaki Nursing New Zealand, 19(10), 12-13. Retrieved from http://ezproxy.ecu. edu.au/login?url=http:// search.ebscohost.com/ login.aspx?direct=tru e&db=rzh&AN=107 939616&site=ehostlive&scope=site Montague, A., Burgess, J., & Connell, J. 2015. Attracting and retaining Australia’s aged care workers: developing policy and organisational responses. Labour & Industry: a journal of the social and economic relations of work, 25(4), 293. doi:10.1080/10301 763.2015.1083367 Montayre, J. 2015.

Negativity surrounds aged-care nursing.

Kai Tiaki Nursing New Zealand, 21(10), 27-39.

Retrieved from http:// ezproxy.ecu.edu.au/ login?url=http://search. ebscohost.com/login.as px?direct=true&db=rzh &AN=111165007&site= ehost-live&scope=site Nicholson, M. 2015.

Choosing to work in aged care. Article by Jed Montayre entitled Negativity surrounds aged-care nursing (p27).

Kai Tiaki Nursing New Zealand, 21(11), 3-3.

Retrieved from http:// ezproxy.ecu.edu.au/ login?url=http://search. ebscohost.com/login.as px?direct=true&db=rzh &AN=111832671&site= ehost-live&scope=site

anmf.org.au

Aged Care FOCUS

PRESCRIPTION FOR LIFE

By Caroline Vafeas and Elisabeth Jacob Younger Onset Dementia (YOD) is dementia experienced by people who are diagnosed before the age of 65 years (Alzheimer’s Australia, 2016).

Alzheimer’s Australia (2016) estimates that there are currently 25,100 people in Australia living with YOD (Alzheimer’s Australia, 2016).

People living with YOD face a variety of age specific challenges that may not be present for people who develop dementia at a later age. These challenges may include transitioning from fulltime employment, caring for young and dependent family members, and reconciling a strong healthy body with cognitive decline (Alzheimer’s Australia, 2016). These specific needs are often not considered by care providers, who may not be familiar with YOD and have little understanding of the ways in which care can be tailored to improve the quality of life of people who are living with younger onset dementia.

Edith Cowan University has developed a talking e-flipbook Prescription for Life, to educate staff

TALKING E-FLIPBOOK PRESCRIPTION FOR LIFE

in aged care facilities on caring for those living with YOD. The Trevor Mast Scholarship provided through The Lovell Foundation, enabled the completion of this resource.

The Lovell Foundation was initiated in 2009 by Garry and Mandy Lovell. Garry Lovell has been living with YOD since the age of 48 years (The Lovell Foundation, 2016).

A training needs analysis was used to establish the learning requirements of staff and assist with strategies on how best to share information to improve the care of people living with YOD within the residential aged care setting. Initial pilot sites included staff at Mercy Health and Aged Care, and The Bethanie Group (Western Australia).

The talking e-flipbook is interactive and accessible to a wide range of people, with varying skill levels. This is indicative of the highly diverse aged care workforce.

The talking e-flipbook content draws on the work of Dr G Allen Power, and the ‘wellbeing’ model of dementia care (Power, 2014). By providing links to resources, and practical tips for caring, it is hoped that this resource can assist carers in developing strategies to assist with meaningful care of people living with younger onset dementia. The talking e-flipbook also incorporates pre- and

References

postknowledge tests, allowing completion of the book to be credited as professional development. This resource is included in the Post Graduate Certificate in Dementia Care currently provided by Edith Cowan University and is now available for general use.

To access the book go to http:// online.flipbuilder.com/tntr/fzax/ Please contact Dr Caroline Vafeas for further details c.vafeas@ecu.edu.au

Alzheimer’s Australia.

2016. What is younger Onset Dementia. https://www. fightdementia.org. au/national/aboutdementia/what-isyounger-onset-dementia Accessed 28 September 2016 Lovell Foundation. 2016.

Our Dream. http://www. lovellfoundation.com. au/our-dream/ Accessed 28 September 2016 Power, G.A. 2014.

Dementia beyond disease: enhancing wellbeing. Baltimore: Health Professions Press.

Dr Caroline Vafeas & Dr Elisabeth Jacob are both from Edith Cowan University

INDIGENOUS AUSTRALIANS LIVING LONGER STILL THE GAP REMAINS

By Linda Deravin-Malone

References

Since the inception of the ‘Closing the Gap Policy’ in 2008 a range of strategies to improve the health and wellbeing of Aboriginal and Torres Strait Islander people have been promoted.

One of the key strategies was to ‘close the gap’ in life expectancy between Indigenous and nonIndigenous Australians within a generation (Council of Australian Governments 2008). According to the Closing the gap: Prime Minister’s report 2015 (Australian government, 2015), there was no change in the 2016 report, Indigenous death rates declined by 16% from 1998 to 2013 and the gap in life expectancy between Indigenous and nonIndigenous Australians declined by 15%. This is cause for celebration that current strategies are in fact working, however the gap remains, so efforts in reducing this gap should remain a anmf.org.au

high priority for our nation.

In the acute healthcare and tertiary education sector, there has been a strong push for cultural sensitivity, awareness and competency programs to be in place. If Indigenous Australians are now living longer, the question needs to be posed - is the aged care sector equipped to meet the cultural needs of older Indigenous Australians who have their own customs and traditional values particularly at end of life?

There is recognition within acute care services that health facilities need to be more culturally friendly.

In order to achieve this, education and awareness programs have been put in place to address this need in the acute care sector and in some instances, the physical appearance of some health facilities have embraced the local Indigenous heritage. Similarly, training for all levels of staff within the aged care sector should be made available and encouraged. As the numbers of older Indigenous Australians continue to grow the focus of cultural care should expand to the aged care sector. The opportunity for residential aged care services to address this unmet need for older Indigenous people exists both now and in the future.

Australian government.

2015. Closing the gap: Prime Minister’s report 2015. Commonwealth of Australia.

Council of Australian Governments. 2008.

National partnership agreement on closing the gap in indigenous health outcomes. Edited

by Financial relations: Australian government.

Linda Deravin-Malone is a Lecturer in Nursing in the School of Nursing, Midwifery and Indigenous Health at Charles Sturt University

February 2017 Volume 24, No. 7 41

FOCUS Aged Care a median gross household income of $472 per week; those 75 years and over lived on an average of $421 per week. These income levels are indicative of the high proportion of older Australians who are reliant, either fully or partially, on Age or Service pensions. Government pensions and allowances are the main source of income for most people aged 65 years and over in Australia (AIHW, 2007).

INHIBITORS TO EXERCISE AND HEALTH PROMOTION PROGRAMS FOR THE OLDER PERSON WITH DIABETES

By Rebekkah Middleton, Lorna Moxham and Dominique Parrish Diabetes care incurs a high cost burden, and is one of the main geriatric syndromes along with its related complications.

To effectively counter this, healthcare needs to be proactive in establishing exercise and health promotion programs that promote healthy and active ageing.

Such programs targeting people with diabetes, who often have lower incomes, need to be mindful of and account for cost concerns and look to support participation by ensuring no or low cost programs that enable people to act on their internal drives for improved health and lifestyles.

Drawing on the lead authors PhD research, participants in the study expressed that their primary motivation to join and participate in an exercise and health promotion program was because the program was accessible. For participants, accessibility meant that it was ‘free’.

These participants described that they were conscious of ‘having to manage their money carefully’. When a program is made accessible, as participants described it, this enabled them to act on internal drives, or an intrinsic motivation that had 42 February 2017 Volume 24, No. 7

DUE TO SUCH ECONOMIC FACTORS, OLDER PEOPLE WILL NOT ENGAGE IN AN EXERCISE AND HEALTH PROMOTION PROGRAM, NO MATTER WHAT THEIR LEVEL OF MOTIVATION IS IF THEY CANNOT AFFORD IT. previously not been able to be acted upon due to cost.

Older people are often in a lower socioeconomic group and their lifestyle decisions are often affected by how much things cost (AIHW, 2007; American Psychologist Association, 2015). The Australian Institute of Health and Welfare (2007) record that in 2005–06, people aged 65–74 had

OLDER PEOPLE ACTIVELY ENJOYING EXERCISE TOGETHER

Due to such economic factors, older people will not engage in an exercise and health promotion program, no matter what their level of motivation is if they cannot afford it. Participants in the lead author’s research spoke about many exercise programs being ‘just too expensive’ and not affordable ‘for people on our income’, even though they described how it would be ‘good for our diabetes’. Therefore, eliminating issues associated with cost facilitates opportunity to be involved. Once cost is removed, personal motivation takes effect, according to participants in this research.

This cost motivation was also linked strongly with an enabling of their participation through being easily accessible – mostly by the program itself being ‘free’ but also through facility access with easy parking and being on a free bus route that ran through the town. Previous research has shown perceived access to a facility is positively connected with initiation (and maintenance) of exercise and health promotion programs (Guicciardi et al. 2014; van Stralen et al. 2009). It suggests that in adults over the age of 50, environmental factors are particularly relevant to their sense of safety and therefore linked to their motivation to join exercise programs (Barrett et al.

2007; van Stralen et al. 2009).

It is hoped that consideration of these factors that inhibit older people engaging in exercise and health promotion programs will inform and ultimately contribute to how we provide and promote person-centred, accessible and effective future programs for people with diabetes.

Rebekkah Middleton is a Lecturer and PhD Candidate; Professor Lorna Moxham is Professor in Mental Health. Both are in the School of Nursing at the University of Wollongong Associate Professor Dominique Parrish is Associate Dean Education in the Faculty of Science, Medicine and Health at the University of Wollongong

References American Psychologist Association, 2015 American Psychological Association (APA). 2015.

Fact sheet: Age and socioeconomic status. www.apa.org/pi/ses/ resources/publications/ factsheet-age.aspx Accessed: 26 October 2016.

Australian Institute of Health and Welfare (AIHW). 2007. Older Australia at a glance, 4th edn. Canberra: AIHW. Barrett, J.E., Plotnikoff, R.C., Courneya, K.S. & Raine, K.D. 2007.

Physical Activity and Type 2 Diabetes: Exploring the Role of Gender and Income.

The Diabetes Educator.

33(1):128-143.

Guicciardi, M., Lecis, R., Anziani, C., Corgiolu, L., Porru, A., Pusceddu, M. & Spanu, F. 2014. Type 2 diabetes: negative thoughts to physical activity. Sport Sciences for Health. 10(3):247251. van Stralen, M.M., De Vries, H., Mudde, A.N., Bolman, C. & Lechner, L. 2009. Determinants of initiation and maintenance of physical activity among older adults: a literature review. Health Psychology Review.

3(2):147-207.

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MAIL FEATURE

FEATURE CLINICAL UPDATE

CLINICAL UPDATE

FALLS AND FALL INJURY IN MENTAL HEALTH INPATIENT UNITS FOR OLDER PEOPLE

By Bryan McMinn, Amy Booth, Elizabeth Grist and Anthony O’Brien Older people in Mental Health Inpatient Units for Older People (MHUOP) are a serious ‘at risk’ group, both for falling and osteoporotic injury post fall (Stubbs, 2010), as well as prolonged length of stay (Greene et al. 2001).

Falls and fall injury are a leading cause of mortality and morbidity in older people generally, but the risk of falling can be exacerbated when affected by a mental health condition.

NSW Health policy mandates that older person units must have fallsprevention processes in place as part of their strategy to prevent the development of secondary comorbidities (NSW Health, 2011, 2012).

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

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

I

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

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

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

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

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

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

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

Sadly, Kylie lost her fight and died in October.

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

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

You think about that human being.”

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

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

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

Gait may be affected by Parkinson’s disease and other degenerative brain disorders like Alzheimer’s disease and cerebral deterioration due to alcohol and other drugs. Shuffling when walking can easily lead to a trip and fall. Those who are admitted and develop delirium can also require higher acuity care, at least initially in the MHUOP. In assessing falls risk and implementing fallsprevention strategies, it is important for clinicians to recognise that this population, despite being ambulant,

GO GENTLE AUSTRALIA DIRECTOR ANDREW DENTON

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

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The ANMF seems to have decided that its views regarding euthanasia are the ‘right’ views and consequently, we, as members were urged to ‘Be the Bill’ in the recent SA Parliament consideration of voluntary euthanasia.

I do wonder however if anyone, particularly those at the ANMF who made this decision, have actually read those proposed Bills?

The original Bill we were instructed to support, was only briefly considered by Parliament due to its controversial and some dangerous aspects. Even the amended version didn’t require a patient to be in the terminal phase of their illness to request euthanasia. I agree with Maree Burgess who carefully wrote in the October 2016 ANMJ, that this is a topic for discussion.

In the Dec / Jan edition of ANMJ, there was a comprehensive article on Death and Dignity. Lee Thomas refers to the article as delving “into the voluntary euthanasia debate in more detail”, and the article itself uses the word “debate” on several occasions. It is hardly a debate however as the ANMF is only presenting its own supportive view. I feel it would be a reasonable thought for the ANMF to actually present both sides of this discussion so that we as members can decide for ourselves which view we support.

Neil Mills RN, SA

FEATURE

FEATURE

Denton began his quest to trigger change two years ago, undertaking research both locally and overseas, where assisted dying laws already exist in countries such as Belgium and the Netherlands.

The countless hours of interviews with nurses, doctors, politicians, academics, and palliative care specialists from both sides of the debate formed the content for his podcast series Better Off Dead, released earlier this year.

Denton says the series was his way of “informing and inflaming” the debate in Australia. True to his mission, Denton’s informed and pragmatic approach, coupled with his intelligence and humour, is noticeably helping dispel a lot of the myths surrounding voluntary euthanasia. Denton says increasing dialogue is the key to greater understanding, and with any luck, acceptance.

“We’ve definitely started to change the public debate and I think the more opportunity we get to talk, not just with politicians, but with doctors and nurses and palliative care people, the more dialogue there is, the more it’s possible to understand that these laws can be written in a way which work first and foremost for patients of course, but also for doctors and nurses, and that nobody is being pressured into doing anything that they don’t want to do.”

THE STATE OF PLAY

Australia’s association with voluntary euthanasia legislation is longstanding.

Australia was the first country to introduce assisted dying laws back in 1995 in the Northern Territory. But history shows only four people were able to use the law before it was swiftly repealed just two years later.

In subsequent years, dozens of Bills have been presented before state parliaments only

Most attempts have been thwarted at their earliest stages and failed to even reach meaningful debate, such as New South Wales’ most recent foray dating back to its Rights of the Terminally Ill Bill in 2013, when proposed laws were soundly voted down in the upper house.

Still, recent voluntary euthanasia legislation considered by the South Australian Parliament and defeated narrowly is providing advocates real hope that genuine consideration is being given into the nuts and bolts of how a law would work in reality.

Many supporters now deem Victoria, where the state government is set to respond to its EndOf-Life-Choices Inquiry in December, as the best chance yet of getting over the line.

Denton adds each state is “chipping away” at voluntary euthanasia laws in their own time, with Tasmania, New South Wales, and Queensland also working hard to pave the way for renewed efforts. He says the single biggest reservation relayed by politicians, and opponents of the movement, is the misunderstanding around the likelihood of “granny being bumped off by the grandkids”.

“I think prospects are improving but it’s still difficult,” Denton cautions. “There’s entrenched opposition. Mostly, there’s a real lack of comprehension and I don’t mean that to sound critical. Politicians, I don’t think they’ve ever really had it explained to them very well how the law works.”

WHY NURSES ARE INTEGRAL

The partnership between Go Gentle Australia and the ANMF was motivated by a mutual understanding of the vital role nurses play in end of life care.

“As a nurse I think that many of us when we’re

working at the bedside see people who are at the end of their life and whilst palliative care is fantastic for some people it doesn’t provide the relief they need,” ANMF Federal Secretary Lee Thomas says.

cancer who shot himself with a nail gun.

Ms Thomas spoke passionately at the national campaign launch in South Australia in late September, illuminating her own past experiences on the ward. “I too remember the patients who asked me to help them die a peaceful and merciful death. I remember their names, their faces, and their families,” she revealed.

Of interest to the push for voluntary euthanasia legislation has been the Legal and Social Issues Committee’s review of existing laws in other countries and how they impacted on society.

These countries included the Netherlands, Switzerland, Canada and the USA.

She points to the fact that upwards of 75% of people across the country now believe laws should be available. She says one of the most important ways nurses can help is by actively joining the debate and lobbying politicians.

“Whether you personally agree with voluntary euthanasia or not it’s a choice for people who might want to take that choice. That’s why it’s voluntary. Even if you wouldn’t choose it for yourself, don’t stop other people from making that choice if nothing else is helping them.”

THE EVIDENCE

In June, a Victorian Parliamentary Inquiry into End-Of-Life Choices handed down its final report, with the analysis marking one of the most comprehensive investigations into voluntary euthanasia undertaken in this country.

The report tabled 49 recommendations emphatically backing the introduction of assisted dying laws.

Chiefly, it outlined six key areas to justify its assessment, including doctors already practising unlawful assisted dying, the limitations of palliative care, and the widespread acceptance of palliative sedation.

NSWNMA PRESIDENT CORAL LEVETT

Alarmingly, the report found many people experiencing incurable illnesses were resorting to taking their own lives in a desperate bid to ease pain.

As part of the evidence submitted to the Inquiry, the Victorian Coroner stated that between January 2009 and December 2013, 2,879 suicides took place in Australia, and that of those more than 200 related to people with incurable diseases.

The largest demographic affected were people aged over 65 and half the cases involved cancer, including a 75-year-old man with prostate

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The Coroner estimated that one person each week takes their own life in Victoria under these circumstances.

The committee noted that while jurisdictions differed slightly in their models, such as whether a patient must be an adult or whether patients are required to take lethal medication themselves, common themes did emerge, specifically that of robust regulatory frameworks which focus on transparency, patient-centred care and choice.

Ms Thomas considers voluntary euthanasia a logical option for members of the community suffering incurable illnesses. She stresses it would always come down to a personal choice and isn’t for everyone. “One of the reasons why it’s so important that we’re involved is because we do see it all. Nurses and midwives see people who are in intractable pain for which very little or nothing is helpful to them.”

Ms Thomas says the ANMF has continued to update its stance on voluntary euthanasia to reflect changing community attitudes.

anmf.org.au

Search strategy

For this clinical update, electronic searches were conducted within CINAHL, EMBASE, Medline and PsycInfo databases using keywords and variants of fall(s), mental health, older people, aged, inpatient and psychogeriatric. Secondary sources and policy documents were included.

In a large US study of all healthcare settings, the odds of a fall injury were found to be between 1.5 and 4.5 times greater for both older men and women with mental health or substance abuse conditions. Odds of a fall injury among older people with Alzheimer’s disease and other dementias are at least three times greater, with this differential rising with age (Finkelstein, Prabhu and Chen, 2007). A study in Western Australia comparing two MHUOPs, reported a total of 139 falls in a 12 month period, with patients admitted to one of these units sustaining more falls per 1,000 bed days than patients admitted to any other clinical speciality at the tertiary hospital (Heslop et al. 2012).

The literature identifies a range of fall risk factors for hospitalised patients, a number of which have already been highlighted in the introduction to this update (Safety and Quality Council of Australia, 2005). These include patient intrinsic risk factors such as, a previous fall, postural instability and hypotension, muscle weakness, cognitive impairment, delirium, urinary frequency or incontinence, effects of medications, and visual impairment. A number of extrinsic risk factors have also been identified, and include environmental factors and the time of day.

While many of the above mentioned risk factors are relevant for assessing falls risk in older people in hospital, there remains a limited understanding of the full range of mental healthspecific falls risk factors for inpatients in MHUOPs (Heslop et al. 2012).

Australia. NSW Health, 2011. Falls - Prevention of Falls and Harm from Falls among Older People: 2011-2015.

Sydney: Ministry of Health, NSW Australia. Specialist Mental Health Services for Older People (SMHSOP), 2012 Acute Inpatient Unit Model of Care Project Report.

North Ryde: NSW Ministry of Health Blair, E., and C. Gruman, 2005.

Falls in an Inpatient Geriatric Psychiatric Population. Journal of the American Psychiatric Nurses Association 11(6):351-354. doi: 10.1177/107839030528 4659.

Brassington, G.S., A.C. King, and D.L. Bliwise, 2000. Sleep Problems as a Risk Factor for Falls in a Sample of CommunityDwelling Adults Aged 64–99 years. Journal of the American Geriatrics Society.\ 48(10):12341240. doi: 10.1111/ j.1532-5415.2000. tb02596.x.

Bunn, F., A. Dickinson, C. Simpson, V. Narayanan, D. Humphrey, C. Griffiths, W. Martin, and C. Victor, 2014. Preventing falls among older people with mental health problems: a systematic review. BMC Nursing.

13(1):1-15. doi: 10.1186/1472-695513-4.

BACKGROUND FACTORS

Age

Poor nutrition

Under nutrition, loss of appetite, poor eating habits and poor fluid intake are common in psychiatric settings (Howard et al. 2007). Dehydration especially can lead to general weakness which has been linked to falls (Edmondson, 2011).

Medical illnesses

Cardiovascular disorders are particularly common and the increased risk of orthostatic hypotension; tachycardia and arrhythmia are related to falls (de Carle and Kohn, 2001; Edelstein and Brown, 2000).

Mental Disorders

Donald, I.P., K. Pitt, E. Armstrong, and H. Shuttleworth, 2000. Preventing falls on an elderly care rehabilitation ward.

Clinical Rehabilitation 14(2):178-185. doi: 10.1191/026921500677 888641.

A broad range of mental disorders are related to falls in MHUOPs including depression and mania (de Carle and Kohn, 2001; Blair and Gruman, 2005) Anxiety (Eriksson et al. 2007), Psychotic illness (Edelstein and Brown, 2000) and Dementia-BPSD (Tängman et al. 2010). Within this broad range of disorders there are many mental state presentations which contribute to increased falls risk including reduced executive cognitive functioning (Thomas and Corney, 1993), positive symptoms of psychosis as well as behavioural factors such as intrusiveness and verbal aggression (Fossey et al. 2006). Mental state, physical dependence and mobility might change during a single admission, from being withdrawn and bedridden, to being expansive, independent, and ambulant (Heslop et al. 2012). Increased paranoid ideation or elevation of mood indicates the need to review falls risk more frequently.

A broad range of treatments are associated with increased falls risk in MHUOPs: • • • •

Psychiatric treatments

Cameron, I.D., L.D. Gillespie, M.C. Robertson, G.R. Murray, K.D. Hill, R.G. Cumming, and N. Kerse, 2012. Interventions for preventing falls in older people in care facilities and hospitals.

Cochrane Database of Systematic Reviews.12.

Art. No.: CD005465). doi: 10.1002/14651858.

CD005465.pub3. de Carle, A.J., and R. Kohn, 2001. Risk factors for falling in a psychogeriatric unit.

International Journal of Geriatric Psychiatry 16(8):762-767. doi: 10.1002/gps.407.

People who fall in mental health units are younger than medical-surgical patients who fall. The mean age of those who fell was 56.3; and for medical-surgical patients the reported mean ranges from 65 to 83 (Edmondson, 2011). Age greater than 70 years is associated with greater risk of falling in MHUOPs (Blair and Gruman, 2005).

• •

Electroconvulsive therapy (de Carle and Kohn, 2001) Mood stabilisers (de Carle and Kohn, 2001) Antidepressants, particularly serotonin selective reuptake inhibitors (Kallin et al. 2004) Neuroleptic medications (Härlein et al. 2009; Blair and Gruman, 2005; Edelstein and Brown, 2000) especially the “typical” antipsychotics in patients age >70 (Blair and Gruman, 2005).

Prolactin raising anti-psychotic medications contribute to increased rates of hip fracture in people with Schizophrenia due to effects on bone mineral density (Howard, Kirkwood and Leese, 2007). Neuroleptic medications are known to cause sedation, orthostatic hypotension and extrapyramidal side-effects, which may predispose some older people on these treatments to falls Benzodiazepines (Monane and Avorn, 1996; Kuchynka, Käser and Wettstein, 2004) Complex medical regimes or polypharmacy even in the absence of usual generalised risk factors such as gait, vision or mobility problems (Knight and Coakley, 2010).

Specific concomitant medications, in conjunction with psychotropic medications, for example, ACE inhibitors, a-1 blockers, and cyclooxygenase-2 inhibitors in an otherwise ambulant population might contribute to physiological instability that contributes to a fall (Knight and Coakley, 2010).

Mobility

Any previous fall (Härlein et al. 2009; Blair and Gruman, 2005) unsteady gait, use of mobility aid (Heslop et al. 2012) or any walking difficulty on level ground (Eriksson, Gustafson and LundinOlsson, 2007) are associated with increased fall risk.

Visual perception

Among people with dementia in a MHUOP, decreased visual perception was found to be independently associated with risk of falling (Eriksson, Gustafson and Lundin-Olsson, 2007).

Sleep

Disturbances of diurnal rhythms present a risk in MHUOPs (Eriksson et al. 2009). An independent association between reported sleep problems and falls was found in an older population in a wider range of settings (Brassington, King and Bliwise, 2000).

Edmonson, D., S. Robinson, and L. Hughes. 2011.

Development of the Edmonson psychiatric fall risk assessment tool.

Journal of Psychosocial Nursing and Mental Health Services 49(2):2936.

Eriksson, S., Y. Gustafson, and L. Lundin-Olsson, 2007. Characteristics associated with falls in patients with dementia in a psychogeriatric ward. Aging Clinical and Experimental Research 19(2):97-103. doi: 10.1007/bf03324674.

Eriksson, S., S. Strandberg, Y. Gustafson, and L. Lundin-Olsson.

2009. Circumstances surrounding falls in patients with dementia in a psychogeriatric ward. Archives of Gerontology and Geriatrics 49(1):8087. doi: http:// dx.doi.org/10.1016/j. archger.2008.05.005.

Evans, D., B. Hodgkinson, L. Lambert, J. Wood, and I. Kowanko, 1998.

Falls in acute hospitals: a systematic review.

Edited by in conjunction with the Royal Adelaide Hospital, The Joanna Briggs Institute for Evidence Based Nursing and Midwifery Vol. 1. Adelaide, South Australia: Citeseer.

Finkelstein, E., M. Prabhu, and H. Chen, 2007. Increased prevalence of falls among elderly individuals with mental health and substance abuse conditions.

The American Journal of Geriatric Psychiatry 15(7):611619. doi: http:// dx.doi.org/10.1097/ JGP.0b013e318033ed 97.

Fossey, J., C. Ballard, E. Juszczak, I. James, N. Alder, R. Jacoby, and R. Howard, 2006.

Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial.

BMJ. 332(7544):756761. doi: 10.1136/ bmj.38782.575868.7C. Greene, E., C.J. Cunningham, A. Eustace, N. Kidd, A.W. Clare, and B.A. Lawlor, 2001. Recurrent falls are associated with increased length of stay in elderly psychiatric

“I’VE ALWAYS FELT THAT EVEN THOUGH ACCESS TO GOOD PALLIATIVE CARE IS FIRST AND FOREMOST IN END OF LIFE CARE, THERE ARE JUST SOME OCCASIONS WHERE DESPITE EVERYONE’S BEST EFFORTS, YOU’RE LEFT FEELING SHOCKINGLY DISAPPOINTED AND A LITTLE BIT TRAUMATISED BY THE DEATHS THAT SOME PEOPLE HAVE TO ENDURE.”

In regards to how many people used the legislation, statistics showed assisted dying accounted for less than 2% of all annual deaths in Belgium, and less than 4% in the Netherlands.

The Netherlands’ Termination of Life on Request and Assisted Suicide (Review Procedures) Act, which came into effect in 2002, saw 5,306 people use the law in 2014. In terms of eligibility and safeguards there, the attending doctor must be satisfied that the patient’s suffering is unbearable with no prospect of improvement, must consult at least one other independent doctor, and must conclude together with the patient that there is no reasonable alternative. The laws apply not only to the terminally ill, but also to the chronically ill and people with mental suffering.

In Oregon, USA, their Death with Dignity Act came into effect in 1997. Doctors can prescribe patients who meet strict criteria a lethal medication that they administer themselves without the presence of their doctor or healthcare provider.

Eligibility requirements include being over 18, a resident of Oregon, suffering a terminal disease from which one will die in the next six months, and being required to make three separate requests. In assessing and granting a request to access lethal medication, two doctors must confirm the diagnosis, that the request is voluntary, and ensure that the patient is making an informed decision.

Last year, 132 deaths occurred in Oregon from prescribed medicine under the law.

NURSES AS ADVOCATES SA NURSES SUPPORTING CHOICES IN DYING CONVENOR SUSIE BYRNE

November 2016 Volume 24, No. 5

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FALLING SHORT A clinical update should review both the reasoning and evidence, so clinicians can adapt its recommendations to the care of the person they are looking after. The paper, Falls and Fall injury in Mental Health Inpatient Units 2016 ANMJ Nov v24 n 5, raises many interesting questions about reasoning, evidence and applicability.

The title refers to falls that occur in Mental Health Units for Older People, (MHUOP). MHUOP settings range markedly in ward layout, staffing and milieu. How these might influence outcomes are not systematically addressed.

I feel however that it has been irresponsible of the ANMF as an organisation to urge its members to vote for the ‘right’ way, without even closely looking at what we were voting for. If the ANMF is representing us, how were we asked for our views on this topic before the ANMF decided what were our views?

to be curtailed by politicians unable to vote unanimously in favour of legislation.

OLDER PEOPLE IN MENTAL HEALTH UNITS CAN ALSO BE BEHAVIOURALLY UNPREDICTABLE DUE TO THEIR MENTAL STATUS AT DIFFERENT TIMES OF THE DAY AND NIGHT.

The incidence of falls within psychiatric units tends to be higher than that within general acute care hospital units (Blair and Gruman, 2005). The proportions of falls resulting in some degree of harm are known to be higher in mental health units (45%) than in community hospitals (37%) and acute hospitals (33.4%). Patients aged 85–89 years old experience a higher-than-expected likelihood of falling, relative to bed days (Healey et al. 2008).

Edelstein, B.A., and S.A. Brown, 2000. Falls Among Psychogeriatric Patients. Clinical Gerontologist 21(4):317. doi: 10.1300/ J018v21n04_02.

Table 1: Risk factors as flags for falls and fall injuries in inpatients of MHUOPs

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READ THE FINE PRINT

the back of a Victorian Parliamentary Inquiry into End-of-Life Choices earlier this year that endorsed voluntary euthanasia.

Overview of the problem

While there are a number of reviews which focus on falls in older people with dementia and cognitive impairment, there is less information recognising other mental health conditions, or the special needs of mental health settings (Bunn et al. 2014).

Discussion

Australia. Clinical Excellence Commission NSW, 2014. Falls Risk Assessment and Management Plan.

Similarly, Victoria appears poised for change on 26

ANDREW DENTON PHOTOGRAPHER: BEN SEARCY

“IT’S THE RIGHT THING TO DO AND I THINK PEOPLE SHOULD HAVE THE RIGHT TO DIE IN A PLACE AND IN A MANNER THAT IS SUITABLE TO THEM WITH THEIR FAMILY AROUND THEM AND AS PAINLESS AS POSSIBLE, RATHER THAN THE ALTERNATIVE, WHICH IS HAPPENING NOW, WHICH IS OFTEN PRETTY UGLY.”

From the point of admission, the risk of falling is high among older people, even in the absence of a history of falls or mental illness. The mental health unit environment places the person at an even greater fall risk due to a multiplicity of issues that include: psychotropic medications, overactivity due to mania, depression, confusion, and/or agitation and frequency of micturition due to bladder control problems (Blair and Gruman, 2005). Older people in mental health units can also be behaviourally unpredictable due to their mental status at different times of the day and night. They may be restless and agitated and are often on the move within the ward, in and out of bedrooms, and wandering in open spaces (Heslop et al. 2012; Blair and Gruman, 2005). Due to age and concomitant comorbid physical problems such as obesity, respiratory disease, metabolic and blood pressure instability, they may experience trans ischemic attacks and dizziness, may be unstable on their feet, and at risk of falling, getting up from chairs and beds, and particularly in bathrooms (Blair and Gruman, 2005; Heslop et al. 2012; Tsai et al.1998).

present with a fluctuating course of illness, and this fluctuation presents risks that require specialised falls assessment, consistent monitoring and management (Heslop et al. 2012).

References

Registered nurse and President of the NSW Nurses and Midwives’ Association (NSWNMA ANMF NSW Branch) Coral Levett has been a longstanding supporter of voluntary euthanasia.

How do you start to describe a setting, let alone measure its effects?

This is where systematic reviews should serve as a guide.

You’d expect they’d tackle the complexity of the care setting, as well as assess and summarise the research for relevance and quality.

In this update the systematic reviews are accorded the same status as the research articles. The inclusion/exclusion criteria and summary qualities of the research articles are not given.

This is despite the uneven quality of the research, and that only some of it was conducted in MHUOPs. So it seems the available research was just not good enough.

There is a deeper problem as well. Even if all the factors were identified and weighed, and all the variables accurately measured, it would not give us a picture of the ways in which nurses in other places care for people at risk of falling.

The problem is not the shortcomings of the evidence, but with the reasoning. The issue is approached as if it was an algebraic problem. Care work as an art as well as a science, as inherently relational rather than mechanical effort, cannot be grasped in this way. In this interactional work, its stories of how other nurses in other places care for vulnerable people, that move us to reflect on what we do and generates ideas for what we try next time.

I congratulate the authors on a difficult, valiant effort, but the pickings are slim. It would be easier and more fruitful I think to gather stories from nurses in MHUOPs around Australia.

EN (name and location withheld)

Ms Levett became a patron of Dying with Dignity NSW many years ago in a bid to trigger change. “I suspect back from my clinical days I just always thought there was an anomaly there.

“We weren’t empowered to have the right conversations with patients who made requests December 2016 / January 2017 Volume 24, No. 6

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February 2017 Volume 24, No. 7 43

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INDIFFERENCE TO ADVICE I’m a 45 year old male in nursing. I completed my BSN in 2006 and worked mostly as an agency hire nurse until June 2015 when I decided to ‘walk-away’ from my hard earned career and get in touch with myself (or deal with Post Traumatic Stress Disorder?).

As a nurse and community member, not currently working in nursing, I find myself confronted with ill and/or ailing people in my local area that I would not otherwise associate with (people on my local streets).

As I spent the main emphasis of my shortened career in trauma based areas such as Accident and Emergency Departments (A&E), Intensive Care Units (ICU) and Coronary Care Units (CCU) in the greater Melbourne area, it is my instinct to respond and care.

I often find myself politely advising people in my community on caring for their health. My point today begins with a recent thunderstorm we experienced in Victoria that caused massive outbreaks of asthma and eight deaths. On the morning of that storm I walked to my local delicatessen to find the store owner short of

LEGALISING EUTHANASIA IS FRAUGHT The article on Death and Dignity (ANMJ Dec 2016-Jan 2017) suggesting nurses get politically active over voluntary euthanasia, focused strongly on the need for assisted dying in our country.

It was pointed out that doctors and nurses would not be pressured into doing anything they didn’t want to do and that their value systems would not be impacted.

Victorian medical professionals have already lost their right to refuse to assist with a termination of pregnancy if it is considered an emergency, so assurances like this ring very hollow.

The article was an emotive one discussing patients in unbearable agony, which is truly distressing. Unfortunately in this debate very little was given to the discussion of improvement in palliative care. Much more understanding is needed on pain relief and palliative management; it is a much neglected part of medical training.

A 2011 PubMed article stated that assisted suicide had been legalised in a small number of countries and states. Laws and safeguards against abuses had been set in place. In all of these jurisdictions laws and safeguards were regularly transgressed.

The Netherlands legalised euthanasia 30 years ago. At that time the case was made that it would be limited to a small number of terminally ill patients with unbearable pain and only as a last resort.

Today in the Netherlands, Dutch law only requires a person to be suffering hopelessly and unbearably and not from a terminal disease. Children 12-16 years of age may now be euthanised with their parents’ consent.

breath, looking withdrawn and pallid and speaking with a hoarse voice. I had no way of knowing what would ensue that afternoon.

I merely acted on my professional instincts. My advice, delivered professionally of course, was simply that when the store owner’s asthma progressed, as it was obviously going to do, that he waste no time and present himself at a particular A&E that I have confidence in to properly and timely treat a serious episode. This store owner ‘brushed-off’ my comments. On my way out of his store he mumbled some smart remark under his breath. This prompted my retort of “fine, die painfully”. And don’t I feel just terrible.

Since then, the store owner has become fully aware of my background, and has become humbled, polite and ‘generous’. There has been no mention of his asthma from him, no admittance of a hospital visit, no ‘thanks’. It’s nice that he has improved his attitude toward me as a professional and a community member yet, why do we need to continuously encounter similar experiences in the community? There was a time that nurses were the most trusted and respected members of our communities. Lately I seem to experience more and more indifference. And it saddens me...

RN (name and location withheld)

Andrew Denton comments on the misunderstanding opponents have of “granny being bumped off by the grandkids”.

Unfortunately this ‘misunderstanding’ is a reality in some areas where assisted suicide has been legalised. Oregon in the US, legalised euthanasia in 1997 and has a number of cases of victims of assisted suicide, the right to die can smoothly morph into the duty to die especially with elderly people who do not want to be a burden on their families.

According to the Oregon Public Health Division the top reasons for requesting deadly prescription from a doctor are: loss of autonomy (91.5%), being less able to engage in activities (88.7%) and loss of dignity (79.3%).

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Extreme pain was not a top reason.

Pressures on an overloaded medical system and the demand for beds, can leave patients very vulnerable.

Patients will lose a valuable safeguard when the medical profession loses sight of the fact that they should do no harm.

Even with the best of intentions and even though we are assured it will not happen, there is a very real chance abuses and coercion will happen if voluntary euthanasia is legalised in Australia as it has happened where it has been legalised overseas.

Therese McLinden RN Victoria

Euthanasia in the Netherlands is not always voluntary, one in seven patients are euthanised without having given explicit consent.

44 February 2017 Volume 24, No. 7

anmf.org.au

MAIL

PANDORA’S BOX

TREAT JUNIOR STAFF WITH THE RESPECT THEY DESERVE

Those proposing to introduce laws to allow the premeditated act of physically assisting in the suicide of another person show a certain level of naivety. They see it as a harmless measure to alleviate one’s suffering but fail to recognise the underlying Pandora’s Box which it will open.

Euthanasia undermines a society’s trust in their medical system, sends alarmingly mixed messages to our children about the justification of suicide and is dangerously open to abuse and eventual broadening of the categories of ailments able to be ‘terminally treated’ with this subtle form of murder. This is already happening overseas.

It is a false belief that we would be providing a dignified death by the act of administering a drug to a patient to end their life at the time of their choosing, when in fact all we would be providing is state condoned assistance to someone wishing to suicide.

Human beings are not dogs. There are incredibly serious repercussions for those left behind. The reason we put sick dogs down is because there is no health system or palliative care facility to care for our sick and frail dogs, so therefore we take the option that provides less impact on our lives and finances.

We must not play politics with our most vulnerable. ‘Nudging’ by our media and personalities such as Andrew Denton must never be a reason to expose our frail elderly and our physically and mentally disabled populations to a “Soylent Green”* future. On the one hand we are outraged by elder abuse, but legal euthanasia hands people a tool for the ultimate abuse.

Nurses must stick to loving and providing first class care for our sick and dying at ALL stages of their life, till its natural end. Fight for that!

It is so much more rewarding for everyone concerned than taking what may be ultimately seen by future governments strapped for cash as a quick and cheaper fix for their struggling healthcare system, all in the guise of dignity. *Soylent Green is a 1973 Sci-Fi movie depicting life as a constant struggle which ends with a state funded euthanasia program which is actively promoted and provides a quiet and peaceful experience to people before they are euthanised.

Mary Sexton RN, Launceston Tasmania

ER 2016 O. 5 / N O V E M B V O LU M E 2 4 , N

ADVERTISE IN ANMJ

LETTER OF THE MONTH

As a student nurse in 1985, several senior nurses stood out from the crowd.

Those nurses were excellent mentors. They were friendly, knowledgeable with loads of experience and were happy to pass on their skills and encouragement to junior nurses.

They retain a happy place in my heart. Some others however are etched in my memory for all the wrong reasons.

Bullying in nursing was rife in 1985. It was delivered by senior nurses and not so senior nurses who happened to hold a position of power and unfortunately used that power to bully and intimidate junior nurses. Very little was done to address the behaviour which inevitably resulted in tears and upset.

Move forward to 2016. Nursing has come a long way since 1985, BUT still junior staff are too often in tears and upset.

While treating junior staff with disrespect and intimidation may be seen by some as ‘character building’ it is unprofessional, unpleasant and unnecessary.

Our students and junior staff need to be guided with friendship and professionalism. They are after all, our future workforce.

Lisa Bancroft RN, Victoria

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 anmj@anmf.org.au Letters may be edited for clarity and space.

ADVERTISE IN THE AUSTRALIAN NURSING AND MIDWIFERY JOURNAL AND GET IN FRONT OF 134,000 NURSES AND MIDWIVES AROUND AUSTRALIA. Each month the Journal is sent directly to nurses, midwives and healthcare professionals keeping them informed on the latest in clinical practices, news, research, education and legal and ethical issues Your brand, product, course, conference or recruitment drive can take advantage of this highly relevant environment and attract engaged readers.

Contact Heidi Adriaanse for the 2017 rates, deadlines and readership information. 0415 032 151 or heidi@anmf.org.au

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CALENDAR

FEBRUARY Ovarian Cancer Awareness Month www.womenscancerfoundation.org.au/ World Cancer Day We Can. I Can. 4 February. www.worldcancerday.org/ Anniversary of the Apology (2008) 13 February Lung Health Promotion Centre at The Alfred Spirometry Principles & Practice 16-17 February P: (03) 9076 2382 E: lunghealth@alfred.org.au World Day of Social Justice 20 February 8th Annual National Dementia Conference 23-24 February, Adelaide, South Australia. http://ow.ly/wMGM3050zTg Women’s Cancer Foundation (Ovarian Cancer Institute) We can walk it out 2017 at The Tan Track, Melbourne 26 February. In aid of ovarian cancer research and awareness.

Mark your calendar and tag your friends! #WeCanWalkItOut or #GetRealSupportTeal #womenscancer #donate Rare Disease Day 28 February

MARCH Lung Health Promotion Centre at The Alfred Asthma Educator’s Course 1-3 March Smoking Cessation Course 9-10 March P: (03) 9076 2382 E: lunghealth@alfred.org.au 35th Annual Dermatology Nurses Association Convention Embracing the world of dermatology 1-4 March, Orlando, Florida. http://www.dnanurse.org/ International Women’s Day 8 March. www.internationalwomensday. com/

NETWORK Prince Henry’s Hospital Melbourne, 1/77 group 40-year reunion 4 February, 12.30 pm onwards at Wheeler’s Hill Hotel ,Wheelers Hill.

Interested? Contact by email: 177phh@ gmail.com or Search Facebook page, Prince Henry’s Hospital 1/77 reunion for further information Prince Henry’s Hospital Melbourne, group 2/2/1972, 45-year reunion 4 February 2017. Contact Jacky Dow (nee Conway) E: g_jdow@internode. on.net or Janet Molan (nee Craig) E: j.em2008@hotmail.com

Australasian Cardiovascular Nursing College Conference 10-11 March, Brisbane Convention & Exhibition Centre, Queensland. http:// www.acnc.net.au/ 41st National Australian Association of Stomal Therapy Nurses Conference Into the sunshine: Storytelling in stomal therapy 12-15 March, Royal International Convention Centre, Brisbane, Qld. http://stomaltherapyconference.com/

7th Biennial Leaders in Indigenous Medical Education (LIME) Network Conference The Future of Indigenous Health Education: Leadership, Collaboration, Curriculum 4-7 April, Melbourne. www.limenetwork.net.au World Health Day 7 April

6th eMedication Management Conference 14-15 March, Swissotel Sydney. www.informa.com.au/conferences/ health-care-conference/electronicmedication-management

Lung Health Promotion Centre at The Alfred Managing COPD 20–21 April Spirometry Principles & Practice 27-28 April P: (03) 9076 2382 E: lunghealth@alfred.org.au

St Patrick’s Day 17 March

ANZAC Day 25 April

National Close the Gap Day 17 March. https://www.oxfam.org. au/what-we-do/indigenous-australia/ national-close-the-gap-day/

14th National Rural Health Conference 26-29 April, Cairns, North Queensland. www.ruralhealth.org.au/14nrhc/

Earth Hour 19 March Harmony Day Australia 21 March. http://www.harmony.gov.au/ World Down Syndrome Day 21 March Building Children’s Nursing for Africa Conference Pillars of Practice 28-30 March, The River Club, Observatory, Cape Town, South Africa. www.buildingchildrensnursing.co.za Digital Health Show 29-30 March, Melbourne Convention & Exhibition Centre. www.digitalhealthshow.com.au

APRIL World Autism Awareness Day 2 April 15th World Congress on Public Health Voices • Vision • Action 3-7 April, Melbourne Convention and Exhibition Centre. http://www.wcph2017.com/

MAY Lung Health Promotion Centre at The Alfred Respiratory Course (Modules A & B) 1–4 May Respiratory Course (Module A) 1–2 May Respiratory Course (Module B) 3–4 May Asthma Update 26 May P: (03) 9076 2382 E: lunghealth@alfred.org.au Star Wars Day 4 May International Midwives Day 5 May Holistic Nurses/Midwives Retreat Bali 8-12 May Relax, Recuperate, Renew, Replenish 25 CPD hours (tax deductible) Contact Angeline von Doussa E: angeline@nurses-healing.com http://nurses-healing.com/holisticnurses-retreat-bali-may-2017/ International Nurses Day 12 May

International Council of Nurses (ICN) Congress Nurses at the forefront transforming care 27 May-1 June, Barcelona, Spain. http://www.icnbarcelona2017.com/en/ National Reconciliation Week 27 May-3 June. http://www.reconciliation.org.au/nrw/

JUNE Lung Health Promotion Centre at The Alfred Spirometry Principles & Practice 5-6 June Paediatric Respiratory Update 26 June Theory & Practice of Non Invasive Ventilation (Bi-Level & CPAP Management) 30 June P: (03) 9076 2382 E: lunghealth@alfred.org.au World Environment Day 5 June World Blood Donor Day 14 June World Elder Abuse Awareness Day 15 June 20th Cancer Nurses Society of Australia Annual Congress Evolving cancer care: Enhancing quality Embracing innovation 15-17 June, Adelaide Convention Centre, South Australia. www.cnsacongress.com.au 13th Conference of the European Council of Enterostomal Therapists Building bridges – from west to east, from south to north Ostomy – Continence – Wound 18-21 June, Berlin, Germany. www. ecet2017.org 31st International Confederation of Midwives Triennial Congress Midwives - Making a difference in the world 18-22 June, Toronto, Canada. www.midwives2017.org/ World Refugee Day 20 June

National Sorry Day 26 May

St Vincent‘s Hospital Melbourne, Jan 1977, 40-year reunion 11 February. Venue TBC via email invitation. Contact Trish Kunek (nee Crommy) E: pkunek@gmail.com Also, our contact base needs updating since last reunion 20 years ago, it would be appreciated if you could circulate this address to your contact group

St Vincents, Feb 1981 group, 36-year reunion 4 March, 12.30pm, Pumphouse, Nicholson Street, Fitzory. Pub meal prices. RSVP to Mary McIntyre M: 0419 310 619 or Facebook Mary McIntyre using maiden name or E: rechargerejuvenation@yahoo.com.au Spread the word, or turn up on the day

RAH, group 772, 40-year reunion 25 February, 12 midday-1600. Venue TBA. Contact Bronwyn Glitheroe (nee Deed), Anne-Marie McBride (nee Rogers), Helen Kirby (nee Osborn) or Rhona Edwards (nee McGarrigle) E: rah772reunion@gmail.com or search Facebook page rah772

Geelong Hospital Nurses League 83rd Annual Reunion and AGM 18 March. If you have a connection to the Geelong Hospital (University Hospital) are a past trainee or current employee and are interested in attending this reunion please contact Bev Lodge Ph:(03) 5243 7794 or E: terrylodge@bigpond.com

Royal Melbourne Graduate Nurses Association 100-year anniversary Luncheon 18 March, 12–3pm, Leopard Lodge, Melbourne Zoo. Entry via Zoo Rail Gate, Poplar Road. Complimentary Zoo Access from 11am. Parking $2 for five hours. RSVP: Lara Taylor 0415 628 131 or Simone Cooley (AH) 0417 587 745. Cost: $85. Book online at www.trybooking.com/236298 Prince Henry’s Hospital Melbourne 89th PTS April Group 50-year reunion weekend 22-23 April. Please contact Lyn Kirby E:lynmkirby@gmail.com

Email cathy@anmf.org.au if you would like to place a reunion notice 46 February 2017 Volume 24, No. 7

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FISH TANK EXPERIENCE

Maree Burgess, ANMF Vice President

Water is the essence of life. In its various forms, it is hydrating, cleansing, mesmerising. In the heat of summer, it cools, refreshes and relaxes.

As you read the February edition of the ANMJ, it will be the last month of summer and the impact of those hot endless days will be paired indelibly with water.

It is also the time when small children begin their preschool year complete with backpacks, sun hats and loaded with parental expectations.

As a Maternal and Child Health Nurse working in an early years’ hub, it is a joy to see their excited faces arrive in the early weeks accompanied by parents, grandparents and guardians.

THE FISH TANK IN THE HUB HAS BEEN A REVELATION, AN UNEXPECTED OPPORTUNITY FOR STAFF, FAMILIES AND THEIR CHILDREN TO TAKE A MOMENT TO SIT MINDFULLY AND INTERRUPT THE BUZZ OF EVERYDAY LIFE. The hub is a new facility in Melbourne’s Northern suburbs where early years services are co-located.

It provides access for families to Maternal and Child Health (MCH) services, Preschool Education, Parenting and Educational groups and playgroups for the culturally and linguistically diverse in the community.

It has a large central open space with comfortable lounges on which to rest either while waiting to see the MCH Nurse or to gather a moment’s respite after the preschool drop off.

It is in this space that families enjoy the special feature of this new centre…the large fish tank. It has become the focal point of all visitors to the centre in both the coming and going throughout the day.

As parents rush through the door to deliver their four year olds to preschool, they are inevitably drawn towards the fish by excited little voices and despite protestations, spend a few quiet moments watching the fish move about silently and 48 February 2017 Volume 24, No. 7

gracefully in the water. It engenders a shared conversation between parent and child which may otherwise be missed. It seems from my observations that in the going to preschool, the separation of parent and child is somehow made a little easier by those few shared moments.

So it is for the families that attend Maternal and Child Health throughout the day. The parents with their newborns, weary from their night feeds and the adjustment to new routines, spend a few moments resting prior to their appointments, gazing into the water. Their toddlers mesmerised with the movement of the fish in the water and three year olds providing endless commentary and questions about the origin of the species. It is inevitably the reward on completion of a visit to see the MCH Nurse to revisit the tank for a final farewell to the fish.

At the end of a busy day, it is not without precedence for a tired MCH Nurse to also gaze at the fish, transfixed by their rhythmic movement and feel the worries of the day fade from consciousness.

In a community setting, as it is in the hospital environment, the levels of stress experienced by nurses, midwives and carers is ever present.

Knowing how to respond to the stress we experience in our professional and personal lives encourages us all to seek our own fish tank experience.

The importance of self care for nurses, midwives and carers is well recognised but knowing how to reach our inner potential may need some guidance. To this end, the ANMF (Vic Branch) is hosting its Nurses and Midwives Conference on 27

April at the Melbourne Convention and Exhibition Centre (MCEC). This Conference is designed to help nurses, midwives and carers better understand the impact of stress on our health and wellbeing and to tap into our strengths. The Wellness Conference ‘will include music and laughter, along with interactive sessions such as yoga and nutrition, all designed to promote physical, emotional, psychological and spiritual health’ (ANMF (Vic Branch) conference flyer).

The program looks amazing with presentations on resilience building

by Hugh van Cuylenburg, Founding Director of The Resilience Project; introduction to mindfulness and meditation by Kay Watts from Smiling Mind; yoga with Carolyn McDonald, Nursing and Midwifery Health Program Victoria (NMHPV); Lola Berry, nutritionist and author presenting a holistic view of nutrition and Clare Bowditch, award winning songwriter and founder of Big Hearted Business on finding happiness and work/life balance. For more information go to: www.anmfvic.asn.au/events-andconferences/2017/04/27/2017-nmhp--anmf-nurses-and-midwiveswellness-conference The fish tank in the Hub has been a revelation, an unexpected opportunity for staff, families and their children to take a moment to sit mindfully and interrupt the buzz of everyday life.

As nurses, midwives and carers, we need to find those moments too. So with the remaining weeks of summer, find some water, check out the fish and remember as Dory said to Nemo: “just keep swimming”. anmf.org.au

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