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CONTENTS Directory 02


Editorial 03 News 04 World 13


Working life – Megan-Jane Johnstone 14 Professional


Feature – Nurse Practitioners 16 Education 23 Legal 24 Clinical update




Focus – Men’s Health 32 Mail 44


Calendar 46 Sally 48

07 04



November 2016 Volume 24, No. 5  1


3/28 Eyre Street, Kingston ACT 2604 Phone (02) 6232 6533 Fax (02) 6232 6610 Email

Cover image: NP candidate Georgie Waugh Photo: Bridgette Nicol @littleriverconnections


Melbourne & ANMJ

Level 1, 365 Queen Street, Melbourne Vic 3000 Phone (03) 9602 8500 Fax (03) 9602 8567 Email

Federal Secretary Lee Thomas

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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:

Northern Territory

South Australia


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:

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:

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:

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



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:

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:

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

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2  November 2016 Volume 24, No. 5




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


Editorial Lee Thomas, ANMF Federal Secretary Legalising voluntary euthanasia is about fairness, dignity and choice. These were the words used by Kylie Monaghan, the face of South Australia’s Be the Bill campaign, to encapsulate what voluntary euthanasia is about just before she sadly passed away with cancer last month. Even in her final days Kylie knew the laws would not assist her, but she remained determined to help others.The right to die with dignity was a legacy she wanted to leave behind. The Australian Nursing and Midwifery Federation and Go Gentle Australia campaign have been strongly supporting the Be the Bill campaign which has been encouraging South Australian politicians to vote in favour of a voluntary euthanasia debate in state Parliament. Support for voluntary euthanasia laws is also building in Victoria, with seven Victorian cabinet ministers recently backing a call for the introduction of legislation. After witnessing the unbearable suffering many patients endure at the end stage of life, it’s not surprising so many nurses and midwives are supporting this campaign. However it is not for everyone, including nurses and midwives. Yet we need to consider that it’s about choice. Whether you would choose it for yourself or not, we should not stand in the way of people making that decision if nothing else helps. In the journal this month the feature looks at nurse practitioners and how they have developed since the 1990’s. Despite the role evolving slowly there are now over 1,380 endorsed nurse practitioners making inroads particularly in chronic health and in aged care as discussed in the professional team’s column this month. However it’s clear that barriers still remain for this cohort of nurses particularly around Medicare rebates which are stifling new nurse led models and innovation.

grievances recorded. Most common were clinical standards in residential aged care facilities which made up more than 80% of complaints. While concerning, these statistics are no great surprise. The results reinforce the data in ANMF’s aged care survey earlier this year. They indicate that because of a lack of safe and qualified staffing levels, care will continue to deteriorate, much to the distress of many of the existing staff at these facilities. It’s abundantly clear that the government needs to wake up to stark statistics like these and, as a matter of urgency, address them comprehensively to ensure appropriate funding and safe staffing levels are provided to aged care.


The focus section this month looks into men’s health. While the health of men can be regularly ignored, often by men themselves, there are significant health issues many of them need to confront. Ways of tackling these include creating more accessible opportunities for men to seek the help that they need. Nurses are leading the way in innovation to provide men with assistance in looking after their health. Please enjoy reading the ANMJ this month.

Also making news this month is the unsurprising rise in complaints made to the Aged Care Commissioner for the first half of this year. There were 2,153



November 2016 Volume 24, No. 5  3


NATIONAL VOLUNTARY EUTHANASIA CAMPAIGN LAUNCHED The Australian Nursing and Midwifery Federation (ANMF) has teamed up with the Andrew Denton led advocacy group Go Gentle Australia to form a national voluntary euthanasia campaign pushing for legislation. Launched at South Australia’s Parliament House in late September, the Be the Bill campaign is aimed at accumulating widespread political support in order to trigger a full parliamentary debate examining the issue. The campaign, which is largely being driven by social media, features the face of 35-yearold Port Pirie woman Kylie Monaghan, who sadly passed away last month after a long battle with cancer. A dedicated website encourages people to support Kylie and the cause by creating a personalised Bill via Facebook bearing one’s own name and picture, which is then forwarded to all South Australian politicians. Mr Denton described the campaign launch as “empowering” and said it was a significant moment for voluntary euthanasia supporters across South Australia who had fought hard on the issue for almost three decades.


“To have that coalition of people, the Premier, the leader of the Opposition, the nurses, the representatives of disability groups, Christians, palliative care, doctors, to have them all in one room saying not only should we do this but can we do this? I don’t think that’s happened before in Australia.” ANMF Federal Secretary Lee Thomas 4  November 2016 Volume 24, No. 5


addressed the event by reflecting on her own past experiences when working as a nurse. “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. Nurses see it all, spending more time with patients than any other health professional. It is nurses who know what options and services really work.” In South Australia, politicians were last month set to vote on whether to support the advancement of a voluntary euthanasia Bill through to the committee stage. In Victoria, the state government has until December to respond to the results of its End-Of-Life Choices Inquiry, released earlier this year. Mr Denton said a growing number of politicians are joining the debate and beginning to understand how the law would work. He praised the courage of Ms Monaghan, whose advanced cancer spread to her liver and bones, for placing the wellbeing of others in the future ahead of her own. “Kylie is an absolutely textbook example of who would use this law. She was diagnosed five years ago with cancer. But it was only a few months ago that things started getting very bad. It was only a few weeks ago that

her oncologist said there’s no meaningful treatment we can give you anymore. She’s at that exact point, where she would, if this law were to exist, be talking to her doctor about other alternatives. She is literally a living example, and unfortunately a dying example, of who this law is for.” Ms Thomas said the ANMF had committed to the partnership with Go Gentle Australia largely because nurses and midwives witness suffering and incurable pain at the bedside more than most. She said that voluntary euthanasia was not for everyone, including nurses, but stressed that any proposed law would include extensive safeguards and be built on the foundation of choice. “Ultimately, it’s in the Australian community’s best interests that everybody has a choice if they want it so it would be terrific to see voluntary euthanasia laws in every state and territory. “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.”



with immunisation and dental care just some of the issues. Ms Marlow said a refugee health nurse often delivers what is known as “incidental counselling” because they are usually one of the first people families and individuals meet and trust. “The thing about a refugee family is it’s not just their physical health that’s affecting them. It’s everything else, their journey, their history of loss and trauma and having to manage many different things in a new country often with very little English.”

Promoting the value and importance of nurses working with people from refugee backgrounds will form one of the key objectives of a new special interest group established last month for nurses working in the growing field. Launched at the Australian College of Nursing’s National Nursing Forum in Melbourne, Refugee Nurses of Australia (RNA) is aiming to provide an open forum that facilitates discussion covering professional, strategic, and contemporary issues facing refugee health nurses. The group’s inaugural Chair, Lindy Marlow (pictured), who is also the state-wide facilitator of Victoria’s Refugee Health Program funded by cohealth, said the group would help connect refugee health nurses across the country. Information and ideas will initially be shared by the committee of refugee nurses in the states and territories via a quarterly online webinar, while the prospect of an annual RNA conference is in the pipeline. “It was really about recognising that it is a stream of nursing that is incredibly important,” Ms Marlow said. “It’s basically a forum for exchange of information. It’s to promote best practice so that we can eventually look at clinical guidelines and things like that.” Ms Marlow explained how refugee health nursing evolved as a speciality in Australia in the early 2000s. Today, each state and territory across the country works under different models and across different settings. Victoria’s trajectory in this space has fallen

Don’t rush to crush The successful book, Don’t Rush To Crush, is now available in its second edition. Recently released in the eMIMSCloud, the book gives professional advice regarding the sustainable crushing of medicines. While developed by the Society of Hospital Pharmacists and medicines information publisher, MIMS Australia, the Australian Nursing and Midwifery Federation

Ms Marlow was working in community health in the early 2000s, when she partnered with The Victorian Foundation of Survivors of Torture and Trauma and became known as a refugee health nurse.


in line with state government funding that has allowed it to expand and grow. The Victorian Refugee Health Program currently has 50 refugee health nurses working across sixteen of the state’s community health organisations. When humanitarian refugees arrive in Australia they first see settlement services case managers before being linked up with refugee health nurses.

Ms Marlow said being a refugee health nurse is about protecting human rights and ensuring everyone has equal access to healthcare in Australia. She said key attributes required for success in the role revolve around being respectful and inquisitive. “When I talk to the nurses I say the most important thing in my nursing career has been that I’ve seen there’s opportunities or gaps and that as nurses we can actually change the way things happen.” With the newly established Refugee Nurses of Australia, Ms Marlow and her colleagues are hoping to promote the significance of nurses working in this space. The group will advocate for appropriate training courses and potentially, nationally streamlined guidelines so that all states work in unison.

Many people from refugee backgrounds have lacked proper access to healthcare,

Ms Marlow said refugee health nurses were an important cog in the health system and provide significant insight when it comes to coordinating a social model of health. “For me, that’s where I think it’s really important because that’s where nurses do a huge job. There wouldn’t be the referral support, health advocacy and connection going on for these families and individuals. They wouldn’t be getting the care they are getting if they weren’t being looked after by the refugee nurses.”

(ANMF) Federal Office Professional team were involved in reviewing the second edition. The resource is beneficial for any healthcare professional prescribing, dispensing or administrating medicines understanding to what can and cannot be crushed. When a tablet or capsule cannot be swallowed, an obvious solution might be to crush the tablet or capsule and add the medication to food or drink but many tablets and capsules are not

designed to be crushed or opened. For example crushing an extended release tablet can destroy the medication time release properties with the whole dose being released in a few minutes rather than the intended 12 or 24 hours. Don’t Rush To Crush also includes recommendations for administering solid oral dose forms to patients with swallowing difficulties and to patients with enteral feeding tubes. Go to for more information.

The process can involve outreach visits to people’s homes where nurses conduct health assessments and begin coordinating referrals.

November 2016 Volume 24, No. 5  5

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State of Australia’s eye health

NURSES AND MIDWIVES CONTEMPLATE LEAVING THE PROFESSION Almost a third of Australian nurses and midwives have considered leaving the profession due to rising work demands and burnout, according to a national survey charting the wellbeing of staff across the sector. Conducted every three years by Monash University’s Business School, the latest research builds on two previous surveys that now collectively paint an increasingly bleak picture of the inner perceptions of the workforce. The survey, What Nurses & Midwives Want: Findings from the National Survey on Workplace Climate and Well-being, was undertaken by Associate Professor Peter Holland, Research Assistant Tse Leng Tham, and Dr Fenella Gill, who is also a Registered Nurse. Key findings from the 2016 survey reveal widespread discontent among nurses and midwives when evaluating workloads, training, job security, and dialogue with management. For example, 71% of nurses and midwives said they often have to do more work than they can do properly several times per day, up from 64% in 2013, while 67% of respondents felt their jobs required them to work very fast at least several times per day, a reflection of increasing work intensification. Alarmingly, 54% of nurses and midwives reported feeling reluctant about openly voicing their opinions and concerns to management due to fear of retribution. Associate Professor Peter Holland said the research signalled a warning bell to key stakeholders charged with managing the workforce and sector. “We’re building a data set that is becoming more and more damning. “You can’t say ‘Oh well that’s just a snapshot in time’. In 2010, in 2013, in 2016, this is what we’re finding and nothing seems to be changing. The longer they leave it the more

A National Eye Health Survey Report has identified the main causes of blindness and visual impairment across Australia. The main causes were identified as uncorrected refractive error, cataract, aged related macular degeneration, and diabetic retinopathy.

they’re damning themselves because the evidence is there.” Associate Professor Holland said the bulk of the nursing and midwifery workforce in Australia was already aged 47 years or older and that a predicted shortage of 100,000 nurses in 10 years’ time raised significant concerns. He said the survey showed nurses across the country were consistently unhappy and that problematic issues appear to be pushing them out of the profession. “I think it’s a concern that no one seems to be addressing these problems at the core. Whether it’s governments, other stakeholders, we haven’t got a workforce that is happy and something needs to be done about it because many of them are looking to leave and looking at other options outside of the industry.” The survey did yield some positives, Associate Professor Holland acknowledged, with nurses and midwives remaining resilient and proud of their work in the face of increasingly difficult environments. “In terms of the individuals themselves, they continue to take pride in their work, they were very engaged in what they did, and they felt they were making a difference.” The Australian Nursing and Midwifery Federation assisted the research team by promoting the survey via its online channels and facilitating data gathering, however the study was entirely carried out independently. Associate Professor Holland said one of the objectives of Monash’s research centred on generating information useful in triggering solutions.

“The National Eye Health Survey Report provides us with valuable data in order to target eye health conditions in more integrated ways, giving us better health outcomes,” said Assistant Minister for Health and Aged Care Ken Wyatt. The report, conducted by Vision 2020 Australia and the Centre for Eye Research Australia, involved completing a series of eye tests on around 5,000 Australians across 30 geographical areas. Participants tested were adult Indigenous Australians 40 years and over, and non-Indigenous Australians 50 years and older. Assistant Minister for Rural Health, Dr David Gillespie said up to date national data on the burden of vision impairment and blindness in both Indigenous and non-Indigenous Australians would continue to inform the Australian government on future policy directions. “Certain population groups are at particular risk of vision impairment and blindness including Aboriginal and Torres Strait Islander people, older people, those with a family history of eye disease and people with diabetes.” The report highlighted that while the eye health gap between Indigenous and non-Indigenous Australians was improving, there was work to be done in further closing the gap.

The research team is currently conducting follow-up surveys in the coming months to gather more data in order to more accurately present how staff view the workforce. “These are very dangerous indicators that we are finding and we can provide more details of where the problems are, but also help find solutions.” Associate Professor Holland said. November 2016 Volume 24, No. 5  7

NEWS alarming. “Health professionals are deeply concerned that neither the Coalition or Labor appear to have any idea of the threat posed by climate change to our physical and mental health.”


In Australia, climate change is thought to be contributing to an increase in heatrelated illnesses and deaths, outbreaks of infectious diseases, mental illness and stress associated with extreme weather events, and greater risk of respiratory and cardiovascular diseases. The survey also revealed huge gaps in federal policies designed to cope with climate change and called on Australia to develop a national strategy to tackle the omnipresent global health problem.

Leading health experts believe Australia’s health system is illequipped to deal with the looming impacts of climate change, with widespread concern suggesting communities could be left unnecessarily exposed to health risks as a direct result of the country’s lack of action. In a national first, the Climate and Health Alliance recently surveyed more than 130 peak health bodies, unions and health professionals – including nurses, midwives, and doctors – to gauge the sector’s readiness for the impacts of climate change. Worryingly, the results uncovered major gaps and extensive concerns regarding the future outlook. More than half (52%) of health professionals surveyed considered the government’s current climate policy a failure, while 78% deemed Australia’s


Public Health Association of Australia’s Dr Peter Tait warned that ignorance on the issue was placing communities at unnecessary risk and said that a national health strategy could curb the dangers. current climate policies lag in comparison to standards set internationally. Nearly 90% of respondents were well informed about the links between climate change and health and said they believed people’s health could benefit from climate change mitigation and prevention strategies. Dr Liz Hanna, President of the Climate and Health Alliance, labelled the results


Researchers from Flinders University’s School of Nursing and Midwifery will attempt to improve collaboration between different professions in a bid to boost outcomes for Australian children under the age of five in areas including health. Led by Associate Professor Dr Julian Grant, the National Interdisciplinary Educational Framework was launched in late September with an aim of ensuring future professionals working with children share common ground, practices, and outcomes when it comes to detecting

8  November 2016 Volume 24, No. 5

It is hoped that the framework will be implemented across universities and TAFE and help build a better network of protection moving forward. After many years working with vulnerable children and families facing social and economic disadvantage, Dr Grant said she noticed professions were working in isolation rather than together to provide children and families the best possible services. Dr Grant said the framework, delivered via free online resources, encourages all disciplines to prioritise a child-centred approach to health, welfare, and care where the child comes first. The flow on

“These results make three points abundantly clear,” Dr Tait said. “First, Australia is totally unprepared for the health impacts of climate change. Secondly, the health sector is demanding a national strategy in order to build resilience and a robust health response to this emerging dilemma. Lastly, that we are running out of time to make our communities as safe as possible, and that responsibility lies at the feet of the federal government.” effect will be a sustainable and capable interdisciplinary early childhood workforce, he added. “Despite co-located services, the different disciplines still often work independently from one another, making collaboration and communication difficult,” Dr Grant said. “This highlighted to us the need for an overarching framework that provides common grounding for aspiring professionals in education, healthcare, and social services. Ideally, this should start at the training level to ensure everyone in those fields learns the same terminology and is aware of what other professions are doing.” Dr Grant said she hoped the framework would assist professionals to communicate with each other and recognise when to refer a child to another discipline, effectively reducing the barriers some families face when engaging with services, and ultimately improving outcomes for children. “What we want over time is to break down the silos between the professions; to ensure that they know what the other is doing, and that we are all singing from the same song sheet when it comes to health, education and care of young children.”


Mental health excellence recognised A therapeutic dog service and a borderline personality disorder carers’ support group have been recognised for their outstanding contributions to mental health services.


Both services received the Mental Health Excellence Award, the Dr Tobin Award, for exceptional leadership and commitment to mental health and wellbeing in South Australia last month. The Therapeutic Dog Service Incorporation won the award for helping transform lives through providing therapy dogs and other animals that can bring unconditional love to people living with acute illness, ageing, disability and mental health. The dogs facilitate healing with nurturing, emotional support and rehabilitation. Robert Burke, facilitator of Sanctuary Support Group for carers of people with Borderline Personality Disorder, also shared the award for forming a group for carers to promote their voice and help their needs, especially information, inclusion and support. The group has grown from three to 140 members within four years. State Mental Health Minister Leesa Vlahos said chances were that we all knew someone struggling with their mental health. “Statistics tell us half of us will need support at some point in our lives and one in five of us is affected now. “I thank all the mental health workers and organisations across South Australia for their ongoing commitment to improving the lives of others.”

Australia’s Sex Discrimination Commissioner Kate Jenkins (pictured) called for a multi-pronged approach to tackle gender inequality in Australia last month.

Ms Jenkins, a lawyer for 20 years, was appointed as Australia’s Sex Discrimination Commissioner six months ago. Her top three priorities had been: preventing violence against women, advancing economic security for women; and women in leadership.

“Laws are not going to deliver gender equality we expect and nor is general cultural change. In some areas in Australia it is absolutely appalling how deeply embedded the system and attitudinal barriers are to women,” Ms Jenkins said.

“Not just family violence but online sexual abuse and harassment, in the workplace, for women with disabilities living in residential care, etc.” she said.

Australia had been successful in behaviour change programs such as wearing seatbelts and sunscreen to prevent skin cancer, she said at the CEDA address in Melbourne. “These things we’ve done well in changing attitudes - we’ve done multiple things not just one thing.” This included multiple intersecting initiatives, Ms Jenkins said. Gender equality needed to be addressed and with an overlap between environments such as social, education, and workplaces. “It’s a community wide problem – we need to look at the setting where we can have the highest impact.” “There is lots to be done and everyone has a role. We need more men to hold men to account, not just wait for the women to speak up. “We need gender inequality to be called out. ‘Once you see it, you cannot un-see it’.”

Statistics showed women retired with half the superannuation of men and were two and a half times more likely to live in poverty in their older age. Economic insecurity accumulated over time for women, Ms Jenkins said. “At every intervening economic financial point women lose out. Even for women who do not have children, at 45 years they will have earned $700,000 less than a man in an equivalent position.” The financial consequences of staying home to look after children reverberated for the rest of women’s lives, she said. One in two mothers experienced discrimination on return to work, some left the workplace altogether. A single elderly female had the highest incidence of poverty and greatest risk of persisting poverty. “We live longer and even that works against us. This inequality is a reality. Poverty over time is true.” November 2016 Volume 24, No. 5  9




CHALLENGES TO REMOTE HEALTH WORKFORCE Leaders from workforces operating in equally dangerous environments have encouraged an “uprising” among remote health clinicians as they strive to enforce a safety first mindset. An expert panel of national leaders managing staff working in complex and diverse environments was assembled at CRANAplus’ 34th annual conference in Hobart last month in remote health’s bid to absorb proactive safety measures implemented by other sectors. Chair Karen Cook said the death of remote area nurse Gayle Woodford earlier in the year had “shocked our workforce to its core”. “What we want to do is learn from them [people from other environments] about how they do these things. What the challenges are. What the solutions are. And talk about who is ultimately responsible for safety.” Brendan Boucher, International Security Advisor for Australian Red Cross, said the humanitarian organisation’s safety considerations began with recruiting the right people and candidates happy to work in high-risk environments. Informed consent was a significant part of the process, he added. “It’s critical for our aid workers to understand the threats and risks inherent in that environment and to accept them. No one accepts being assaulted. However, it’s important to understand that despite the fact they’re paid professionals we see them as volunteers and they’re not obliged to travel. They’re not compelled to absorb more risk than they’re comfortable with and a particular

10  November 2016 Volume 24, No. 5

aid worker can return home at any time of their choosing.” Pat Allen, President of Tasmania’s Police Association, revealed the union’s longstanding battle to implement greater safety measures. He said the focus had been on remote rural policing, specifically improving radio service dispatch systems and eliminating single unit patrols. Landmark changes were made, with a new Operational Response Model that began in September. Ambulance Victoria’s General Manager of Emergency Operations, Mick Stephenson, said his organisation sees more people injured at work than any other across the state. “We had grown very accustomed to workplace injury and accepting that people came to our workplace and were injured.” Since his appointment, Mr Stephenson said improving safety had been paramount. In the past 12 months the essential service has managed to slash serious claims made against it by 30%, as well as reduce hours lost through injury by 20%. Mr Stephenson attributed the improvements to proper leadership and a line of attack. He described the Occupational Health and Safety Act as one of “the most powerful tools you guys have” and said using and enforcing it was the key to changing culture. Mr Stephenson said the ambulance service’s significant push for safety, which now includes screening employees psychologically, had helped drive awareness and shift perceptions. Mr Stephenson said he was still astounded daily by the risks people are prepared to take and that it boiled down to drilling what should and shouldn’t be done into the workforce. He said the remote health workforce had to draw a line in the sand and take responsibility for its own safety, calling for a grassroots “uprising” to prompt action. “We’ve had to educate people over and over again to actually pull the trigger and act on that clause.”

The tragic murder of remote area nurse Gayle Woodford has triggered a wide-ranging study into the safety and security of Australia’s remote health workforce. The Remote Area Workforce Safety and Security Project was officially unveiled last month at CRANAplus’ 34th annual conference in Hobart. The 12-month project, funded by the Department of Health, is investigating problematic issues impacting safety and security across the sector including violence and the adherence of ‘Never Alone’ guidelines, which promote nurses working in pairs. The broad study is also tackling genuine concerns such as the prevention of vehicle accidents, the most frequent cause of injury or death of staff working in remote areas, and responding to emerging social challenges including the escalating use of Ice among remote communities. The project aims to develop a national set of practical safety and security guidelines for health professionals working in remote areas, plus an industry safety handbook, security safety assessment tool, and free online learning modules detailing working safely in

ENGAGE NURSING LEADERSHIP WHITE PAPER INFORMS The Australian College of Nursing (ACN) launched its Nurses are Essential in Health and Aged Care Reform White Paper at Parliament House in Canberra last month, marking a strategic bid to challenge and drive positive health and aged care reform across the country.

NEWS factors related to proactive clinic managers, adequate staffing, and the employment of local staff. Similarly, 85% of clinic buildings were considered safe and secure, while 90% of clinic vehicles were seen as reliable.


However, the findings also showed that 25% of respondents felt their accommodation was unsafe, emergency communication equipment, while usually available, was not always functional or stored in clinics, and that 60% of remote area nurses (RANs) had never been offered any formal workplace orientation.

remote practice. Project Officer Rod Menere, who led a symposium at the conference outlining the study, acknowledged that the nature of remote work came with risks but argued improvements could be made by strengthening safety and security. He said the heart-breaking death of Ms Woodford had put pressure on a range of organisations to engage in a national conversation on safety and had created “a window of opportunity” that the sector now needed to capitalise on in order to achieve progress. Earlier in the conference, a minute’s silence was observed in honour of Ms Woodford, followed by the announcement of the newly established Gayle Woodford Memorial Scholarship, a joint initiative between CRANAplus and the Centre for Remote Health, where Gayle completed her studies. “We need to respond and need to work together now to get things moving before it becomes history and other issues are seen to be more important,” Mr Menere said. “The

The White Paper asserts that the delivery of health and aged care services in Australia is unsustainable and that growing demand from an ageing population and increased consumer expectation is rapidly exceeding funding and workforce capacity. It argues the nursing voice is going unheard and the profession not being used to its full potential during a critical period for health and aged care reform, with noticeable underrepresentation in strategic policy debates and decision making. “Australia’s nursing workforce is highly educated, flexible, fiscally accountable and responsive to patient and community needs,” the report states. “As such, health and aged care reform offers significant opportunity for the nursing profession to take a leading role in designing and transforming the health and aged care system so that it is better able to reconcile and meet the myriad of challenges.”

Alarmingly, the study revealed 40% of clinicians had experienced or directly observed episodes of threats, bullying, or assault that had impacted on their personal wellbeing and ability to continue working. “There’s some good news and a lot of things we can do but when you read some stats like that it’s really disturbing when you consider the impact of the work environment on people,” Mr Menere said. ASSOCIATE PROFESSOR SUE LENTHALL, FROM THE CENTRE FOR REMOTE HEALTH, WITH THE GAYLE WOODFORD MEMORIAL SCHOLARSHIP HONOUR BOARD.

bottom line at hand- ask not what safety and security can do for you, but ask what you can do for safety and security. It’s part of all our responsibilities to contribute.” About 70 remote area clinicians have already completed the project’s questionnaire. Initial findings paint a mixed picture. Staff from several locations indicated improvements in safety and security, with 38% of clinics reportedly consistently implementing ‘Never Alone’ guidelines. Contributing

To achieve progress, the White Paper calls on Australian governments to actively engage nursing leadership when adopting future health and aged care reform. Specifically, it demands recognition of the nursing role when considering health and aged care reform, investment in policy platforms that enable greater participation from the nursing profession, the inclusion of nursing leaders in strategic policy debates, and acknowledgement of the value of nurse-led innovation. The White Paper also recommends further investment in nursing research and innovation to advance new models of care, as well as greater support for nurses to enable them to work to their full scope and expanded scope where necessary. “The role of nursing in this reform cannot be underestimated, nurses voices must be heard and influence the reform agenda,” the report declared.

Mr Menere listed safety and security as a shared problem that required the collaboration of all stakeholders to make inroads. He said remote area clinicians must fully recognise the increased levels of responsibility concerning safety and security when working rural and remote, and equally called on the workforce to support each other in developing a culture where nurses are empowered to promote safety and won’t tolerate risks.“I think sometimes we are exhausted. We’re overwhelmed. And we’re not really looking out for each other as well as we could. It’s making people aware of that.”

Last month’s launch was attended by Prime Minister Malcolm Turnbull as well as numerous key nursing leaders, including Adjunct Professor Debra Thoms, the current Commonwealth Chief Nursing and Midwifery Officer. ACN CEO Kylie Ward described the White Paper as an important step on addressing the need for reform and utilising the nursing profession and its valuable insights to more effectively run the system. “The success of the launch has highlighted that the collective voice of the nursing profession cannot be ignored in the health and aged care reform agenda.” Assistant Rural Health Minister, Dr David Gillespie, said the White Paper provided a useful perspective on health and aged care reform from professionals working on the frontline. He said nurses had an integral role to play in contributing to a strong health system on the road to reform.

November 2016 Volume 24, No. 5  11


ANTI-VACCINATION AND SOCIAL MEDIA WARNING Nurses and midwives found promoting anti-vaccination could risk their registration status and face prosecution by national regulatory authority AHPRA. The Nursing and Midwifery Board of Australia (NMBA) warning last month followed a reported number of nurses and midwives posting anti-vaccination messages on social media. Several nurses/midwives have had conditions placed on their registration. A spokesperson from the NMBA and AHPRA would not comment on the individual cases which are dealt with under National Law. “As trusted health professionals, nurses and

AGED CARE COMPLAINTS ON THE RISE An aged care provider being forced to replace a resident’s missing teeth after they were lost by the service is among thousands of complaints cases resolved by the country’s new Aged Care Complaints Commissioner during the first half of the year. Commissioner Rae Lamb, who took up the position in January after official powers were transferred from the Department of Health over to an independent body, released her first annual report last month detailing the latest results of the complaints system. Findings revealed an 11% spike in the number of complaints received for the same time last year, with 2,153 grievances being recorded. More than 80% of complaints related to residential aged care, with the most common issues concerning clinical care (267), the administration of medication (200), continence management (178), and the choice and dignity of the person

12  November 2016 Volume 24, No. 5

midwives play a key role in helping people make decisions about their healthcare. The Board’s statement makes clear its expectations of nurses and midwives when providing advice about vaccinations.” The NMBA recognises evidence based guidelines from the Australian National Immunisation Handbook. The guidelines support the safe and effective use of vaccines and public benefit of vaccination. “The NMBA expects all registered nurses, enrolled nurses and midwives to use the best available evidence in making practice decisions, as set out in the NMBA’s standards for practice and competency standards. This includes providing information to the public about public health issues.” The spokesperson said the NMBA’s social media policy was clear in that the National Law and codes of ethics and conduct applied in any use of social media by nurses and midwives. Nurses or midwives who provided antivaccination information could be found in breach of their professional obligations. The NMBA can issue a caution, impose

conditions or restrict registration which is made public on the online register of practitioners. “All nurses and midwives should be aware of the NMBA’s social media policy and their professional obligations and act in the best interests of the profession and the public at all times,” ANMF Professional Officer Elizabeth Foley said. The NMBA position statement and social media policy is available at

“Any published anti-vaccination material and/or advice which is false, misleading or deceptive which is being distributed by a registered nurse, enrolled nurse or midwife (including via social media) may also constitute a summary offence under the National Law and could result in prosecution by AHPRA.” Nursing and Midwifery Board of Australia


receiving care (163). Family members or representatives of people receiving care accounted for 1,272 (59%) of all complaints, while 347 (16%) were made from care recipients themselves. Ms Lamb attributed the increase in complaints to the service’s newfound presence and growing awareness. “It’s not the number of complaints but what services do about them that really matters. “As our annual report shows complaints often lead to lasting improvements to aged care. If people don’t speak up this won’t happen.” In the past six months, the Commissioner made 231 referrals to external organisations due to complaints surrounding the number and qualifications of training personnel, quality of clinical care and food, infection control, and administration of medication.


Ms Lamb said it was important to note the rise in complaints reflects a small proportion of the hundreds of thousands of people receiving aged care across the country.


TACKLING GLOBAL ISSUES FOR A BETTER WORLD It’s almost one year since the United Nations General Assembly launched the Sustainable Development Goals (SDGs) to tackle a range of global issues from gender inequality to climate change.


The SDGs build on the Millennium Development Goals (MDGs), which made significant progress in eradicating poverty and improving access to education over the past 15 years. Covering a wider agenda than the MDGs, the SDGs comprehensively focus on developing sustainable development in all countries and regions by responding to the many challenges faced by the world today and into the future. The SDGs came about after three years of negotiations and debate involving 193 countries, including Australia. In 2015 the nations agreed to set the development goals in place and use them to frame their agendas and political policies over the next 15 years. Making up the agenda are 17 sustainable development goals encompassing 169 targets that allow for a range of measures that address poverty, environmental sustainability, innovation, economic growth, equality and consumption. Goal three, Good Health and Wellbeing, specifically addresses health issues. Equitable and universal coverage to quality health services; the protection from the financial risk of sudden health expenditure and tackling the disease burden, are the key issues under this goal (European Commission, 2014). The 13 targets encompassed within this goal are dedicated to reproductive and child health; communicable diseases, noncommunicable diseases and addiction; environmental health; universal health coverage; tobacco control, vaccines and medicines, health financing, workforce and global health risk preparedness. In a global health study measuring the

health-related Sustainable Development Goals, Australia ranked the tenth best performing in achieving the targets. The analysis assessed 188 countries, showing good progress being made around the world in achieving some of the targets, which include reducing childhood mortality, providing family planning and the rollout of universal healthcare. The challenges in meeting the goals included domestic violence, HIV and tuberculosis, childhood obesity and alcohol consumption. Despite Australia’s high ranking in the study there are still considerable obstacles to address, particularly in relation to the reduction of chronic diseases which represent a significant cause of illness, disability and death in Australia (AIHW, 2014). One of the collaborators of the research, Professor Bruce Neal from the George Institute for Global Health, Sydney, said he had expected Australia to perform well on a global level in regards to healthcare. But despite being ranked as the tenth best country in the world he said there was no room for complacency. “There are areas we can definitely improve in and where other countries are doing far better including our high levels of childhood obesity and rates of suicide. The gaps have been highlighted, now it’s time for governments, policy makers and health professionals to work on meeting the 2030 targets.” Addressing the SDGs more broadly, the recent SDGs index placed Australia twentieth in a global ranking of SDG performance. The key challenges identified for Australia related to hunger, affordable and clean energy, climate change, life below water, life on land, and partnering for the goals. The inaugural Australian SDGs Summit held in Sydney last September, involving

the Australian government, business, civil society, academia and youth, helped identify the implementation gaps based on the index. The summit also showcased the significant momentum and support for the SDGs across all sectors in Australia that had already occurred. Speaking at a MDGs symposium at the University of Melbourne last month, Department of Foreign Affairs and Trade’s, First Assistant Secretary of the Development Policy Division, Blair Exell, highlighted some of the areas Australia planned to participate in as well as the work that had already occurred towards achieving the agenda. Emphasising the Australian government’s strong commitment to the 2030 agenda, Mr Exell said there were six priority areas that Australia was planning to participate in, including health. “Agriculture, water, fisheries, effective governments, institutions, education, health, build resilience, humanitarian responses, social protection, gender equality. These are all at the heart of the SDGs when you look at the 17 goals, and they are priority areas for Australia.” Some of the key areas Australia has started working on globally include reframing the water narrative, strengthening taxation systems, overseas infrastructure, gender equality leading to economic empowerment, as well as foreign aid funding. Domestically, Mr Exell said there were a number of projects being launched addressing a range of issues such as a woman’s safety package and the national disability scheme. Reference Australian Institute of Health and Welfare (AIHW). Australia’s health, 2014. Canberra (AU): AIHW; 2014. 563 p. Cat. No. AUS 178. European Commission, 2014, A decent life for all: From vision to collective action. Brussels.

November 2016 Volume 24, No. 5  13



her greatest achievements. It was the first book on nursing ethics to be published from an Australian perspective. “Nursing ethics books by other authors published in that era, have not gone to a sixth edition. Internationally that’s very humbling and gratifying both at once,” she says.

Megan-Jane Johnstone was delving into the study of philosophy at New Zealand’s Waikato University in the early 80s when her lightbulb moment hit.

Other notable successes include being selected as the curating editor of a prestigious three volume Sage Major Reference Work titled Nursing ethics, released last year, as well as developing and teaching the first distance education unit on nursing ethics, administered by the Royal College of Nursing, Australia in 1990-92.

The then fledgling student stumbled upon ethics and suddenly realised that the issues she had been tackling in the hospital system as a nurse were bound by core ethical principles and considerations. “I guess the quest for justice and fairness, and preventing harm,” Dr Johnstone replies when asked what sparked her interest.

Without doubt, Dr Johnstone’s career as a prominent nurse ethicist has both challenged and changed the nursing ethics landscape in Australia and beyond.

“Just making the world a better place I suppose and, like most organisations in healthcare, we know that these systems are fraught with all sorts of difficulties. But I saw things that went totally against everything I was taught.”

While Dr Johnstone has enjoyed all aspects of her career, she lists her bi-monthly column on nursing ethics for the ANMJ, a publication she has written for since 2008, as one of the most fulfilling.

Dr Johnstone began her nursing career in 1974 at the Waikato Hospital in New Zealand, an organisation she now looks back on as a progressive training ground that had a profound and lasting impact on her career. “First and foremost I loved the opportunity to engage in what was a very rewarding profession,” she says. “It was very rewarding caring for people in a way that I really had not envisaged. I particularly loved learning and I used to hold tutorials for my classmates after class. We were allowed to do that and some of them wouldn’t have got through their exams without those classes.” Teaching remained a burning ambition and it’s unsurprising that Dr Johnstone’s career followed that path when she moved to Australia in 1984 to expand her studies across a variety of fields. Today regarded as one of the most eminent nurse ethicists in the world, Dr Johnstone recalls arriving in Australia during an evolving period. “When I came to Australia I could see that the future of nursing rested on higher education.” During her early studies, it was the endorsement of a university philosophy professor who encouraged her to seriously consider pursuing an academic career in her own right and gave her the confidence to become an academic leader. The period coincided with the shift of nursing education into universities and Dr Johnstone grabbed the opportunity with both hands when it arrived, with one of her first roles delivering lectures within RMIT 14  November 2016 Volume 24, No. 5


“I’ve really enjoyed all the other work that I’ve done, particularly in the area of crosscultural healthcare, patient safety and that sort of thing. But what the ANMJ column has given me, and it’s been an absolute gift and one that I’m very grateful for, is the unfettered freedom. I have been totally free to write what I wanted to write and to address issues that may have been quite difficult to get out there to a broader audience in the more constrained peer reviewed journals.” Dr Johnstone is clearly content with her legacy and believes the next wave of nursing students set to make up the future workforce have a bright future ahead of them.

University’s Department of Nursing and Midwifery. Over the years Dr Johnstone has held a diverse range of positions at leading education institutions in what she describes as the cornerstones of an academic career – teaching, research, scholarship and administration. She has been the Professor of Nursing/ Academic Chair at Deakin University’s School of Nursing and Midwifery since 2008 but recently announced her retirement and celebrates her final day this month. “What I am most known for and what I get the most feedback for is certainly around my leadership in establishing nursing ethics as a distinct discipline in its own right,” she says. Dr Johnstone counts the publication of her book Bioethics a nursing perspective, first published in 1989 and which recently marked its sixth revised edition in 2016, as among

She says an important message she shares with colleagues is the value of being goal oriented rather than opportunistic, and to aim high. “With my hand on my heart, one of the things that I can look back on and my advice to the next generation, is the value of being goal oriented. Because where I am sitting now, I have this overwhelmingly gratifying feeling that I have achieved absolutely everything that I set out to achieve and more. I can truly say “I’m done”’.



Elizabeth Foley

Julie Reeves ANMF Federal Professional Officers

References Australian Government Department of Health Ageing and Aged Care. Nurse Practitioner – Aged Care Models of Practice Initiative. Retrieved 7 October 2016 from: https://agedcare. nurse-practitioner-agedcare-models-of-practiceinitiative Davey, R., Clark, S., Goss, J., Parker, R., Hungerford, C., and Gibson, D. 2015. National Evaluation of the Nurse Practitioner – Aged Care Models of Practice Initiative: Summary of Findings. Centre for Research & Action in Public Health. UC Health Research Institute. University of Canberra. Canberra. Available from: au/research/institutes/ health-research-institute/ annual-reports/reports/ NPACM-Summary-ofFindings-Dist-Low-res.pdf

The nurse practitioner role is now well established in Australia, with these nurses driving clinical leadership and innovation, across a diversity of care settings. The aged care sector, however, was slower than other areas to create positions for nurse practitioners.

The ANMF argues this is an area in which nurse practitioners can make a significant contribution to the health and welfare of frail elderly people, as well as achieve savings for aged care funders. The Australian government’s 2010-11 federal Budget included funding of just over $17 million for a four year project to “explore appropriate models of practice for Nurse Practitioners in aged care” (Australian Government Department of Health, 2016). The 30 organisations selected for the initiative received funding to develop, and then test a model for nurse practitioners that could be applied to their work in aged care practice. The stated aims of this initiative were to: • identify effective, economically viable and sustainable models of practice, • facilitate the growth of the aged care nurse practitioner workforce, and • improve access to primary health care for clients of residential and community aged care services. (Australian Government Department of Health, 2016) As a professional nursing and midwifery organisation, the ANMF was excited about this project as we were already convinced nurse practitioners would be able to play an effective role in coordinating the chronic and complex care of elderly people, in community and residential aged care settings. What we needed was hard evidence to back our assertions when arguing the case to policy makers and funders of aged care services. However, while the initiative was completed in mid-2014, we have been waiting for publication of the study outcomes. Funding was also provided in the initial federal Budget measure for an evaluation of the extent to which the various models, developed by the 30 organisations, met the aims outlined above. A team of researchers from the University of Canberra and the Australian National University undertook independent evaluation throughout the period of the initiative


(Davey et al. 2015). A document outlining the summary of findings from the evaluation has only recently been made publicly available. Not surprisingly these findings confirm the valuable contribution nurse practitioners are making to aged care. Members are encouraged to read the full report (reference cited). To whet your appetite, highlights taken from the report are listed below. Nurse practitioners: • spent considerably more time with the elderly people than did general practitioners; • being attached to the facilities, were more accessible than general practitioners and thus able to initiate more timely care; • visited elderly people in their homes and thereby increased access to care for those who were not mobile or not able to drive themselves to services; • undertook more comprehensive assessments of the older person

than other registered nurses, meaning better quality of the clinical information to be used by the broader healthcare team; ability to order diagnostic tests or initiate appropriate medicines meant more timely treatment of acute episodes of care. In many instances this prevented the older person needing to be transferred to an acute facility and/or circumvented complications of the condition; were able to review medicine regimes, and in some cases, to reduce unnecessary poly pharmacy; were reported to bring greater confidence, more knowledge and stronger networks when dealing with specialised services; played strong coordination roles in bringing together health professionals and family members; and, provided valuable translation of information into language the elderly person and their family could understand; and, in their understanding of the importance of advance care planning, were able to help people document plans for end of life choices.

From an economic perspective, nurse practitioners in aged care demonstrated they save dollars for government funders through their timely and accurate care interventions. Economic efficiencies were gained through reductions in: unnecessary transfers to acute health facilities, ambulance costs, hospital bed days and thus hospital costs. The study estimated that “if all aged care facilities had nurse practitioners visiting, the savings from reductions in hospital bed days would have been $97 million in 2013-14” (Davey et al. 2015). For the elderly person and their family, being able to remain in their place of residence for treatment, avoids disruption and enhances wellbeing and safety. The ANMF continues advocating for more nurse practitioner positions to provide clinical leadership in improving care for elderly people in community and residential aged care. November 2016 Volume 24, No. 5  15




With the Australian healthcare system struggling to keep up with surging demand, nurse practitioners are ideally placed and suited to fulfil the role for which they were envisioned. Natalie Dragon looks at the challenges to realise the NP potential.


hile I was working as an acute clinical nurse in a community health position doing Pap smears I realised there was a different world out there,” says Nurse Practitioner (NP) candidate Georgie Waugh of her move into primary healthcare. Georgie works on the south-west Queensland side of the state border with NSW in Mungindi, population 800, more than 300 Indigenous. She juggles her work at the Mungindi Medical Practice and as the community health nurse. “I could be in at 8am doing all the bloods, in the practice for four hours, then four hours in the community, and then get pulled back into the acute sector ED. I do the primary healthcare for our 15-bed hospital.” Georgie started her position in Mungindi and her NP studies at the University of Queensland in January 2015. “I can be in the clinic performing chronic disease management, assisting the MO in emergency and then back performing Pap smears. “In the community, I am brokering a deal for a client with NGOs; setting up a care plan for a client in the community; and organising a case conference through videoconference with a specialist and a multidisciplinary team – truly embracing the collaborative approach. “Healthcare out west is changing in a big way - all healthcare is changing, with

a primary healthcare focus instead of an acute focus we want to be proactive in treatment.”

RN Frances Barraclough says she could see the potential and struggle of NPs early on.

Becoming a nurse practitioner is a commitment that will change your life, Georgie says. “When they tell you in the first week of uni that your life is going to change and you will have no spare time and things are going to get tough. It’s that and worse. I finish eight to 10 hour days, have dinner and then come back to my case studies and do research.”

As Senior Manager with New England Area Health Service, Ms Barraclough organised meetings with key stakeholders including doctors with NP pioneers. She says there were ‘no shows’. “The NP movement has been fairly major. Initially for some NPs there was no place for them to work, they weren’t given a computer and there was no admin support.”

However that’s the beauty and trap of being a NP, says Georgie. “The more information you get, the more you want. “Your life will change – you do not switch off. I am reading Medical Observer on my weekend and am constantly up to date in my practice – the minute you stop you are left behind.” Her advice to others wanting to travel this road is “make sure you have stable grounding and really want to do it.”


Figures released at the recent Australian College of Nurse Practitioners’ (ACNP) conference show there are now over 1,380 endorsed NPs. Despite their introduction around the world more than 50-60 years ago, the NP role has evolved more slowly in Australia since the 1990s. University Centre for Rural Health Program Manager in Clinical Education,

Guest speaker at the ACNP conference held in Alice Springs in August, Canadian NP Dr Tammy O’Rourke says “it is the constipation of the system of why we cannot move forward.” There have been political barriers and resistance, University of Sydney’s Emeritus Professor Lesley Barclay says. “I do think it’s such a pity it’s taken too long to value NPs. But their value is being realised. I think medicine is less nervous now. I think there is more wisdom and more sense now; that there can be roles across the health team to fill the need. There are a whole range of areas in rural and remote communities that do not have access to expert health or medical care.” ACNP President and one of the first emergency NPs in Victoria, Grainne Lowe agrees it’s been slow progress. The first NPs in Australia were endorsed in NSW in 2000. “In NSW in the early



nineties the first committee was set up to look at the possibility of this role and to recognise that this is a workable solution to address some of the problems with patient outcomes and service delivery.” Ms Lowe started in the first batch of ED NPs in Victoria in 2004 at a time of media backlash with waiting times and patients having extended periods on ED trolleys. ED subsequently became the biggest group of NPs – 33% are ED NPs. “However I see that changing. The numbers are growing in identified areas of need,” Ms Lowe says, in particular primary healthcare. “It’s a beginning; we are starting to see expansion in that area. If it’s on the politicians’ radar it seems to get a lot of traction.” There’s been much debate about where NPs fit, says Ms Lowe. “They fit everywhere and anywhere. There are so many gaps in services, so many places where services are inaccessible and inequitable. That’s where they go. “The key is to get together the whole gamut of stakeholders to work out where there are gaps and inequities or inaccessibility of services. Let NPs go out and fill them – that’s what they want to do. And not be constrained in their efforts to achieve that – that’s one of the biggest stumbling blocks.”


In 2011, research showed about 28.5% of endorsed/authorised NPs not employed in NP positions.

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There is still a lack of understanding of policymakers, organisational as well as in government, says Ms Lowe. “We are still caught up in substitution – why have a NP when it costs this much? It’s not realising the capability of a NP to sit across both disciplines and do so much more than what a doctor or a nurse can do. It’s the duality of those skills and recognition of what the NP is capable of doing.” Evidence debunks traditional demarcations of roles, argues Ms Lowe. “It’s not about competition; it’s not about getting someone else’s slice of the pie. I would question anyone who says there’s not enough healthcare to go around.” Lowe says there have been significant achievements, including title protection of the nurse practitioner. “This clearly paved the way for a structured approach to the implementation of NP roles and services.” One of the most significant achievements was to be recognised as health service providers and be granted access to MBS and PBS within our own right, she says. “Whilst this is not as ideal yet, we are certainly maintaining the dialogue with key stakeholders. The challenges that remain for us are those which prevent us as a group and as individual NPs to provide adequate services to a variety of patient groups.”

Demand and supply

ACNP Immediate Past President and Emergency Care NP Chris Raftery says there will be more than 1,400 NPs when the next

Nursing and Midwifery Board of Australia endorsement statistics are released. “Over the past year, the rise of endorsement is about 12%. While this seems like a small number, it is still keeping momentum forward.” While there are more than 200,000 NPs in the United States, the Australian health system is more comparable to Canada, which has around 3,500 NPs. Mr Raftery believes Australia will head towards the Canadian number of NPs. He says it’s a balance in matching work opportunity with the time it takes for training for NP endorsement. “While 1,400 NPs in a population of a couple of 100,000 nurses is relatively small, this is reflective of the high level of education and experience required to be endorsed at this level. “To prepare a senior RN for endorsement as an NP, this takes around two years to achieve (including Masters’ degree and internship). Funding cycles however, are often delivered with shorter notice, making it often difficult to match new NP service development and NP endorsement timeframes.” Mr Raftery says there are now about 10% of NPs not currently employed in NP positions. “In the beginning, many public hospitals were ‘given’ state government funding, to build and develop NP roles including training and then continue these roles’ development into the future without central funding.



“This was the first problem, where money was being taken by hospitals and NP roles being developed, without looking into the future at ongoing development needs. “From a state perspective, government needs to have a consistent consideration for appropriate NP services and funding across the public hospital networks. However with the future of NP service benefit lying with private practice, a review of MBS funding arrangements needs to be considered in order to enable NPs to work to their full scope to benefit the health of the community.”

Access to Medicare

NPs in the public sector are generally paid by states and territories. For those that work in NGOs or the private sector access to Medicare - the Medicare Benefits Schedule (MBS) - is their source of income or viability. ACNP CEO Amanda Davies says access to the MBS for NPs in 2010 was bittersweet. “The government introduced new item numbers for nurse practitioners instead of using the medical ones or existing item numbers.” The rebates for the four NP item numbers are not enough to sustain independent business models to cover costs, she argues. That, or NPs charge a fee for service with a gap. “NPs often have clients from the lowest socioeconomic groups where people do not use traditional health services – people who are disadvantaged, with chronic disease, aged care, Indigenous communities, people who do not use services because of the cost who seek alternative services and in areas where there is not a lot of coverage.” Former Federal Health Minister Nicola Roxon’s agenda back in 2010 was for an alternative for improved access to healthcare. However, the system doesn’t allow for it to work, says Ms Davies.

of care and its stifling innovation. There are pockets of innovation where it’s happening but it’s how we replicate that financially and how it’s sustainable. Nurse practitioners will not be fully utilised until they can use full scope of practice. Until then, they are constrained.” Despite the widely anticipated innovative NP models of care in the private primary healthcare sector, expansion of the role has been hindered by inadequate or absent MBS reimbursement rates for equivalent NP services (Helms et al 2015). ACT NP Chris Helms, works within a model of care in a large bulk-billing general practice that has shown to provide complementary, cost-neutral, safe and effective NP care. However viability of the model appears dependent on income indirectly generated by the NP for GPs through management of chronic and complex illnesses. Direct earnings generated by billings for NP attendance were $52,439.30, while indirect billable items were $101,365.20.

Not only is a lot of NP work ‘hidden’ by only having four item numbers, it’s a deterrent to providing care, says Mr Helms. “There are many diagnostic and therapeutic procedures, such as surgical procedures, implanon insertion and removal, toenail wedge resections, ECG and spirometry that I have been asked not to perform in the past as it detracts from the amount of income brought into a practice if a GP instead performs it. “The fact that I can diagnose a worrisome skin lesion, excise it and discover it is a malignant melanoma, then quickly and independently refer my client to see the appropriate specialists and get approximately $35 (over two consultations) whereas a GP would get a minimum of $260 is inexplicable. “Ultimately, such MBS restrictions result in narrowing of my scope, deskilling my practice, reduces timely access and potentially negatively influences evidence based practice.” In late 2013, the ACNP published a position paper Responsive Patient Centred Care: The Economic Value and Potential of Nurse Practitioners in Australia. It recommends MBS provider numbers be granted to public sector NPs, initially on a trial basis if necessary, to help maximise NPs. The financial impacts could then be tracked. “The recommended way forward should not result in cost blowouts but rather increased efficiency from the existing NP workforce.” Currently underway is the federal government’s taskforce to review the Medicare Benefits Schedule. Mr Helms, along with other NPs, want to see further access to MBS item numbers for NPs. “A complete integration into the current comprehensive MBS dataset is needed.” Adequate pay for comparable work through the same MBS item numbers or a caveat


“It creates barriers to new nurse led models

November 2016 Volume 24, No. 5  19



similar to Canada is proposed. NPs receive 85% of the fee for a service, which would create substantial savings in the current model of care and facilitate growth of the NP role in primary healthcare. NPs are already beginning to demonstrate the effectiveness of NP care from a systems savings perspective, says Mr Helms. A recent national evaluation of Aged Care NP practice models showed a NP in an aged care facility reduced hospital leave days for residents aged over 80 by 12%. If each facility had an aged care NP it could mean a potential savings of $97 million.

Improving care

Rural Queensland GP Andrew Reedy says investment in NP Liz Waugh has definitely paid off. “If we can get doctors to stay two to three years we’re lucky – they come and go. Often we cannot recruit and have vacant positions. We have a NP who actually lives and is a member of the community who is brilliant.” Millmerran is about 50km west of Toowoomba; the practice and local hospital service a population of around 4,000. “It’s not a profit making value but it has decreased the burden with a NP doing care plans, diabetic education, etc. There’s also an indirect income not only billing which help offset costs significantly – in spirometry, ECGs and audiometry,” says Dr Reedy

[Liz] quarantines those who need to be seen for me to be able to organise my time,” Dr Reedy says. Liz likes that she is part of the community. She lives on a property about 32km from Cecil Plains and works between Millmerran Medical Centre and Cecil Plains. “What I probably love most is that I never know what’s going to walk through the door. I also like the continuity of care in that you refer to allied health/specialists and you get to see the outcomes. It’s one thing to dispense from a phone order and another to prescribe yourself, says Liz on the extended scope of practice of the NP. “Before I was a NP I could never prescribe and technically I couldn’t diagnose. Before I would ring a GP and I would get a remote phone order and dispense medication. But GPs are busy people and sometimes I could be waiting for a while – now I can prescribe and titrate medications such as insulin. “I think it’s important to think past the RN role, extending your practice, taking it to the next level.” Endorsed in 2013, Liz has undertaken grad certs in child health and diabetes. “I try to improve my knowledge and skills each year. This year I have done primary skin care – skin incisions and biopsies. I’ve done immunisations, Pap smears, sexual health. I see where my gaps are and I want to learn more.”

Dr Reedy acknowledges initially there were reservations by some medical colleagues. “I would never go back to the old system – it’s been so beneficial to the health of our communities.”

Clinical learning

Liz helps significantly with minor injuries and illnesses. She visits the 50-bed nursing home with residents with minor conditions to write up repeat scripts, perform wound checks, etc.

A research program aimed to address some of the complexities and inconsistencies in NP clinical specialty learning and teaching in Australia is nearing completion, says lead investigator and Australian Catholic University Professor of Nursing, Anne Gardner.

“I do not have to be on site to see 30 to 40 patients within a three to four hour period. I can focus on those that are unwell. She 20  November 2016 Volume 24, No. 5

An important area for NP students is the way they gain clinical experience in their specialty areas during their Master of Nurse Practitioner degree.

The research project, funded by the Australian

Research Council and known as CLLEVER2 (Educating for health service reform: CLinical LEarning, goVERnance, and capability), has established specialist clinical standards for NP education and developed a governance framework for learning and teaching of advanced clinical specialty practice. For NP students undertaking clinical placements there are often tensions between the clinical and academic requirements, in part due to lack of understanding in some clinical areas about the role of the NP. “Clinical mentors and students themselves have said they would benefit from more guidance about the specialty clinical skills, knowledge and expertise that NP students need to develop in order to practice once endorsed,” says Professor Gardner. Preliminary findings of the CLLEVER2 study have been presented to the ACNP and a toolkit for use by NP students and clinical mentors will be made available to the ACNP in the next few months.

Accreditation standards

Professor Gardner was asked about the current NP accreditation standards for course providers offering programs leading to an NMBA approved program of study for endorsement as a NP. Professor Gardner was invited to chair the Expert Advisory Group that reviewed and made recommendations to ANMAC for the 2015 Accreditation Standards. However, she spoke to the ANMJ in her capacity as a Professor of Nursing and researcher. The 2015 Standards have a mandatory requirement of 300 hours minimum supernumerary integrated professional practice, which is a new stipulation in the accreditation standards for course providers. “There has been much debate about the number of mandatory minimum hours and that these are supernumerary; some think it is too difficult, others are strongly supportive of it,” Professor Gardner says.




“There is some evidence that the quality of learning and teaching is better if students are supernumerary. If not, the service needs to drive the clinical experience. Our recent research findings support this. “NPs push the boundaries to a different level, if working as a paid RN, they are must practice as a RN - not as a NP.” However there is very little research on how many hours should be required, even internationally”, says Professor Gardner. “I think this is a compromise between what people thought was practicable and what was the minimum desirable.” Charles Darwin University Course Coordinator Professor Sandra Dunn says ANMAC’s requirement of 300 hours supernumerary practice is arguably the hardest challenge for prospective NPs. She says several states and territories raised robust concerns, including the NT, NSW and SA. “The definition of a NP is that you have to be at advanced practice level and practising at a very high level. You are not just studying but working at a very advanced level which is part of your study. There is no requirement that it


has to be unpaid in their own workplace but they cannot be part of the numbers. “Many are mature aged women; most have families and work and study – who can afford 300 hours or 10 weeks unpaid?” Professor Dunn says there’s no evidence to suggest that 300 hours is a magic number. “I am absolutely and totally in support of NP candidates undertaking supernumerary practice, that’s not my issue. I strongly encourage my students to take at least two weeks to undertake supernumerary work elsewhere; to work with a NP in a wellestablished position in their field such as orthopaedic or cardiac, elsewhere not their own hospital or health organisation to see how they have set up referral pathways and learn the tricks of their trade. It’s an evolving profession.”

Road ahead

The Productivity Commission released its Efficiency in Health report in April 2015. A key recommendation was to ensure NPs work to their full scope of practice. The announcement of the federal government’s Health Care Homes (HCH)

is also promising, says ACNP CEO Amanda Davies. “Health Care Homes is an opportunity to showcase the contribution of nursing and for us to have some recognition of how highly skilled NPs function and how they improve access and patient outcomes.” HCH is a real opportunity for change and reform, argues Ms Davies. “In the HCH funding is bucket funding looking at how you pay for outcomes rather than per episode of care.” The aim is for best care for the consumer which is multidisciplinary, which may help NPs to coordinate the care and manage medication. Questions remain however, says Ms Davies. “How will the mechanism look? Will it [funding] go to the clinician or the Health Care Home? Consumers should be able to decide how to spend the money.” The NP role has the potential to assist and solve some of the biggest health workforce challenges, says Chris Raftery. “If the barriers are reduced and MBS funding opportunity is increased, we will see a surge of highly skilled NPs, expanding into roles across the health spectrum, for the benefit of the health of the community.” November 2016 Volume 24, No. 5  21


HealthTimes UPDATE

NURSE PRACTITIONERS TAKING URGENT CARE OF PERTH By Karen Keast, provided by From chronic disease management to emergency care, Nurse Practitioners (NPs) have been redefining the face of health care in Australia since 2000. While the role continues to remain a largely untapped health solution, two endorsed nurse practitioners are treading their own career path with an innovative business venture. When the Perth hospital they worked at was listed for decommissioning, Robin Moon and Alan Noonan decided the time was right to assess the next stage of their nursing careers.

As part of their business, Robin and Alan also share a three-week Fly In Fly Out (FIFO) nurse position at a health clinic in the iron-ore mining town of Pannawonica, south-west of Karratha.

Robin, a nurse with 40 years’ experience who was endorsed as a nurse practitioner in 2006, and Alan, who began his nursing career while serving in the Australian Army before being endorsed as a nurse practitioner in 2008, worked together in the fastpaced environment of the emergency department.

Nursing and Midwifery Board of Australia registration statistics show there are now 1,380 endorsed nurse practitioners nation-wide. As highly educated, skilled and experienced registered nurses, nurse practitioners can prescribe medications, order and interpret X-rays and blood tests, as well as refer to medical specialists.

A year later and the duo are now business partners. Robin and Alan decided to take redundancies and launched their own company, Dusk to Dawn Nurse Practitioner Healthcare Service.

Nurse practitioners are transforming health care provision, often filling a crucial service gap in far-flung remote locations, regional areas and in cities right across Australia.

nurse practitioners within their clinics.” In their new career journey, Robin and Alan are collaborating with the three pharmacy partners, who initiated the idea to launch the after hours urgent care nurse service. Behind the scenes, Robin and Alan have established the infrastructure and IT to enable access to Medicare payments, sourced equipment, and have also forged connections with pathology and imaging providers. Robin says the novel after hours urgent care nurse service will work to ease the pressure on emergency departments while providing essential nursing care to the community, when it’s needed.

Through their venture, Robin and Alan recently opened the doors to the city’s first after hours urgent care nurse practitioner service at Perth’s only around-the-clock pharmacy, Beaufort Street 24 Hour Chemist. The after hours urgent care nurse clinic, which is open Friday to Sunday nights from 6pm to 2am, is being trialled for three months. Robin hopes the service may eventually be rolled out to seven nights a week. “It’s an opportunity,” he says. “I’m 60 and Alan’s 58, and we’ve got over 70 years’ experience between us. “We could retire but we have nothing to lose. I call it two old guys having a bit of fun. It’s innovative for Perth in that it’s the first after hours urgent care nurse clinic in Perth - it’s probably the first in WA and probably the first in Australia.” Robin, a board member of the Australian College of Nurse Practitioners (ACNP), says the clinic is not an emergency department. Instead, it provides urgent care services such as repeat prescriptions through to vaccinations, chronic disease management, travel health, injury and wound care. The service also provides treatment for common infections and urine drug screening, as well as pre-employment medical examinations by appointment. 22  November 2016 Volume 24, No. 5

But the specialised role continues to face a range of obstacles, from a general lack of understanding about the full scope and potential of nurse practitioners through to a shortage of employment opportunities. “One of the issues has been that there hasn’t been jobs or positions for nurse practitioners, so people have been looking for the public sector to provide the employment but the public sector is dealing with budgetary issues,” Robin says.

“Hospitals don’t want their emergency departments cluttered up with people who would normally go and see the GP,” he says. “This is a highlight for us - it’s the opening up of health care. It’s all about people getting health care from the right people, with the right skills, at the right time, in the right place. “Sometimes when I write a script I think ‘this is really great for nursing’.

“Nurse practitioners probably have to be a bit entrepreneurial and be prepared to go out there in the private sector.

“And that’s at the back of my mind now - that this is great for nursing and this is helping to break down the barriers to the access of health care.”

“The areas that are growth areas are primary health care and aged care. Quite a few GPs are starting to incorporate

More articles at





UNDERSTANDING EBOLA VIRUS The ANMF’s Body Systems Training Room is the most comprehensive library of anatomy and physiology online education programs for all health professionals. Currently we have 55 topics to choose from and the excerpt below is from the Understanding Ebola Virus Disease. The Understanding Ebola Virus Disease (EVD) learning program is designed to provide fundamental education on the basics of EVD, the history of the disease, its effect on the body, and how to recognise the disease and provide supportive care. The program begins with an overview of the history and epidemiology of EVD, followed by a discussion of the Ebola virus, its pathogenesis, and its mechanisms of transmission. Finally, you will learn about the clinical presentation, diagnosis, and treatment of the disease. The outbreak of Ebola Virus Disease in West Africa in 2014 caused untold suffering in the affected countries and dominated news headlines across the world. Many myths and misconceptions have been propagated about the nature of the disease, how it is spread, and how best to care for those affected. EVD was first reported in Central Africa in 1976 near the Ebola River in Zaire, which is now known as the Democratic Republic of the Congo (DRC), and in the area of Sudan that is now South Sudan. The next major outbreak occurred in the DRC in 1995. Since then numerous outbreaks have occurred across the continent, claiming thousands of lives with the largest outbreak being in 2014 mainly involving Guinea, Liberia and Sierra Leone, with additional cases noted in Mali,

Spain, the USA, Nigeria and Senegal. The natural reservoir for Ebola virus is thought to be fruit bats, but it is unknown how the virus survives within this animal population. Once infected, bats can infect other animals. Sporadic outbreaks with high mortality in nonhuman primates and a type of antelope, known as a duiker, have been noted. Animal-to-human transmission can occur after contact with infected animals, such as when handling wild animal meat during hunting. Like all viruses, the Ebola virus must enter a host and infect susceptible cells to cause disease. The Ebola virus genus belongs to the Filoviridae family of viruses. Ebola viruses are enveloped viruses with a negativesense, single-stranded RNA genome. The genome of the virus contains seven genes that encode for nucleocapsid and envelope proteins, which are necessary for replication and assembly of the virus, as well as its entry into host cells. The pathogenesis of EVD begins when the Ebola virus first enters the body of a host by crossing mucous membranes, by entering breaks in the skin, or by being injected parenterally. Once inside the host, the virus infects immune cells. Studies have shown that monocytes, macrophages, and dendritic cells are the early and preferred sites of

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Ebola viral replication. Infected cells travel to nearby lymph nodes via the lymphatic system. The infected cells can then migrate via blood circulation and spread the virus to the liver, spleen, and adrenal glands. Ebola viruses have the ability to replicate in almost every type of cell in many organs. Infected cells then die by necrosis. Necrosis of liver cells is associated with coagulopathy, whereas necrosis of adrenal gland cells can cause hypotension and impaired steroid production. The Ebola virus also causes the release of pro-inflammatory cytokines, which result in multiple organ failure and shock. During an acute Ebola virus infection, high levels of virus and viral antigen circulate. As a result, the immune system may mount a specific response to the virus, which may lead to clinical improvement. Patients who develop an early and well-regulated immune response to Ebola virus infections are known to survive. The information presented is just a portion of the information provided in this comprehensive tutorial. To access the rest of the EVD content, accompanied by high quality graphics, register or log in at www.anmf. AOD1Index For further information, contact the education team on 02 6232 6533 or

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Healthcare practitioners are generally aware of the need to obtain a patient’s consent before providing treatment to avoid legal liability. When practitioners fail to obtain a lawful consent it is possible that they could be subject to criminal and or civil proceedings. For example, in 2011, Dr Reeves an obstetrician and gynaecologist in NSW, was charged and found guilty by a District Court jury for maliciously inflicting grievous bodily harm with intent when he surgically removed his patient’s clitoris and labia without her consent during an operation to take out a small pre-cancerous lesion. However, civil actions for trespass to the person (assault, battery and false imprisonment) and negligence are more likely when patients claim that there was no consent or the consent was flawed. This was the case in Candutti v ACT Health and Community Care when the plaintiff sought damages for negligence following a laparotomy - an operation she claimed she had not consented to.

Reference Canutti v ACT Health and Community Care [2003] CTSC 95.

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

Following the birth of her second son, the plaintiff, 32 years of age, decided to seek advice from her GP regarding her options for sterilisation. She was advised that this could be done in day surgery through a laparoscopic procedure which would involve two small incisions that would leave her with ‘hairline scars the size of her fingernail’ (p96). On a preadmission hospital visit a MO explained the procedure to her ‘...there would be two keyhole incisions, and …[your] abdominal cavity would be inflated with gas...and the tubes would be clamped’ (p96) she was also advised that the procedure was irreversible. Whilst the plaintiff recalled being told of some risks – internal bleeding and an allergic reaction to the gas which might in an emergency require the surgeon to ‘open her up’, she had no recollection of any mention of the possibility that the laparoscopic procedure may not work. She signed a consent form for a ‘tubal ligation’. On the day of the surgery some eight months later Dr Mukerjee introduced himself as the surgeon and holding her previously signed consent form asked if she was having her ‘tubes

24  November 2016 Volume 24, No. 5

cut and tied’ to which she replied no – she had been told she was to have two keyhole incisions and be bloated with gas. Dr Mukerjee said ‘Oh, that’s called a laparoscopic ligation, that’s not what you’ve signed for, you’ve signed for a tubal ligation’. Following some clarification it was agreed that she wanted a laparoscopic ligation and the surgeon put a line through tubal ligation and wrote ‘lap tubal sterilisation’ on the consent form and ‘matter explained. She agreed’, the plaintiff then signed the form.


Unable to perform the laparoscopic procedure the surgeon proceeded with a laparotomy – the subject of this action, which the plaintiff claims she never consented to. In his evidence the surgeon claimed that just prior to the surgery he explained the possible need for a laparotomy and did not recall any concerns about this raised by the plaintiff. In her evidence the theatre nurse said that after checking the consent form she raised concerns with the surgeon that due to the patient’s size the laparoscopic procedure may not be successful as the needle would be too short. Her recollection is that he said that this had been discussed with the patient to which she responded, ‘ doesn’t say that on the consent form’. The surgeon then said ‘ok well, I’ll fix that’ and the nurse recalled hearing a conversation between the patient and the surgeon to that effect. However, there were no contemporaneous notes confirming that this conversation occurred and no further amendments to the consent form were made.

The plaintiff’s version of the event, that she had only made arrangements for day surgery for a laparoscopic procedure and was not advised of the possibility of needing a more invasive procedure were preferred by the court. Whilst it was found that both the surgeon and theatre nurse believed their version of the facts to be true it was held that their evidence was more likely to be false and the product of a subconscious reconstruction of the event. Furthermore it was noted that apart from an emergency situation, it would be ‘highly undesirable’ for a patient who had consented to an operation some months prior to the surgery to be provided with ‘last minute’ additional warnings in the operating room prior to the procedure. This it was held would raise doubts as to whether it was a truly informed consent. As such, it was held that once the surgeon realised that the laparoscopic procedure could not be completed he should have terminated the surgery and explained the difficulty to the patient once she had recovered from the anaesthetic. This would have enabled her to consider her options including losing weight, other forms of contraception or a further surgical procedure. Hence this case serves to remind us that in the absence of an emergency the surgeon cannot go beyond what was consented to and the importance of good documentation. As in this case given the absence of contemporaneous notes to support the staff’s claims, the court concluded that the plaintiff had only consented to a laparoscopic procedure and would not have consented to a laparotomy.

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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). 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). 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, 26  November 2016 Volume 24, No. 5

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).

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).


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.


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). 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).

References Australia. Clinical Excellence Commission NSW, 2014. Falls Risk Assessment and Management Plan. 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. 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. 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.

CLINICAL UPDATE 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 BACKGROUND FACTORS


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).

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

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: 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). • • • •

Psychiatric treatments

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).


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).


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:// 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:// 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

November 2016 Volume 24, No. 5  27


Adverse drug effects

Acute illness

Tängman et al. (2010) found in a BPSD acute unit, that adverse drug effects were judged to precipitate the falls alone, or in combination with other factors, in more than half of all falls. Falls were most frequently precipitated by the side effects of neuroleptics, benzodiazepines, chlormethiazole and antidepressants. The adverse effects of neuroleptics, (extra-pyramidal symptoms with gait and balance problems) were judged to precipitate 47% of falls. In an all age study in a psychiatric inpatient unit, sedation, dizziness and light headedness occurred prior to 33% of falls (Knight and Coakley, 2010). Postural tachycardia was associated in this younger population (Knight and Coakley, 2010). Acute illness or symptoms, alone or in combination with other factors, precipitate almost half of all falls. Infections precipitated one out of five falls. Of these, urinary-tract infection was most common, with a larger proportion of falls among women than men (Eriksson et al. 2009). Delirium was judged to precipitate 14% of all falls, more frequently among men than women. This is consistent with the disorientation and confusion noted by Heslop et al. (2012).

Interaction with others

The most commonly reported situations were interaction with another person (particularly being pushed by another person), together with environmental elements such as slipping or tripping during daily activities. Many falls occurred during the evening and night shift when staffing levels are lower and assistance and supervision may be limited. Periods of low fall incidence coincided with periods when most of the patients and the staff were together in the same place on the ward, for example eating breakfast or lunch (Tängman et al. 2010).


Transferring to or from a chair or bed (Blair and Gruman, 2005) or attempting to get out of bed and walking to the bathroom (Tsai et al. 1998) are common situations linked to falls as are darkness and not wearing any shoes (Eriksson et al. 2009).

Site of fall

Standing, walking or wandering, were the most commonly-reported activities at the time of the fall. This relates to older people in mental health units being more ambulant during hospitalisation than the older adult population within the general healthcare setting (Heslop et al. 2012). An earlier systematic review of acute hospitals revealed that falls are likely to occur at the patient’s bedside or transferring from bed to chair (Evans et al. 1998).

Floor coverings

There is no evidence that carpeted bedroom areas reduce the incidence of falling for all populations (Donald et al. 2000) but there is some evidence to suggest that type of floor covering may reduce the fall injury rate. One study found that 15% of older patients who fell on carpeted floors suffered an injury compared to 91% who fell on vinyl floors (Healey, 1994). Another study found that carpeted wooden floors had the lowest hip fracture rate than other surfaces (Simpson et al. 2004).

Standardised falls risk assessment tools are used widely in healthcare settings. The Falls Risk Assessment and Management Plan (Australia. Clinical Excellence Commission NSW, 2014) details interventions to manage risk factors and is mandated for use in NSW. The tool includes strategies for increasing supervision of patients during busy times of the day, consistently and regularly reorientating patients to the environment, and providing appropriate mobility aids. However, the Falls Risk Assessment and Management Plan does not include the known specific risk factors for older adults who have a mental illness or disorder (Heslop et al. 2012). Many hospitals use a single instrument throughout all hospital units, but these have not been validated in psychiatric settings 28  November 2016 Volume 24, No. 5

(Rutledge, Donaldson and Pravikoff, 2003). Inpatient psychiatric patients have unique risk factors for falling associated with the ambulatory nature of the psychiatric setting, which are compounded by other factors such as medications, anxiety and agitation, poor judgment, sleep deprivation, and under-nutrition. For these reasons, a falls risk assessment targeting inpatient psychiatric patients is justified. The Edmondson Psychiatric Fall Risk Assessment Tool [EPFRAT] (Edmonson, Robinson and Hughes, 2011) is one such instrument. The EPFRAT includes higher weightings for factors such as sleep disturbance, recent increases in medication and under-nutrition, thus making it more predictive of falls in the acutely-ill psychiatric population, compared to other tools in common use. The tool however has not yet been applied to Australian MHUOPs.

Furthermore, Bunn et al. (2014) has reviewed the effectiveness of fall prevention interventions for older people with mental health problems across all settings, however, the evidence relating to fall reduction was inconsistent. Of the papers examined for this update, eight of the 14 studies identified a reduction in the number of fallers. Nine of the 14 studies reported a significant reduction in rate or number of falls. Four studies found a non-significant increase in falls. Multifactorial, multidisciplinary interventions and those involving exercise, medication review and increasing staff awareness appear to reduce the risk of falls, but the evidence is mixed and the study quality varied. Most of the studies were undertaken in nursing and residential homes and

inpatients. International Journal of Geriatric Psychiatry 16(10):965968. doi: 10.1002/ gps.463. Härlein, J., T. Dassen, R.J.G. Halfens, and C. Heinze, 2009. Fall risk factors in older people with dementia or cognitive impairment: a systematic review. Journal of Advanced Nursing. 65(5):922-933. doi: 10.1111/j.13652648.2008.04950.x. Healey, F., 1994. Does flooring type affect risk of injury in older inpatients? Nursing Times 90(27):40-41. Healey, F., S. Scobie, D. Oliver, A. Pryce, R. Thomson, and B. Glampson, 2008. Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports. Quality and Safety in Health Care 17(6):424430. doi: 10.1136/ qshc.2007.024695. Heslop, K., D. Wynaden, K. Bramanis, C. Connolly, T. Gee, R. Griffiths, and O. Al Omari, 2012. Assessing falls risk in older adult mental health patients: A Western Australian review. International Journal of Mental Health Nursing 21(6):567-575. doi: 10.1111/j.14470349.2012.00825.x. Howard, L., G. Kirkwood, and M. Leese, 2007. Risk of hip fracture in patients with a history of schizophrenia. The British Journal of Psychiatry 190(2):129134. doi: 10.1192/bjp. bp.106.023671. Kallin, K., Y. Gustafson, P.-O. Sandman, and S. Karlsson, 2004. Drugs and falls in older people in geriatric care settings. Aging Clinical and Experimental Research 16(4):270-276. doi: 10.1007/bf03324551. Knight, M., and C. Coakley, 2010. Fall Risk in Patients with Acute Psychosis. Journal of Nursing Care Quality 25(3):208215. doi: 10.1097/ NCQ.0b013e3181d37 66f. Kuchynka, J., L. Käser, and A. Wettstein. 2004. [Can falls in nursing homes be avoided?]. Praxis. 93(37):1503-1508. doi: 10.1024/03698394.93.37.1503.


Monane, M., and J. Avorn. 1996. Medications and falls. Causation, correlation, and prevention. Clinics In Geriatric Medicine 12(4):847-858. Rutledge, D., N. Donaldson, and D. Pravikoff. 2003. Update 2003: Fall risk assessment and prevention in hospitalized patients. Online Journal of Clinical Innovations 6(5):1-55. Safety and Quality Council of Australia. 2005. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities. edited by Safety and Quality Council of Australia. Canberra.

not in MHUOPs. Changes to the environment such as increased supervision or sensory stimulation to reduce agitation may be promising for people with dementia, but further evaluation is needed on an ongoing basis in all units providing treatment to older people living with mental illness. In a mental health hospital setting, increased staff awareness, monitoring and supervision of patients is known to produce a reduction in falls (Savage and Matheis-Kraft, 2001). A Cochrane collaboration systematic review of interventions for preventing falls in older people in care facilities and hospitals (Cameron et al. 2012) found evidence that Vitamin D supplementation and exercise in subacute hospital settings appear effective in reducing the rate of falls. There is also evidence that multifactorial interventions reduce falls in hospitals. Multifactorial intervention to prevent falls and fallsrelated injury may typically include: exercise, increased supervision, safe wandering areas, patient education, sensory interventions (vision and hearing), safe footwear, safe flooring, medication review and staff education.


There is a dearth of falls research in mental health settings for the older person, or which focus on patients with mental health problems, despite the high number of falls experienced

by this population group (Bunn et al. 2014). Patients admitted to MHUOPs are automatically at high risk of falls from the moment of their admission; they have unique risk factors for falling created by the ambulatory nature of the psychiatric setting, in conjunction with other factors such as the environment and other patients, medications, the postictal effects of electro convulsive therapy (ECT), anxiety and agitation, depression, psychosis, poor judgement, sleep deprivation, and under-nutrition (Edmonson, Robinson and Hughes, 2011; Bunn et al. 2014). This review highlights that there is little evidence to support the use of single interventions in reducing the rate of falls in MHUOPs, although Vitamin D supplementation and exercise may have some utility.


The following recommendations have arisen from the literature review conducted for this update: • Multi factorial individualised interventions based on the findings of specific and comprehensive assessment tools should be tailored to the unique needs of this population; • increased attention should be given to problems with sleep disturbance and under nutrition as part of falls assessments; • thorough clinical care planning

and reassessment should occur upon change of condition, change of location, or following a fall and • close supervision is vitally important in the prevention of falls in this ambulant population – in particular including at least hourly rounds when patients are resting or asleep. Bryan McMinn is Specialist Mental Health Service for Older People, Hunter New England Local Health District, Calvary Mater Hospital, NSW and Clinical Nurse Consultant, (RN, CMHN, BSc., MNURS.(NP), FACMHN) Amy Booth is Specialist Mental Health Service for Older People, Hunter New England Local Health District, Calvary Mater Hospital, NSW and Clinical Nurse Specialist, (BNurs., Grad. Cert.Dual Dgn. MMHNsg.)

Savage, T., and C. Matheis-Kraft. 2001. Fall occurrence in a geriatric psychiatry setting before and after a fall prevention program. Journal Of Gerontological Nursing 27(10):49-53. Simpson, A.H.R.W., S. Lamb, P.J. Roberts, T.N. Gardner, and J.G. Evans. 2004. Does the type of flooring affect the risk of hip fracture? Age and Ageing 33(3):242-246. doi: 10.1093/ageing/ afh071. Stubbs, B. 2010. Falls in older adult psychiatric inpatients. International Psychogeriatrics 22(01):160-160. Tängman, S., S. Eriksson, Y. Gustafson, and L. Lundin-Olsson, 2010. Precipitating factors for falls among patients with dementia on a psychogeriatric ward. International Psychogeriatrics 22(04):641-649.

Elizabeth Grist is Executive Director, Clinical Services, Nursing and Midwifery, Hunter New England Health District, NSW, (BNurs., Grad Cert HSMgt., Grad Dip Midwifery, MN {Mental Health}).

Thomas, R.V., and R.H. Corney. 1993. Working with community mental health professionals: a survey among general practitioners. British Journal of General Practice 43(375):417421.

Anthony O’Brien is Professor, School of Nursing and Midwifery, University of Newcastle, NSW, Professor, Head of Discipline (Nursing) (RN, PhD, BA, Master Ed.Studies).

Tsai, Y.-F., N. Witte, M. Radunzel, and M.L. Keller. 1998. Falls in a psychiatric unit. Applied Nursing Research 11(3):115121. doi: http://dx.doi. org/10.1016/S08971897(98)80112-2.

November 2016 Volume 24, No. 5  29


CARDIOVASCULAR DISEASE KILLING AUSTRALIAN WOMEN Cardiovascular disease has emerged as the ‘hidden killer’ of Australia women, with its prevalence causing more deaths than the most common forms of cancer and costing the health system $3 billion annually, according to new research. Undertaken by the Mary MacKillop Institute for Health Research at Australian Catholic University, the Hidden Hearts: Cardiovascular Risk and Disease in Australian Women report found cardiovascular disease, which includes acute heart attack and diseases such as diabetes and kidney failure, contributes to at least 31,000 deaths of Australian women each year, far greater than the 12,000 deaths caused by other diseases including breast cancer. Alarmingly, the report found more than 3,000 each year suffer a sudden and fatal cardiac event without ever making it to a hospital. Of those fortunate to receive hospital treatment, more than a third admitted for the first time with heart failure and stroke die within a year, while one in nine women admitted to hospital for the first time with coronary artery disease (CAD), the leading cause of CVD deaths, die within 28 days. Professor Simon Stewart, principal investigator behind the report, said despite the high prevalence of CVD in women 35 and over, low awareness means many women ignore the warning signs before it’s too late. He said increased obesity rates was also making CVD more common in younger women. “The large majority of women are still under the impression that heart disease and stroke are male diseases,” Professor Stewart said. “This is simply not true and without urgent education more Australian women are at risk of falling victim to this killer.”

30  November 2016 Volume 24, No. 5

MIDWIVES PRONE TO POST-TRAUMATIC STRESS DISORDER Almost one in five midwives meet the criteria for developing posttraumatic stress disorder, new research has found. Leading contributors include witnessing a traumatic birth event, such as injury or death, which trigger feelings of horror or guilt. The national study of 707 midwives, conducted by Griffith University, measured post-traumatic stress symptoms in a bid to assess exposure to different types of birth trauma, peritraumatic reactions, and the prevalence of post-traumatic stress. It found midwives carry a higher psychological burden related to witnessing birth trauma, and consequently argued that post-traumatic stress should be acknowledged as an occupational stress within the profession. It also warned that the incidence of traumatic birth events experienced by women and witnessed by midwives needed to be reduced. The study found midwives reported developing strong emotions during or shortly after witnessing a traumatic birth event, with 74% feeling horror, and 65% feeling guilt over what happened to the woman. Griffith University Professor Jenny Gamble said midwives deal with a variety of stress triggers during their day-to-day work. “Midwives, unfortunately often say that they feel powerless to intervene to change the way care is provided by other healthcare providers, or they may feel pressured to make a decision by another professional. “Alternatively, they may feel that the mother’s expressed wishes are overridden by organisational requirements of the hospital during birth. If a midwife feels that she can’t do anything about these situations, then these can produce feelings of stress which can escalate.”

YOUNG ADULTS MOST AT RISK OF ALCOHOL ABUSE Young adults are more likely than any other age group to drink at risky levels but on the other hand are the least likely to seek treatment for alcohol abuse, according to a new report released by the Australian Institute of Health and Welfare (AIHW). The report, Trends in alcohol availability, use and treatment 2003-04, to 2014-15, reveals that 18 to 24 year-old’s are the most likely demographic to report consuming alcohol at dangerous levels. The age group reported risky drinking levels across a variety of measures, with 47% admitting to risky single occasion drinking on a regular basis, 33% yearly, and 18% monthly. Despite the problematic findings, the study found older age groups are more likely to receive treatment related to their alcohol use, with almost half (495) of clients seeking help aged over 40. “Overall, the use of alcohol treatment has increased, at 30 treatment episodes per 10,000 people in 2013-14, an increase of 20% from a decade ago,” AIHW spokesperson Tim Beard said. While treatment for alcohol use has consistently risen over the past decade, conversely, alcohol consumption has dipped. Similarly, there were some positive trends to emerge from the analysis, with an 11% drop in the rate of Australians binge-drinking at risky levels on a single occasion between 2004 and 2013. AIHW believes the results demand strategies, such as increasing the price of alcohol and restricting trading hours, be implemented to reduce overall consumption levels. Mr Beard said patterns of risky drinking and alcohol dependence remain significant issues across Australia, particularly within remote and very remote areas.

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The ANMF (Vic Branch) and the Nurses Memorial Centre are pleased to present a seminar to interested nurses and midwives looking at the contribution made by nurses and midwives in caring for soldiers in times of conict, as well as the vulnerable in humanitarian aid programs.


Monday, 21 November 2016 8.30am – 1.10pm ANMF House 540 Elizabeth Street Melbourne

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FOCUS – Men’s health


CHALLENGING ASSUMPTIONS ABOUT MEN: PROPOSITIONS FOR MENTAL HEALTH NURSING By Brett Scholz “The worst mistake... [is] making assumptions. It often proved fatal.” David Brin There are many assumptions when it comes to how men view and seek treatment for their own mental health. This article highlights some of the assumptions and proposes how healthcare providers can address them. Men are assumed to be ignorant of mental health. Popular discourses suggest men should defer to women for healthcare decisions (Scholz et al. 2014). This assumption is heteronormative and places undue responsibility on women to have insight into men’s minds, discouraging men from helpseeking. Proposition 1: Health professionals should empower men in mental health decisions, challenging the views that this is women’s responsibility. Men wanting masculinised health services is another assumption. Exaggerated masculinity has been used to target men – for instance, referring to depression as a ‘fight’, and using stereotypically-masculine images such as moustaches and power tools (beyondblue, 2016). 32  November 2016 Volume 24, No. 5

Hyper-masculinised health messages are assumed to attract men, but evidence suggests they will only interest some men (Mocarski and Butler, 2016), discouraging most from accessing services. Proposition 2: Health professionals should promote mental health services for a plurality of men, rather than those that emphasise stereotypical masculinity. It is also assumed that men do not want to show ‘weakness’ (particularly to other men). There is an ‘impossible to achieve’ ideal placing pressure on men to be stronger than others (Ogrodniczuk et al. 2016). Nonetheless, evidence suggests men will engage in health behaviours when connected to other in-group men (Ford et al. 2015). Proposition 3: Health professionals should foster connections between

men in clinical spaces, allowing them to engage in mental health promotion behaviours together. The last assumption is that men will not talk about mental health. Even when men say they want to discuss mental health issues, health professionals avoid such talk (Feo and LeCouteur, 2013). In interviews with men with depressive symptoms (Scholz et al. 2016), participants said nobody had asked them about mental health before, but that they wanted to talk. Proposition 4: Health professionals should provide space for men to discuss mental health concerns should they desire. Brett Scholz, PhD, is a Postdoctoral Research Fellow at SYNERGY Nursing and Midwifery Research Centre, University of Canberra and ACT Health

beyondblue. 2016. Guide to mind health au/man-facts/guide-tomind-health Accessed June 2016 Feo, R. and LeCouteur, A. 2013. I just want to talk: Establishing reason for call on a men’s counselling helpline. Australian Feminist Studies. 28(75):65-80. Ford, S., Scholz, B. and Lu, V.N. 2015. Social shedding: Identification and health of Men’s Sheds users. Health Psychology. 34(7):775778. Mocarski, R. and Butler, S. 2016. A critical, rhetorical analysis of Man Therapy: The use of humor to frame mental health as masculine. Journal of Communication Inquiry. 40(2):128-144. Ogrodniczuk, J, Oliffe, J., Kuhl, D. and Grass, P.A. 2016. Men’s mental health: Spaces and places that work for men. Canadian Family Physician. 62(6):463-464. Scholz, B., Crabb, S. and Wittert, G.A. 2014. We’ve got to break down the shame: Portrayals of men’s depression. Qualitative Health Research. 24(12):1648-1657. Scholz, B., Crabb, S. and Wittert, G.A. 2016. Males don’t wanna bring anything up to their doctor: Men’s discourses of depression. Qualitative Health Research. Article in press.

Men’s health – FOCUS

DON’T FORGET DAD: MEN’S PERINATAL MENTAL HEALTH By Lorna Moxham and Christopher Patterson The news that a couple is expecting a baby brings excitement. Pregnancy is often an exhilarating time in an expectant parent’s life. In among the joy and thrill that thinking about the new arrival brings, can lurk the challenges. Pregnancy can be a journey of joy, but can also be one that may adversely impact the mental health of both parents. A large proportion of the research regarding perinatal anxiety and depression has, and for obvious reasons, focused on the mother. Women have regular appointments in the lead up to the birth of the baby with their health practitioner and that’s often when mental health issues are first identified. Men however, don’t access these same support services at all or usually to a much lesser extent which means that it is less likely that a health professional will have the opportunity to notice symptoms of anxiety and depression.

MEN’S HEALTH – THE MAN WITH PROSTATE CANCER By Rebekkah Middleton Cancer of the prostate is the most common form of cancer present in Australian men over 50 (excluding some forms of skin cancer), with over 19,000 men diagnosed annually, accounting for one third of all new diagnoses of cancer in men (AIHW, 2015). With one in nine men developing prostate cancer in their lifetime (Prostate Cancer Foundation of Australia [PCFA], 2015), it is the second most common cause of death from cancer in men. At even higher risk of prostate cancer are men living in rural and regional areas, with the

So what about the mental health of dad? It is increasingly understood that some men can develop anxiety and depression and that this can occur antenatally (during pregnancy) or postnatally (after their baby is born). Research undertaken by Deloitte Access Economics (2012) indicates that up to 1:20 men experience antenatal depression. Paulson and Bazemore (2010) suggest that up to 1:10 new fathers may experience postnatal depression. Some warning signs that men may exhibit, include: • feelings of being overwhelmed and unable to cope; • anger and irritability; • withdrawal from relationships; • lack of energy; • loss of libido; • changes in appetite; • sleep problem; • engaging in risk taking behaviours; and • increased use of drugs and alcohol. Nurses and midwives must, as part of their practice, assess for changes in mood or patterns of behaviour that may indicate the dad is experiencing distress or ill health. Strategies to help men during pregnancy and after the baby is born include simply engaging with them throughout the journey, and letting both parents know that issues of mental health may be mortality rate being 21% higher than in capital cities (AIHW and AACR, 2012). This has been attributed to lack of awareness and education about prostate cancer along with distances from testing and treatment, poor general practitioner awareness and limited access to specialists. The incidence of prostate cancer increases with age, with the majority of diagnoses (85%) made in men over 65 years of age (Cancer Council Australia, 2015), with one in seven men at risk up to age 75 (AIHW, 2014). Comparatively, the number of deaths annually from prostate cancer in men is equivalent to the number of women who die from breast cancer, approximately 3,300 (PCFA, 2015a). The AIHW envisage that prostate cancer will remain the most common cancer in men, presenting the biggest burden by 2020 (AIHW, 2015). Since this is such a prevalent disease, which is curable if diagnosed early, nursing care of the man with prostate cancer centres on recognition of symptoms and early diagnosis. It needs to focus on elimination


experienced by dads as well. Get men talking. The old saying – a problem shared is a problem halved is fundamentally a truism. The feelings that such an upheaval elicits are normal and men need to be prepared for this and open to talking to someone about it. Parenting consists of teamwork, needing open and honest communication, and often the support of others. Encourage men to share their experience with their partner, a friend, family member or a health professional. Christopher Patterson is a Lecturer in Mental Health Nursing and Lorna Moxham is Professor of Mental Health Nursing. Both are at the University of Wollongong and prevention (or treatment) of complications. Since there is no clinical strategy to prevent the development of prostate cancer, early detection continues to be the key intervention related to the disease. Nurses are in key positions to ask relevant questions and observe physiological signs that may indicate the potential diagnosis that can then be followed up with appropriate tests. Recognition of prostate cancer signs is imperative for nurses, along with providing effective nursing care in a person-centred manner so that each individual is supported and included in their own care. Discussion with the man about psychosocial aspects associated with prostate cancer need to be considered and addressed compassionately and transparently. Engaging both the man and his family in the process is essential so that treatment and ongoing therapeutic care is optimised. Rebekkah Middleton is a Lecturer in the School of Nursing at the University of Wollongong and PhD Candidate

References Deloitte Access Economics. 2012. The cost of perinatal depression in Australia Report. Post and Antenatal Depression Association. Paulson, J.F. & Bazemore, S.D. 2010). Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis. JAMA, 303(19), 19611969. (doi:10.1001/ jama.2010.605).

References Australian Institute of Health and Welfare (AIHW). 2015. Australian cancer incidence and mortality (ACIM) book. Prostate Cancer. Sydney. acim-books/ Accessed 19/07/16 Australian Institute of Health and Welfare (AIHW). 2014. Cancer in Australia: an overview, 2014. Sydney. www. Accessed 19/7/16 Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR) 2012. Cancer in Australia: An overview, 2012. Cancer series no. 74 (Cat. no. CAN 70). Canberra: AIHW. Cancer Council Australia. 2015. Early detection of prostate cancer. Sydney. Healthprofessionals/ patientfactsheets/ Early_detection/ ED_prostate_cancer.htm Accessed 19/7/16 Prostate Cancer Foundation of Australia (PCFA). 2015. How is localized prostate cancer diagnosed? Sydney. www.prostate. for-recently-diagnosedmen-and-their-families/ localised-prostatecancer/diagnosis/howis-localised-prostatecancer-diagnosed/ Accessed 19/7/16

November 2016 Volume 24, No. 5  33

FOCUS – Men’s health a review of the literature and the results of the qualitative research. Completed questionnaires were obtained from men and their partners from Australia, the USA, UK, Ireland and South Africa. The survey explored the supportive care needs of men at various stages of the cancer journey, the self-reported needs of partners, and the perceived understanding of both about the impact of cancer treatment on their lives and relationships.



SUPPORTIVE CARE NEEDS OF PROSTATE CANCER SURVIVORS By Kevin O’Shaughnessy Recent advances in detection combined with increasingly effective treatment for prostate cancer has led to significant improvements in life expectancy. More men are living longer with the significant physical and emotional after-effects of prostate cancer treatment. Understanding and providing appropriate supportive care for cancer survivors and their partners is a key component of modern healthcare provision. Yet the physical, psychological, emotional and spiritual burden of prostate cancer has received scant attention. Existing research in the field of supportive care for prostate cancer survivors has focused primarily on the physical consequences of prostate cancer treatment. The lived experience of men, their needs at different stages of disease progression for different treatment choices, and the influence and role of partners and family in supportive care has received comparatively little attention. Inspired by the death of his best mate from cancer a South Australian nurse has completed a doctoral study 34  November 2016 Volume 24, No. 5

The results highlight critical differences in the supportive care needs of men and their partners at different stages of the cancer journey and for different treatment types. Partners can provide nurses with insights into aspects of supportive care which men are often unable to recognise, acknowledge or articulate. Participants without partners reported more distress than men who had a partner. This distress was observed to endure.

exploring the experience and needs of men with prostate cancer and their partners as their journey post diagnosis and into treatment and long-term management continues. Peter ‘Kevin’ O’Shaughnessy at the University of South Australia’s School of Nursing and Midwifery employed a two part mixed method approach. Four focus groups were conducted with prostate cancer survivors and their partners from metropolitan and outer metropolitan Adelaide and rural South Australia - a total of 26 participants. Three additional couple interviews were undertaken with male prostate cancer survivors and the partners/spouses of these men.

The study highlights the importance of providing nursing care geared to changes in male identity as a result of treatment outcomes. Love, acceptance, intimacy, gratitude, spirituality and hope were all found to be important concepts in enabling prostate cancer survivor’s to cope. Taken together, the findings suggest that nurses involved in the supportive care of men with prostate cancer and their partners should consider differences according to stages of the cancer journey, specifically whether men are managing a chronic illness or facing a terminal outcome. Wives and partners of men with prostate cancer are a powerful resource for nurses and healthcare providers and are integral in the provision of supportive care for men challenged by prostate cancer.

An international web-based survey investigating the experiences and needs of prostate cancer survivors and their partners was crafted from

Kevin O’Shaughnessy is a Lecturer in the School of Nursing and Midwifery at the University of South Australia

Articles published from this study O’Shaughnessy, P., Laws, T. & Esterman, A. 2015. Love, faith and hope: A secondary analysis of prostate cancer survivors and their partners. Contemporary Nurse. O’Shaughnessy, P. K., Ireland, C., Pelentsov, L., Thomas, L. A. & Esterman, A. J. 2013a. Impaired sexual function and prostate cancer: A mixed method investigation into the experiences of men and their partners. Journal of Clinical Nursing, 22, 3492-3502. O’Shaughnessy, P. K., Laws, T. A. & Esterman, A. J. 2013b. The Prostate cancer journey: Results of an online survey of men and their partners. Cancer Nurs. O’Shaughnessy, P. K., Laws, T. A., Pinnock, C., Moul, J. W. & Esterman, A. 2013c. Differences in self-reported outcomes of open prostatectomy patients and robotic prostatectomy patients in an international webbased survey. European Journal of Oncology Nursing, 17, 775-780.

Men’s health – FOCUS

PERINATAL MENTAL HEALTH AND MINDFULNESS FOR MEN WITH PREGNANT PARTNERS, PILOT PROJECT By Donovan Jones, Michael Hazelton and Lyn Ebert Currently an online pilot project is underway through the University of Newcastle examining the benefits of an online mindfulness program for men with pregnant partners at This current research, using mindfulness interventions for men with pregnant partners, provides the possibility to change emotions and behaviours that unchallenged might otherwise have the potential to manifest into stress, anger and violence. An improved ability to cope with stressors is postulated to improve wellbeing and decrease the chance of stress and anger becoming uncontrollable. Mindfulness is a process of awareness and acceptance of the present moment, including thoughts, feelings, sensations, environment and physical being. Mindfulness involves using a state of relaxation that emphasises not getting caught up in emotional reactions through techniques allowing the regulation of emotional reactivity and fast recovery from negative/unpleasant emotional experiences (Klainin-Yobas et al. 2012). Mindfulness as a therapeutic practice has been developed from the philosophical and theoretical concepts of Buddhism. Developed from 2,500-year old cultures of South and Southeast Asia, Buddhism

as MBSR have become recognised for their potential to reduce stress and increase the person’s ability to develop skills that improve psychological functioning (Monshat et al. 2013). MBSR has been shown to achieve improved outcomes in the treatment of depression and anxiety for pregnant women (Dunn et al. 2012; Vieten and Astin, 2008). Furthermore, MBSR has begun to attract attention from maternity researchers, who wish to explore interventions that can reduce the high prevalence of stress and anxiety often experienced by women during the perinatal period (Allison et al. 2010; Rallis et al. 2014; Willinger et al. 2005). Recent studies have reported MBSR interventions as effective in reducing fear prior to childbirth and anxiety levels in the postnatal period. While the Department of Health has mandated routine screening for depression and referral to mental health services for women during the perinatal period (Rowe et al. 2013), there are no similar services for the partners. Furthermore, childbirth education in Australia provides mental health

References Allison, J., Stafford, J., & Anumba, D. 2010. The effect of stress and anxiety associated with maternal prenatal diagnosis on feto-maternal attachment. Women & Health, 11 (1), 33-33. doi:10.1186/1472-687411-33 Dunn, C., Hanieh, E., Roberts, R., & Powrie, R. 2012. Mindful pregnancy and childbirth: effects of a mindfulnessbased intervention on womens psychological distress and wellbeing in the perinatal period. Archives of Womens Mental Health, 15(2), 139-143. doi:10.1007/ s00737-012-0264-4 Epstein, M. 1998. Going to pieces without falling apart (1st ed.). New York: Broadway Books. Gunaratana, B., & Gunaratana, H. 2011. Mindfulness in plain English: Wisdom Publications Inc. Hughes, A., Williams, M., Bardacke, N., Duncan, L., Dimidjian, S., & Goodman, S. 2009. Mindfulness approaches to childbirth and parenting. British Journal of Midwifery, 17(10), 630-635.

offers an effective system for the exploration of the mind and consciousness of one’s self (Gunaratana and Gunaratana, 2011). Buddhism has been described as a theology, offering a direct connection to the spiritual or divine realm through meditative practices (Epstein, 1998). As mindfulness became more popular as a niche practice for mental health and medicine an escalated growth in the cultural uptake of mindfulness practices also occurred. Hybridised forms of mindfulness interventions were developed and research literature on mindfulness based interventions increased (McCown, 2013). Mindfulness Based Stress Reduction (MBSR) is increasingly gaining acceptance as a treatment option for a wide range of psychological health issues. Mindfulness based interventions such

interventions including stress reduction and emotional management skills for pregnant women but fails to include expectant fathers. This is despite research reporting on the positive outcomes of mindfulness interventions for pregnant women (Hughes et al. 2009). In contrast, perinatal education in Australia does not include mental health interventions such as stress reduction or emotional management skills targeted specifically to expectant fathers (Jones et al. 2014). Donovan Jones is Lecturer, Deputy Program Convenor Bachelor of Midwifery; Professor Michael Hazelton is Professor of Mental Health and Dr Lyn Ebert is Senior Lecturer, Program Convenor Midwifery Studies. All are in the School of Nursing and Midwifery at The University of Newcastle

Jones, D., Rossiter, R., & Ebert, L. 2014. Research project supports the emotional wellbeing of young fathers during the perinatal journey in parenthood. Australian Nursing & Midwifery Journal, 22(5), 37. Klainin-Yobas, P., Cho, M. A. A., & Creedy, D. 2012. Efficacy of mindfulness-based interventions on depressive symptoms among people with mental disorders: A meta-analysis. International Journal of Nursing Studies, 49(1), 109-121. doi:10.1016/j. ijnurstu.2011.08.014 McCown, D. 2013. The ethical space of mindfulness in clinical practice: Jessica Kingsley Publishers.

Monshat, K., Khong, B., Hassed, C., VellaBrodrick, D., Norrish, J., Burns, J., & Herrman, H. 2013. A conscious control over life and my emotions; mindfulness practice and healthy young people. A qualitative study. Journal of Adolescent Health, 52(5), 572577. doi:10.1016/j. jadohealth.2012.09.008 Rallis, S., Skouteris, H., McCabe, M., & Milgrom, J. 2014. The transition to motherhood: towards a broader understanding of perinatal distress. Women and Birth : Journal of the Australian College of Midwives, 27(1), 68-71. doi:10.1016/j. wombi.2013.12.004 Rowe, H. J., Holton, S., & Fisher, J. R. W. 2013. Postpartum emotional support: a qualitative study of women and mens anticipated needs and preferred sources. Australian Journal of Primary Health, 19(1), 46-52. doi:10.1071/ PY11117 Vieten, C., & Astin, J. 2008. Effects of a mindfulness-based intervention during pregnancy on prenatal stress and mood: results of a pilot study. Archives of Womens Mental Health, 11(1), 67-74. doi:10.1007/s00737008-0214-3 Willinger, U., DiendorferRadner, G., Willnauer, R., Jörgl, G., & Hager, V. 2005. Parenting stress and parental bonding. Behavioral Medicine Washington, DC, 31(2), 63-69. doi:10.3200/ BMED.31.2.63-72

November 2016 Volume 24, No. 5  35

FOCUS – Men’s health


A great opportunity exists at Precision brain spine and pain centre for an experienced RN Div1/EN with sound neurosurgery, neurology, and pain management experience to join our cutting edge multidisciplinary team. Our team offers friendly, supportive, collaborative working environment. The successful candidate will be offered a terrific salary and working hours, no weekend or evening work, complimentary group personal training at our onsite gym , ADO and free onsite parking. For a full position description and to submit applications (CV and cover letter) please email

For the majority of men, becoming a father is a time of joy that enhances their personal growth and wellbeing. However, similar to the experience of some women, this time can be overwhelming when adjusting to the necessary demands of parenthood and can undermine men’s mental health. Depression in fathers during the first year of a child’s life can have a detrimental impact on the child’s behaviour, and social and emotional development (Fletcher et al. 2011) and these risks are independent of the mothers’ mental health. Paternal depression also affects fathers’ parenting and couple relationships (Giallo et al. 2014; Wilson and Durbin, 2010). In order to develop mental health strategies and support for fathers that complement the mental health support that mothers already receive, the Paternal Perinatal Depression Initiative (PPDI) was established across Australia as a multidisciplinary approach that brings together clinical, research and policy development activities.

IN ORDER TO DEVELOP MENTAL HEALTH STRATEGIES AND SUPPORT FOR FATHERS THAT COMPLEMENT THE MENTAL HEALTH SUPPORT THAT MOTHERS ALREADY RECEIVE, THE PATERNAL PERINATAL DEPRESSION INITIATIVE (PPDI) WAS ESTABLISHED ACROSS AUSTRALIA AS A MULTIDISCIPLINARY APPROACH THAT BRINGS TOGETHER CLINICAL, RESEARCH AND POLICY DEVELOPMENT ACTIVITIES. As part of the PPDI research agenda, the Screening Dads for Depression in Early Parenting Centres (EPC) research study was conducted in 2015. EPCs provide short term intensive residential care to families facing complex parenting issues, such as child behaviour, parent-child relationships and maternal perinatal mental health. EPCs provide support to an estimated 200,000 Australian families a year (Australian Association of Parenting and Child Health [AAPCH], 2016). But although mothers are assessed for mood disorders as part of the admission process to an EPC, and that the centres support the family as a unit and encourage all members to be involved, it is unclear if there is a similar assessment process for fathers. This is important to know because the presence of mood disorders in fathers may be more common than previously understood and is estimated to be up to 25.5% (Paulson, 2010). A telephone survey of staff at EPCs was conducted to identify, describe and quantify the instruments used and the procedures for screening fathers for depression as well as referral processes and pathways for fathers attending residential and day stay services. Findings from this study will help to inform future nursing care of fathers attending EPCs with their partner and the delivery of their mental health assessment and referral. Richard Fletcher, PhD is Associate Professor, Family Action Centre; Eileen Dowse, PhD is Midwifery Lecturer in the School of Nursing and Midwifery and Jennifer St George, PhD is Senior Lecturer in the School of Health Sciences, Faculty of Health and Medicine. All are at The University of Newcastle

36  November 2016 Volume 24, No. 5

References Australian Association of Parenting and Child Health (AAPCH). 2016. Services. www.aapch. Accessed August 2016 Fletcher, R.J., Feeman, E. Garfield, C. & Vimpani, G. 2011. The effects of early paternal depression on children’s development. Med J Aust.1 95(11): 685-689. Giallo, R., A. Cooklin, C. Wade, F. D’Esposito and J. M. Nicholson. 2014. ‘Fathers’ postnatal mental health and child well-being at age five: The mediating role of parenting behavior. Journal of Family Issues. 35(11): 1543-1562. Paulson J.F. 2010. Focusing on depression in expectant and new fathers, Psychiatric Times, 27(2): 48-52. Wilson, S. & Durbin C. E. 2010. Effects of paternal depression on fathers’ parenting behaviors: A metaanalytic review. Clinical Psychology Review. 30(2): 167-180.


PSYCHS ON BIKES – NURSES REVVING UP FOR MEN’S MENTAL HEALTH By Susan Sumskis How do you reach blokes in the bush who don’t use health services? Show them your motorcycle. Psychs on Bikes is a group of passionate nurses and mental health professionals who use their annual leave and pay their own way to ride their motorcycles around rural and remote Australia to check on men’s mental health. The Psychs use a pit stop style health check and find that the simple act of touch, such as through applying a blood pressure cuff can facilitate a meaningful wellbeing check in a very short time. Over the years, we have learned that we really do connect with blokes who aren’t connected with health services. Perhaps the fact that the nurse is wearing motorcycle leathers might help break down barriers. Psychs seek

PERHAPS THE FACT THAT THE NURSE IS WEARING MOTORCYCLE LEATHERS MIGHT HELP BREAK DOWN BARRIERS. to embed a simple message on suicide: • look out for the warning signs, • let someone know, and • live another day. The Psychs have conducted men’s mental health checks, delivered community education and engaged with local health services and professionals on rides from Perth to Sydney, Melbourne to Darwin, Sydney to Maryborough and around Tasmania. We find our work is even more effective when we are able to partner with services and community groups along the way. Our recent trip around Tasmania was in partnership with Rural Alive and Well (RAW) an organisation dedicated to addressing men’s suicide in rural areas. On a professional note,

spending many days on the road with fellow practitioners is a rolling conference. Meals together are a rich source of contemporary practice and professional discussion, debate and insight. How often do five psychiatrists, five psychologists and around 15 mental health and drug and alcohol nurses who come from all over Australia and practice in broad range of contexts join up in one place at the same time? Psychs ride out for weekend events and do one or two big rides a year and are able to keep the rubber on the road largely thanks to the support of Ramsay Healthcare. Psychs’ next big ride is through rural and remote Queensland in Autumn 2017. If Psychs on Bikes can assist your community to address rural and remote men’s mental health, please contact us at psychsonbikes@ If you work in mental health, ride a motorcycle and want to go rural and remote to help us check up on men’s mental health, come join our charity. Dr Susan Sumskis is Lecturer and Postgraduate Coordinator in the School of Nursing, Faculty of Science, Medicine and Health at the University of Wollongong November 2016 Volume 24, No. 5  37

FOCUS – Men’s health

GUIDING HEALTH CONSULTATIONS WITH MEN By Del Lovett In Australia, health areas of concern for men include: average shorter life expectancy; higher levels of avoidable mortality; and higher mortality from almost all common causes of death including heart disease, cancer, respiratory disease and suicide (AIWH, 2014; DHHS, 2015). Male socialisation may create the tendency for men to be less aware of their health and wellbeing issues and to present later or to seek shorter consultations than women (Malcher, 2006). Good communication and engagement skills are vital aspects of successful health consultations and are the nuts and bolts or building blocks in which those working with men need to be fluent. Communication preferences may exist among subgroups of men one size does not fit all (eg. among Aboriginal men, eye-to-eye contact can be threatening, and some may prefer sideby-side communication with opportunities for silence and reflection (Malcher, 2009). It is important not to treat men as a homogenous group and understand and respect their differences (DoHA, 2010). Communication has traditionally been seen as verbal or nonverbal. However, these domains more recently include: telehealth interactions; digital literacy including email and texting; social media and; virtual environments for instance, ePortfolios, Facebook, Twitter, and Instagram (Iksan et al. 2012). Research suggests the following are qualities many men value when communicating with healthcare professionals: Table 1: Qualities men value in communication (adapted from Parsons, 2009; Smith et al. 2008; Lovett, 2014) • A concise, matter of fact

communication style

• Stating facts clearly during

Ambivalence is one of the biggest challenges that healthcare professionals face when helping people change longstanding behaviours that pose significant health risks. Ambivalence is ‘a conflicted state where opposing attitudes or feelings coexist in an individual where they are stuck between simultaneously wanting to change and not wanting to change’ (Hall et al. 2012) (eg. substance abuse and obesity). While there is evidence to demonstrate when the approach is right, men are willing to engage and be proactive about their health, contact with nurses may often be opportunistic or ad hoc (Lovett et al. 2014). Richardson and colleagues (2013) recommend the use of a framework to guide

1. Establish rapport with the client and set the agenda.

2. Ask about the positive (good things) aspects of the target behaviour. This is often an engaging surprise. However, it will only work if you are genuinely interested. 3. Ask about the negative (less good things) aspects of the target behaviour

same level as the patient

• The ability to listen and understand

the patient’s perspective and respond with empathy

• Prompt resolution of health issues

(directly or by referral).

• Father-inclusive practice 38  November 2016 Volume 24, No. 5

• What are some of the good things about…? • What do you enjoy about…? • How would life be harder or worse for you if you didn’t…? • Exhaust this side of ambivalence, and then summarise all the positives. • Can you tell me the not so good things

about…? • What are some of the things you would not miss if...? • How would life be better if you…? • Exhaust this side of ambivalence, and then summarise all the negatives. • Use the change ruler to assess importance

5. Summarise the entire discussion and ask about next steps.

• Summarise the discussion, and re-state their

• Communication based on trust and

respect with the sharing of power and responsibility


4. Assess the client’s readiness to change and evoke ‘change talk’.

• Use of appropriate humour to reduce • The ability to communicate at the

• Find the target behaviour (eg. smoking or

behaviour about which there is ambivalence.


tension and facilitate communication

Del Lovett is a Registered Nurse with a background in men’s health and community nursing. Del has 15 years’ experience working as a practice nurse and diabetes educator in general practice and is also a nurse immuniser for the City of Melbourne and author for the Australian Primary Healthcare Nurse Association and Australian College of Nursing.

• Clarify the agenda around the target

• Less use of medical jargon or medical

and knowledgeable, including conveying latest evidence to the patient

Take home message: It is important for nurses to review their clinical practice through a male gendered lens, and what they can do to make their consultations more gender competent for men.

Table 2: Framework for guiding health consultation with men (Richardson et al. 2013, pp62–63)


• Health professionals being confident

successful consultations with men.

6. If action is decided upon, then set goals.

and confidence. • Use other strategies to evoke ‘change talk’. • Probe and ask for elaboration throughout this discussion. dilemma or ambivalence. • Ask “after this discussion, are you more clear about what you would like to do?” • Ask “where would you like to go from here?” • What will be your next step? • What will you do in the next one or two days? • Have you ever done any of these things before to achieve this? • Who will be helping and supporting you? • If you like, I could give you an idea of several options that you could choose from.

Men’s health – FOCUS

INCLUDING MEN IN THE GLOBAL HEALTH AGENDA: AN INVESTMENT IN FAMILIES By Carley Jans Male health outcomes continue to be significantly poorer than females in many parts of the world. By 2010, women were generally outliving men by six years, with a life expectancy at birth approximately 5.3 years less (Baker et al. 2014).

References Australian Institute of Health and Welfare (AIHW). 2014. Australia’s health 2014; Australia’s health series no 14, AUS 178, AIHW, Canberra, Australia, viewed 2 August 2016, www.aihw. Commonwealth of Australia 2010. National male health policy: building on the strengths of Australian males’, DoHA, Online ISBN: 978-1-74241205-4, Canberra, Australia, viewed 2 August 2016, www. main/publishing.nsf/ Content/7935AC781599 69D4CA257BF0001C6 B07/$File/ MainDocument.pdf Department of Health and Human Services (DHHS). 2015. Engaging men in healthcare: information resource paper, Victorian government, Melbourne, Australia, viewed 2 August 2016, (European Commission 2011) ABF1ED71403DE136CA 257E66001393BF/$FILE /Engaging%20men%20 in%20healthcare%20 %20information%20 resource%20paper%20 JUNE%202015%20 Final-v02.pdf Hall, K., Gibbie, T. & Lubman, D. 2012. ‘Motivational interviewing techniques; facilitating behaviour change in the general practice setting’, Australian Family Physician, vol. 41, pp. 660-7 viewed 2 August 2016, www. september/motivationalinterviewin:- techniques Iksan, Z.H., Zakaria, E., Meerah, T.S.M., Osman, K., Lian, D.K.C., Mahmud, S.N.D. 2012. Communication skills among university students. ProcediaSocial and Behavioral Sciences. vol,59, pp. 71-6, viewed 2 August 2016, <researchgate>

Lovett, D.F., Rasmussen, B., Livingston, T., Holden, C. 2014, ‘Primary healthcare nurse perception and men’s expectation of the role of the primary healthcare nurse in providing men’s health service in the primary care setting in Victoria’. Unpublished thesis, Deakin University, Melbourne, Australia. Malcher, G. 2006. ‘What is it with men’s health? Men, their health and the system: a personal perspective’, Medical Journal of Australia, vol. 185 (8) pp. 459–60 viewed 2 August 2016, journal/2006/185/8/ what-it-mens-healthmen-their-healthand-system-personalperspective Parsons, J. 2009. ‘Not mission impossible’ Australian Family Physician, vol. 38(3), p. 85, viewed 2 August 2016, www. afp/200903/200903pars ons.pdf Richardson N., Brennan L., Lambe B., Carroll, P. 2013. ‘Engage’ national men’s health training, Men’s Health Forum, Ireland. Smith, J.A., BraunackMayer, A.J., Wittert, G., Warin, M.J. 2008. ‘Qualities men value when communicating with general practitioners: implications for primary care settings, Medical Journal of Australia, vol. 189(11/12) pp. 618-21, viewed 2 August 2016, journal/2008/189/11/ qualities-men-valuewhen-communicatinggeneral-practitionersimplications

A reason for this disparity may lie in male attitudes towards health. Men are more likely to partake in risky behaviour than women, such as dangerous driving and substance abuse (Australian Bureau of Statistics, [ABS] 2010). Men are also more likely to have a higher incidence of many conditions and are more likely to die from many conditions, such as lung cancer, skin cancer, heart disease, liver disease, respiratory disease and stroke (ABS, 2010; Australian Commonwealth government Department of Health, 2015). Additionally, and of concern, despite being more likely to develop one of the above health conditions, males are less likely to access and use health and community services, often seeking help in the later stages of illness. Traditional masculine values, including stoicism, suppression of emotion and self-reliance also negatively impact on the health behaviours of men (Department of Health and Human Services 2015). In most western countries men are conditioned to be emotionally strong, physically robust, independent and are more prone to risk taking. This results in a higher likelihood of engaging in unhealthy practices and a decreased likelihood of admitting to pain or seeking medical attention, resulting in delayed treatment and in many instances serious health consequences (Ricciardelli et al. 2012). According to the Australian Institute of Health and Welfare, [AIHW] (2016) two in three men are overweight or obese. Excess body weight and obesity are factors for several diseases, including cardiovascular disease, high blood pressure, Type 2 diabetes, sleep apnoea and osteoarthritis. Regular exercise and physical activity assists in maintaining a healthy body weight, improving mental health and reducing the risk of many chronic conditions, however, only two in five males participate in adequate exercise (AIHW, 2016). Excessive use of alcohol is also a

significant risk factor for many health issues and is often a contributor of injuries and accidents, such as motor vehicle accidents and homicide. Australia is well known for its drinking culture and alarmingly more than half of all males over the age of 14 consume alcohol on a daily or weekly basis. Not only are Australian men consuming alcohol at worrying rates, they are contributing to ill health through smoking. Smoking is the single most preventative cause of ill health and disease. The 2007 National Drug Strategy Household Survey estimated that 1.1 million males over the age of 14 smoked tobacco daily (AIHW, 2016). Of great concern is the fact that these statistics are inclusive of children – from 14 years. Given that the World Health Organization’s definition of health goes beyond the absence of disease, finding ways to encourage men and boys to make use of Australia’s world class healthcare system in ways that optimise their health and help prevent early complications of preventable conditions is important. With males contributing significantly in cultural, economic and political arenas as well as within family and the community, it is no wonder that male health is eliciting increasing interest in recent years. Indeed, in March 2016 a Young Men’s Health Stakeholder Forum was conducted in Canberra that explored contemporary issues affecting the health and wellbeing of young men. A healthy male population is important for the individuals concerned, family, friends and the Australian society as a whole. Therefore, a strong focus needs to be on promoting male health and providing information on key health concerns. Nurses, as the largest clinical workforce are in a prime position to do this.

Carley Jans is a Lecturer in the School of Nursing, Faculty of Science, Medicine and Health at the University of Wollongong


References Australian Bureau of Statistics. 2010. Men’s health, available from AUSSTATS/abs@.nsf/ Lookup/4102.0Main+F eatures30Jun+2010 Australian Commonwealth government Department of Health. 2015. Ten to men: the Australian longitudinal study on male health, available from: www.tentomen. Australian Institute of Health and Welfare. 2016. Men’s health: Lifestyle factors, viewed 4 August 2016; from Baker, P. et al. 2014. The men’s health gap: men must be included in the global agenda, Bulletin of the World Health Organization, available from www. volumes/92/8/13-1327 95/en/ Department of Health & Human Services. 2015. Engaging men in healthcare, available from www2. about/publications/ policiesandguidelines/ Engaging%20men%20 in%20healthcare%20 -%20practice%20 and%20policy%20guide Ricciardelli, L., Mellor, D. & McCabe, M. 2012. The quiet crisis: Challenges for men’s health in Australia, InPsych, 34(4), 10-13.

November 2016 Volume 24, No. 5  39


HEALTH IN CAPTIVITY, A NURSELED WELLBEING CLINIC FOR MALE PRISONERS By Amanda Smith It is traditionally hard to engage men in preventive healthcare, and it is no easier in a custodial environment. The health of men in prisons is so much poorer than in the general community, that prisoners are often considered geriatric by age 50. The Health of Australia’s Prisoners Report 2015 (AIHW, 2015) recognises that prisoners have higher levels of mental health problems, risky alcohol consumption, tobacco smoking, illicit drug use, chronic disease and more communicable diseases than the general population. At men’s maximum security Barwon Prison in Victoria, nurses have opened a Men’s Health and Wellbeing Clinic, supported by the Australian Primary Healthcare Nurses Association (APNA) under their Enhanced Nurse Clinic Project. This project is funded by the Australian Commonwealth Government Department of Health to develop original, nurse-led models of clinical primary healthcare. The clinic positively engages male offenders and gives them knowledge, skills, tools and confidence to better care for their own health. We do comprehensive health assessments, covering a wide range of areas. We 40  November 2016 Volume 24, No. 5

address risk factors and lifestyle modification amongst the 35-49 year age group, and detect chronic disease early, so it can be better managed. How is this different from the everyday healthcare available in prisons, you may wonder? The focus is what makes it different. Our everyday health service is reactive and opportunistic, but the clinic is proactive, focusing on health prevention and shared decision making between nurse and patient. It is good for nurses because it lets them interact positively with the prisoners, and expand their scope of practice. And it’s good for patients because we can identify risk factors before they develop into chronic disease, implementing a plan of care that encourages patients to be active participants. It’s innovative in its collaborative nature, moving away from telling patients what to do, towards helping patients set and meet their own health goals. The prison setting provides a unique

opportunity to address the physical and mental health needs of this disadvantaged group. Yet despite the captive nature of the prisoner population, engaging male offenders in preventive healthcare activities has traditionally been problematic. This perhaps reflects the state of men’s health within the general community, whereby men have demonstrated a poor knowledge and awareness of symptoms, and a reluctance to present for preventive health checks. Also, men typically present late for diagnosis and management of acute problems (Department of Health and Ageing, 2010). Prisoners have significant and complex health needs, often longterm or chronic in nature. Limited medical practitioner time is one of the most frequently reported barriers to the provision of preventive care by medical staff in the prison primary healthcare setting. Our nurse-led clinic will run one day a fortnight for the next 18 months. For information about APNA’s Enhanced Nurse Clinic Project, contact Jane Henty at Amanda Smith is a registered nurse with 18 years experience working in complex health environments in a variety of senior management positions. Amanda is currently the Health Service Manager for Correct Care Australasia at HM Barwon Prison

References Australian Institute of Health and Welfare. 2015. The health of Australia’s prisoners 2015. Cat no PHE 207. Canberra: AIHW Australian government Department of Health and Ageing national male health policy supporting document: Healthy Routines. 2010. Canberra: AGDHA

Men’s health – FOCUS



CHALLENGES IN THE PREVENTION OF HIV AMONG THAI HOMOSEXUAL MALES IN THE ERA OF DIVERSITY AND FREEDOM OF CULTURE By Praditporn Pongtriang and Wilawan Makyod Undeniably, Thai society has changed dramatically, the way of life, values, beliefs and practices have shifted from what they were previously. Exposure to western culture, values and lifestyle are responsible for changes in the way of life of Thai people and their society. In addition, the growth of the economy, as a result of the influx of tourists, has also had its impact. This is an important point as we face the challenge of working with health issues that move in the opposite direction to striving for business profit and the desire to meet the needs of tourists from all over the world. Sexual diversity in Thai society is open and widely accepted. The different styles of homosexual males can be seen on the streets, in the media and also in public places. However, we still cannot understand the depth of human behaviour based

References Butterworth, B. 2014. Sex survey 2014. Gay Times (430), 58-65. Pongtriang, P., O’Brien, A. P., & Maguire, J. 2015. Sexual diversity and social stigma on HIV prevention for Thai gay men. Australian Nursing & Midwifery Journal (23:5), 34


on surface level observations of behaviour. (Pongtriang et al. 2015). The behaviours of homosexual males are diverse and come with a variety of specific sexual risks. These facts may impact on the effectiveness of HIV prevention strategies, which is reflected in the high rate of homosexual males exposed to HIV infection, especially in the big cities that support and accommodate the tourist industry.

Capitalist society and the change in health related behaviours

With the number of homosexual males rising, it is evident that entertainment and sex business operators that meet the needs of visitors with a preference for the same sex have increased noticeably. Different marketing tactics have been used to attract and to increase the number of tourists to these businesses. From my experience exploring the entertainment venues of Bangkok, it appears that these venues often use different tactics to attract visitors. These include sex shows and sexually provocative performances. Pole dancing bars are another type of entertainment venue that attracts a high number of visitors. Racy and revealing shows with goodlooking dancers are used to provoke sexual desire. Inevitably, the sex trade often employs this type of marketing tactic. In addition, strategies that provide discounts, and premiums, around alcohol promotions increase the number of customers who want to seek pleasure.

The borderless world of the 21st century

The advance of communication technology is another aspect that is challenging to the work of HIV prevention in an era of the borderless world. The survey by Butterworth highlights that homosexual males often use dating applications on smart phones that can pinpoint the location and distance of their chat partners (Butterworth, 2014). For this reason, it’s no longer difficult for homosexual

males to find partners. This behaviour leads to a high rate of change in sexual partners that also results in an increased risk of contracting HIV, especially if protection during sexual activity is not observed. The aforementioned factors contribute to the intensifying spread of HIV and a higher prevalence of infection in many areas. Meanwhile, government agencies including independent organisations have progressed toward finding ways to prevent HIV. The aim is to reduce the incidence of HIV infection among homosexual males. Funding from various sources is used for a variety of projects aiming to promote safe sex and prevent widespread infection of HIV. However, HIV infection is still difficult to control and it seems that the hard work being undertaken by healthcare providers around the promotion and prevention of HIV must continue, addressing the ever-changing nature of Thai society and culture. The cooperation from entertainment establishments plays an important part in supporting the health service in addressing these issues. An example is a campaign to promote and to encourage nightlife visitors to realise the importance of protected sex and the correct use of condoms. This is an avenue that could enable entertainment establishments to take a lead role in pushing for the campaign. This could possibly be integral to the prevention of the spread of HIV. However, this article is not intended to stigmatise any specific organisations that challenge HIV prevention. The writer only wants to present reliable, accurate information that may change the direction of HIV prevention and one that responds more appropriately to the context of male homosexuals. Dr Praditporn Pongtriang is Associate Dean and Wilawan Makyod is a Lecturer in the Faculty of Nursing at Suratthani Rajabhat University, Thailand November 2016 Volume 24, No. 5  41

FOCUS – Men’s health

MEN URGED TO CHECK THEIR BREASTS Every week around three men will be diagnosed with breast cancer. While breast cancer in males is uncommon, Cancer Australia is encouraging men to see a doctor if they notice any new or unusual breast changes. Cancer Australia CEO Professor Helen Zorbas said that early detection, appropriate referral and treatment are key to surviving the disease. “Breast cancer is considered a woman’s cancer, but both men and women have breast tissue. It’s important that men don’t let embarrassment or uncertainty prevent them from seeing their doctor if they

SUICIDE STATISTICS FOR MEN PEAKS TO AN ALARMING NEW HEIGHT MOVEMBER The annual Movember campaign kicks of this month, where men will grow moustaches to bring awareness and raise funds for men’s health. Funds will also be raised throughout the month by individuals being active or those hosting an event. The Movember Foundation, which is the only global charity solely focused on men’s health, is committed to reducing the number of men dying prematurely by 25%; halving the number of deaths from prostate and testicular cancer and reducing the number of men taking their own lives by 25%, by 2030. The money raised during the month and throughout the year funds programs while positively changing the way in which men’s health issues are researched and addressed. Since the Foundation started in Melbourne 2003, $770 million has been raised funding more than 1,200 projects focusing on prostate and testicular cancers and suicide prevention. To get involved or to find out more go to:

Men are three times more likely to die by suicide than women, while suicide amongst Aboriginal and Torres Strait Islander men, between the ages of 25 and 29, are four times higher than the rate for nonIndigenous males, a recent report reveals. According to the latest ABS statistics suicide is still the main cause of death amongst Australians aged between 15-44. The statistics reported 3,027 people died by suicide in 2015, up from 2,864 in 2014, a rate of eight people a day. beyondblue is urging Senators from all states, territories and political parties to come together to tackle the national suicide rate. “Nearly three times as many people died by suicide in 2015 as were killed on the roads. People demonstrated in the streets to bring an end to the decade-long Vietnam War which 500 Australians lost their lives. We lost six times that many to suicide in 2015 alone,” said beyondblue Chairman Jeff Kennett. “We need a breakthrough! We need a sense of urgency! We need a new language when talking about suicide. We need a champion- or a team of champions- to take up the advocacy that will start reducing this unacceptable death rate.”

notice a change in their breasts.” The most common symptom of breast cancer in men is a painless lump in the breast, often behind the nipple. Other signs and symptoms of breast cancer in men include: • discharge from the nipple; • change in the shape or appearance of the nipple or chest muscle; • change in the shape or appearance of the breast, such as swelling or dimpling; • unusual pain that doesn’t go away and • swollen lymph nodes ( glands) under the arm. “Breast cancer in men can be treated successfully. Finding and treating breast cancer early, before it has spread to other parts of the body, is as important for men as it is for women in surviving the disease,” Professor Zorbas said.

mental health, thousands of Australian males have joined the UK ‘selfie’ campaign #ItsOkayToTalk. The campaign, which has gone viral globally, is led by UK rugby player Luke Ambler, who was distraught when his brother-in-law died by suicide. Similar rates of suicide amongst men have been reported, in the UK and after his brother-in-laws death Mr Ambler decided to dedicate a safe space for men to talk about how they feel and what’s been getting them down in his home town. The response was so overwhelming that he is now planning to set up clubs all over the UK with the goal of halving the suicide rate in men. On the back of the clubs, Luke decided to kick off the online campaign spreading the message that suicide is the biggest killer of men under 45 and asking people to share their “OK selfies’. The selfies feature men making an okay hand sign, as well as details of suicide statistics for men.

If you need help in a crisis, call Lifeline on 13 11 14, 24 hours a day. For further information about depression contact beyondblue on 1300 224 636 or talk to your GP, local health professional or someone you trust.

Meanwhile, in an attempt to promote open conversations about suicide and 42  November 2016 Volume 24, No. 5


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Dabars and Rob Bonner for this support). Also at the booth were SA Nurses Supporting Choices in Dying and Drs4VE so nurses could discuss with their peers their opinions on this issue.

I would like to say thank you to all of the nurses who have and are continuing to engage in the voluntary euthanasia debate. I especially enjoyed the article Undergraduate nursing education related to euthanasia” by Lyn Croxon and Judith Anderson in the ANMJ, September 2016. In teaching the topic of ethics, I discuss VE with nursing students through the Code of Ethics Value Statement Number 5.1 which states, “Nurses make informed decisions in relation to their practice within the constraints of their professional role and in accordance with legal and ethical requirements… Nurses are responsible for ensuring their decision making is based on contemporary, relevant and well-founded knowledge and information” (NMBA, 2013). Value Statement 5.4 goes on to say that “Nurses also assist in keeping the community informed on nursing and health-related issues”. To inform the community on this topic, the ANMF (SA Branch) at their recent annual conference allowed the South Australian Voluntary Euthanasia Society to provide information to conference participants, including nursing students, about the current VE legislation in the South Australian Parliament (thank you ANMF SA Branch CEO/ Secretary Adj Associate Professor Elizabeth

ARE PAP SMEAR PROGRAM CHANGES WARRANTED? As a DES daughter* I read with concern ‘Have you had the HPV vaccine’ Viewpoint, ANMJ September 2016. This article perpetrates the myth that ‘cervical cancer’ is the HPV-related squamous-cell cancer. What DES daughters know is that there are two main types of cervical cancer – the slow-developing squamous-cell cancer (squamous carcinoma); and the much more aggressive glandular-cell cancer (adenocarinoma). We know this as we are at increased risk of both types of cervical cancer (Hoover et al. 2011).

We need to understand how society wishes to manage death when our legal system is set up to respect free will and the fact that medically assisted death is already allowed to occur in many different ways (White and Willmott, 2012). Thanks also to Annie Butler, ANMF Assistant Federal Secretary for emphasising that nurses are not bystanders to healthcare. We have worked long and hard to get away from the 'handmaiden' image of the past. As nurses, we help people to recover and get better, we help people to bring new life into the world and we help them to die with as little pain and suffering as possible. We help people to survive and families to grieve. Our work is hidden but the community trusts us to deliver the care needed at the time required - and that includes a manner of death consistent with legal, ethical, personal and professional standards agreed to by the community. References White, B. and Willmott, L. 2012, How should Australia regulate voluntary euthanasia and assisted suicide?, Health Law Research Centre, Faculty of Law, Queensland University of Technology. Nursing and Midwifery Board of Australia. 2013, Code of Ethics for Nurses in Australia, Nursing and Midwifery Board of Australia, the Australian College of Nursing and the Australian Nursing and Midwifery Federation.

Sandra L Bradley, RN, SA

Three years after receiving the full course of Gardasil, and 17 months after her previous normal Pap smear, my daughter was diagnosed with cervical adenocarcinoma. Pap smears saved her life, not Gardasil or HPV DNA testing.




es: Referenc


_ Nov2013 Final_27 HA.pdf. SentToDo ical rian Cerv

ary Victo et al. Registry Dillner the prim the predictive Cytology Report 2014 Final_27Nov2013_ l Long termcytology and types as References: As Statistica of SentToDoHA.pdf. s primary the asaviru ch nic HPV d 25-74. oncogenic values types HPV p13 for a mu oncoge women age and papillom Dillner et al. 2008, the Asp11human aged e test hash-grad test for for in cervical25-74. Victorian Cervical term predictive JM, teste for women sensitiv screening ng test : joint testing oomers Long much n os MM, cytology and andy, has aWalb e for hig & 3) much screening Stud screeni is much more Cytology Registry sensitive cancer MV, Manvalues of t test tive valu HPV 2 is tha more cohort mj. Jacobse Kummer Statistical Report 2014 peanvalue (CIN human papillomavirus high-grad for HPV tes n Euro e predic sia 36/b FX, h itiv pla greater 0.11 wee predictive al. Bosc positive pos p11-p13 in cervical thanKV, ettesting lial neo BMJ doi:1 rval bet (CIN 2 & 3) greater avirusscreening: joint JA, Shah neoplasia rs 4 aepithe ear), the inte eliala175 cancer yea intraepith intr papillom l of an cervical e five Hum V between to cohort Study, Walboomers JM, cervica (the Pap sm European ssary caus g HP er Pap smear), thenalinterval ended (the canc is a nece Agency Jacobs MV, Manos MM, doi:10.1136/bmj. BMJ gram, usin er. years ive cervical five natio cytology tests will be extnew procytology uce to Canc ol Inter extended red invas Bosch FX, Kummer J Path tests will be Research on of e negative HPV dwide. a1754 ected to using s for new program, worl negativ al. 2008). The t, is exp 1):12-9 JA, Shah KV, et al. The handbook n: 2008). al. Sep;189( 18% et et tes at r IARC (Dillner 151999 ary able entio Human papillomavirus by to reduce availInternational (Dillne prim Agency is expected er prev 3).primary canc test, l cancertesting [Abstract 201 the as the - cervix is a necessary cause of ittee,as on Cancer. me 10 cervica Comm . testing for Research . 15-18% www.ncbi.nlm by of volu 482] cancer ning invasive cervical cancer cervical er scree s; 0451 ry of idence the incidence of d canc Committe Pres e, 2013).pubmed/1 IARC handbooks the inc Service Adviso worldwide. J Pathol covereAdvisory cancer prevention: Lyon: IARClable from: Service al not (Medical is dic 1999 Sep;189(1):12-9 CM, (Me - cervix 10 and 2005 Avaifr/en/ ng test, Wheeler volume Trial (a X, Garl [Abstract available at e/ covered screening. a screeni Compass ellsagué onlin cancer www.iarc. test, not Bu cervical as dfs Cast is all sby V, ns/p Nearly xis Cros ted as a screening al. 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The NSW) two Studies are ere are thirds Colla pilloma 99(Walboo and prec HANDBOOK1 Th HP Co Pa oncogeni types logic t ). HPV Council n protective efficacy of ine tal cer tes cos emio Cancer anogeni 40an er. their ng Epid testing Can d non-vacc s: 4-year epcost HPV to no nPr of Huma rs et al. 19 about HPV-16/18 AS04ical Cancas screeni no d to of Cerv on of risk domiseded lwith randomise HPV typeInternational associat cost Thi V types ately me are analysis cancer 15 ran The no h oo HP udy adjuvanted vaccine test. e l paris vica wit of of-st alb approxim ive Com Collaboration end(W ing cancer screening enita cervical ary cer omised, her d will havprimary for invas ThinPrep against cervical infection ociated noma ICIAal Studies factorsnoscost l is gat l cancer ass 40 anog Epidemiologic of the rand by cell carci of of the cervix.primaining one thirmpass Triaremaining will have are ind PATR Cancer. third cancer and precancer caused one mou le-bl about 15 ma 2012 vica squa Cervical doub of et rem Co Oncol. will ocarcino tive ately ut cer gathering non-vaccine oncogenic et Trial is aden of risk Lanc Compass gy. 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Lancet Oncol. 2012 inform n are at nic type ofisHP carciare to of ht J, pra involvedsexual cell me The 37 on with Wrig ck al mainly reanalysis d en Victoria Wo 12 practices in smissi EL, Cuzi Jan;13(1):e1]. The Lancet ualskin contactmedic skin to is by r oncoge tran 1,374 wom virus ws weekl 400 medical men age ett women 400for on 8,097 Franco ma from data been has inly sex on trialcino Research JT, Garn Oncology 2012;13:100ber groonrecruiting wo have an ent. Nearly all d younge weekly. The ller nal Agency adenocar logical studies, tact- ma(Internatio ter with squamous number ly neegrows this in conactivity this numinfection earch to Schi 10. al. Chap emio aged ents and perate resrecruiting epid er 37 women GP, et is persist skin to skin cessful and cell carcinoma very common desvery y for Res l in vaccines with 2005). 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24, No.

Pap smears have long been the proven preventative public health strategy for cervical cancer. The National Cervical Screening Program (NCSP) was established in Australia in 1991 and has been a wonderful success story, with incidence and mortality of cervical cancer both halved since the NCSP was introduced. So why would you mess with a success story? That’s exactly what’s happening. Without any community consultation and very little evidence, as from May 2017, the biennial Pap smear screening will be replaced by HPV DNA testing every five years, starting at age 25.

oint_Research.indd 20 20 20-21_ANMJ Sep16_Viewp arch.indd oint_Rese 6_Viewp

MJ Sep1


While we applaud the Compass Trial, surely this research should have been carried out before such significant changes to the NCSP.

The specialist who diagnosed and treated her said clinicians were concerned at the apparent recent increased incidence of cervical adenocarcinoma in young women under 30 years of age. Surely these clinical observations warrant further research. Now is not the time to be changing the biennial Pap smear screening program. Reference

Hoover, R.N., Hyer, M., Pfeiffer, R.M. et al. 2011. Adverse health outcomes in women exposed in utero to diethylstibestrol. NEJM. 365:1304 14. NEJMoa1013961 22/08/2016 4:43 pm

*Diethylstilboestrol (DES) was a medication commonly prescribed to prevent miscarriage, between 1946 and 1971 in Australia. DES daughters are female offspring of women who took DES while pregnant. DES exposure in the womb can cause a range of reproductive changes and fertility problems later in life. Marian Vickers, Convenor, DES Action Australia, Vic

According to the Compass Trial website: “If the HPV test is negative, the likelihood of developing cervical cancer is so low that it is safe to leave the next screening test for five years.”

44  November 2016 Volume 24, No. 5




It is interesting to read Dr Suzan Barker’s article expressing her personal and professional experiences on the refugees in Nauru.


CTOB O. 4 / O E 24, N

6 ER 201


I agree that the Naruan community should be acknowledged and recognised for their role in helping out towards the current world wide refugee crisis.


Perhaps the photo supplied by the Asylum Seeker Resource mail Centre could have been of the Naruan community members welcoming and giving each refugee a frangipani flower on their arrival, as described in the article.


A health check of all Austra -up shows the burde lians time we chang now have a chron n of chronic diseas e is ic disease ed course while recog while 20% crippling our nation to prioritise nising the have multip . About half skyrocketing valuable contri prevention, health le promotion chronic diseases. incidence bution of It’s of chronic and early nurses and illnesses, detection, writes Karen midwives, to comb at the Keast.


I write in response to the letter by Chris Goerg, ‘opposing voluntary euthanasia’, in ANMJ September, 2016. While I am in agreeance with the ideas regarding human euthanasia put forward, I am appalled to read how human life could be viewed as more valuable and precious, ‘than that of an animal’ and how one could just kill their dog if it was dying. Luckily, I was not faced with this terrible choice when my dear Kelpie friend Kane, of 17 years, died three years ago of an AMI. However, I felt the pain basically as much as some of the human deaths in my life. Unfortunately, for many of the pet owners I know, or have talked to in passing, it has been an agonising choice for them; and one not left without guilt or wondering. As nurses, I feel we should view all life as sacred, no matter what the species, as this is where the heart of our compassion and empathy comes from. For some people, their pet’s life is way more precious than that of the humans in their lives – the pet is a dear friend, full of trust and unconditional love for its owner and vice versa. What could be more precious than this? Sandra Jennings RN, Vic

ONE SIZE DOES NOT FIT ALL Regarding Maree Burgess’ tale in last month’s ANMJ of putting her dog down...and then explaining Andrew Denton’s loss of his father almost 20 years ago. I fail to understand the logic, given the many advances in palliative care since then. Our palliative care system does an amazing job but of course with our ageing population and intense pressure, could do with more research and funding so dying with dignity is achieved in each and every case. Let us look at all the options ... One size does not fit all. That is the discussion that must be started. Emilia Maria Mazzei EN





Gabrielle Brandt, RN, SA




hen Laurie West’s weight peaked at Gladstone 198kg in his and Hervey early 20s, Bay. he knew it THE STATIST ICS: and their In this primary lifestyle to was time to overha family ul his change the healthcare better connec members to was able to health. 1 IN 2 course of role, he share his his health practiti t with their team own discuss the AUSTRALIANS of importance story and oners. He education HAVE A CHRON preventative completed of taking An Aborig on inal descen IC DISEASE. introduced telehealth and disease with measures for chronic dant Kalkadoon case confere tribe of Mount of the _ a yarn when his patients. “They ncing. Queensland, Isa, like Case confere start sharing they come in. When number on Laurie says the high ncing CHRON you stories the scales has improv IC the experie about - this what’s gone bells. “I looked rang alarm ed nce of patient DISEASES is in the mirror healthcare how I prevenon in my family, this and remem SUCH AS in more ways s using one day is bered the boosted commu can be done’.ted it, they say - ‘oh, than one. of my family medical history CARDIOVASCUL it nication betwee It’s patient, their AR on - my fatherand the genetics going DISEASE, n the family and CANCER had had a and, most “I’ve had practitioners AND DIABET also had a stroke, import other ES he’d heart attack, patient patient unders antly, enhanced ARE THE Cover_v2.indd are doing had a history my mother J Oct16_ really well s in there who tanding. 00_ANM LEADIN with their and progre family, and of hypertension in G CAUSE health ssed, and the we also had OF ILLNESS “Usually the I’ve said to of the other the family,” diabetes , patients want some out patients in DISABILITY he says. so and they’ve ‘this is of a consult to get AND DEATH done really so and can just becaus as quick as they As one of well’. AUSTRALIA. IN just a handfu e they don’t care anymo “It’s not about and Torres l really _ re, they’ve Strait Islande of Aboriginal getting out the medica heard all of tooting my registered there and r male l jargon and own nurses in them,” Laurie it confuses sure the elders horn, it’s about Austral knew he had ALMOST ONE says. in each commu making into a to start practisia, Laurie I worked in THIRD COULD he preach case confere “You get them nity that could see ed to his Indigen ing what nce and you’re able BE that done, PREVEN disease patient to it encour can be it’s about ous chronic TED getting THROUGH say - ‘Aunty/ age them. You can zone and lost an astoun s. Laurie has since having that in that mental REMOVING ding 102kg questions? Uncle, do you have thought proces of ‘yeah I describes and now any Ask now.’ can do this’.” his EXPOSURE s It’s things that watches his health as “great”. TO make them those simple RISK FACTO He diet and exercis look after Laurie, who RS from attend themselves just want to SUCH AS recently began ing his mornin es daily better.” for the Congre at the gym workin g workou SMOKING, to t HIGH The burde Torres Strait ss of Aboriginal andg division one playing basketball BODY MASS, Islander Nurses and netball. disease n of chronic Midwives ALCOHOL and (CATSINaM), Chronic disease nurses and USE, PHYSIC says it’s crucial For the past other health AL four years, nation’s bigges has been labelle INACTIV take a holistic practised professionals d the HIGH ITY AND as a regiona Laurie t approa health ch, looking challenge. beyond treating BLOOD chronic disease l nurse tackling PRESSURE. the diagno with the Institut Australians bid to tackle for Urban sis, in a may be living e Indigenous high rates _ but major, disease in longer he worked Health, where and Indigenous of chronic across 18 lifestyle-relatedmostly preventable, health. sites east Queen ONLY 1.5% sland along in southrisk factors OF high rates Laurie saw such as with sites SPENDING, of obesity a in AS , poor nutritio alcohol consum conferencingneed to utilise telehea PROPORTION A n, lth to enable physical inactivi ption, smoking, his patient TOTAL HEALTHOF s ty are contrib and to greater EXPENDITURE, levels of disease uting IS DEDICATED and TO




October 2016

Volume 24,

No. 4


TIME TO TACKLE CHRONIC HEALTH DISEASE Last month’s feature, ‘Chronic disease crisis - why prevention is better than cure’, written by Karen Keast, is a timely reminder for policy makers and politicians to wake up and urgently address chronic health disease which is the root cause of our failing health system. As Karen states, chronic diseases kill 38 million people around the world each year, and rates are surging. Governments need to reframe healthcare to help prevent the surge, while also find ways to support the acute healthcare system buckling under the strain of chronic health diseases. Ultimately it is the responsibility of each and every one of us to live a conscious, healthy lifestyle but this must be supported by society and not just talked about. As nurses and midwives we are well placed to support this shift to better health within our healthcare communities, and within ourselves. We can make the difference. I commend Registered Nurse Laurie West, who featured in Karen’s story. Working in primary care, Laurie decided to practice what he preached and lost 102kg. He is a perfect exemplar that each of us should follow. Susie Frazer RN, ACT

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

November 2016 Volume 24, No. 5  45

2:06 pm


NOVEMBER Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) International Indigenous Health Workforce Meeting 7 November, Melbourne Convention Centre. conference/conference-catsinam The Lowitja Institute Indigenous Health and Wellbeing Conference 8-10 November, Melbourne Convention Centre. conference Family Violence Forum Reducing stigma and promoting prevention 9 November, Shedley Theatre at Playford Civic Centre, Adelaide. familyviolenceforum2016 9th European Public Health Conference All for health -health for all 9-12 November, ACV, Vienna, Austria. 11th National Australian Wound Management Association Conference State of play 9-12 November, Melbourne Convention and Exhibition Centre. 25th National Conference on Incontinence 9–12 November, Adelaide Convention Centre. South Australia. www. php Australasian Sexual Health Conference 14-16 November, Adelaide Convention Centre SA. ehome/index.php?eventid=146943& 7th Biennial Ngā Pae o te Māramatanga International Indigenous Research Conference 15–18 November, Auckland, New Zealand. www. 26th Annual Australasian HIV&AIDS Conference 16-18 November, Adelaide Convention Centre SA. ehome/index.php?eventid=146943&

NETWORK Australian Women’s Health Nurse Association 30-year anniversary inservice and reunion dinner 17-18 November, Carrington Hotel Katoomba (17 and 18 November inservice/18 November reunion dinner). E: Jenny.Bath@hnehealth. Royal Children’s Hospital, October 1974, 42-year reunion 18-19 November. Contact Elizabeth Zambotti E:

46  November 2016 Volume 24, No. 5

Lung Health Promotion Centre at The Alfred 16-18 November – Asthma Educator’s Course 24-25 November – Smoking Cessation Facilitator’s Course P: (03) 9076 2382 E: 5th International Australasian College of Infection Prevention and Control Conference 20-23 November, Pullman Melbourne, Albert Park Vic. http://www. National Primary Health Care Conference 23-25 November, Pullman Albert Park Melbourne. event/NPHCC-2016 International Congress on Innovations in Nursing (ICIN) Conference 24-25 November, Parmelia Hilton Perth. Showcasing innovation and leadership in clinical practice, research and education. Modern Clinical Nursing – In Search of Excellence 28-29 November, Comfort Inn Haven Marina, Glenelg North. www.ausmed. Considering Behavioural Expression Melbourne Workshop 30 November, Essentia Health & Wellbeing Centre, Highett Victoria. http:// consideringbehaviouralexpression/

DECEMBER World AIDS Day 1 December. http:// Adelaide Nurses’Conference 1-2 December, The Lakes Resort Hotel, Adelaide. International Indigenous Health Conference 1-3 December, Pullman Cairns International Hotel, Cairns Qld. Law and Nursing 8-9 December, The Lakes Resort Hotel, Adelaide. 8th International Conference on Healthcare, Nursing and Disease Management 21-22 December, Flora Grand Hotel, Deira, Dubai, United Arab Emirates.

Royal Adelaide Hospital, Group 771, 40-year anniversary 22 January 2017, Cremorne Hotel Unley @2pm. $10 per head. Contact E: or E: Mercy Private A’77 40-year reunion 29 January 2017, Lunch from 1200 (venue TBC) Contact Megan Burgmann E: or Cathy Sullivan (nee Mulchay) E: or via facebook A77 – 40 year reunion


National Close the Gap Day 17 March 2017. https://www.oxfam.

International Conference on Impact of Global Issues on Women 9-12 January 2017, Manipal University, India. ic2017/

Earth Hour 19 March 2017

FEBRUARY Ovarian Cancer Awareness Month World Cancer Day We Can. I Can. 4 February 2017. Anniversary of the Apology (2008) 13 February 2017 8th Annual National Dementia Conference 23-24 February 2017, Adelaide, South Australia.

MARCH 35th Annual Dermatology Nurses Association Convention Embracing the world of dermatology 1-4 March 2017, Orlando, Florida. International Women’s Day 8 March 2017. Australasian Cardiovascular Nursing College Conference 10-11 March 2017, Brisbane Convention & Exhibition Centre, Queensland. 41st National Australian Association of Stomal Therapy Nurses Conference Into the sunshine: Storytelling in stomal therapy 12-15 March 2017, Royal International Convention Centre, Brisbane, Qld.

Harmony Day Australia 21 March 2017. Building Children’s Nursing for Africa Conference Pillars of Practice 28-30 March 2017, The River Club, Observatory, Cape Town, South Africa.

APRIL 15th World Congress on Public Health Voices - Vision - Action 3-7 April 2017, Melbourne Convention and Exhibition Centre. 14th National Rural Health Conference 26-29 April 2017, Cairns, North Queensland. au/14nrhc/

MAY National Sorry Day 26 May 2017. International Council of Nurses (ICN) Congress Nurses at the forefront transforming care 27 May-1 June 2017, Barcelona, Spain. National Reconciliation Week 27 May-3 June 2017.

6th eMedication Management Conference 14-15 March 2017, Swissotel Sydney. health-care-conference/electronicmedication-management St Patrick’s Day 17 March 2017. australia/st-patrick-day

RAH, group 772, 40-year reunion February 2017. 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 Prince Henry’s Hospital Melbourne, Group 2/2/1972, 45-year reunion 4 February 2017. Contact Jacky Dow (nee Conway) E: g_jdow@internode. or Janet Molan (nee Craig) E:

St Vincent‘s Hospital Melbourne Jan 1977, 40-year reunion 11 February 2017. Venue TBC via email invitation. Contact Trish Kunek (nee Crommy) E: 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

Email if you would like to place a reunion notice

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de arukimasu 歩く = to walk WALKING TOGETHER My children study Japanese at school and I have enjoyed learning more about the rich vocabulary history and sounds as they navigate a new language. I have learned many new words this year but “de arukimasu” (say arookey-mus) is one that I not only enjoy saying because it rolls beautifully off the tongue but because of its meaning. Arukimasu, the Japanese term for ‘walk with’. When I hear this word, I can imagine one person walking respectfully and reassuringly beside someone who is not moving so well or confidently. This is not its literal meaning, it is my interpretation of the meaning. Walk along, come this way, follow me, to walk with… sounds simple and we probably think we all do this every day in our clinical and professional practice no matter what setting. But reality is that whether with our patients or with our colleagues, we will report that the busyness of our daily work is not conducive for walking along with each other. We prefer, choose or make a habit to rush. There are consequences of that for ourselves and for our patients. Walking features in a myriad of songs, movies and book titles and the meaning is often far deeper than simply the action of putting one foot in front of another. Walk the Line, Walk like an Egyptian, Walk this way, Dead Man Walking…you get the idea. A lot of political energy is currently being exerted on the issue of occupational violence towards healthcare workers, the perpetrators of which are named as the patients

48  November 2016 Volume 24, No. 5


or their family members we care for. And as strategies are put in place to raise awareness, deter and deescalate the incidences of occupational violence in healthcare environments, it is becoming clearer that there remains an issue of health worker to health worker intolerance. We have stopped walking along with each other – that respectful reassuring interaction. Whether it be graduate nurses who take time to get up to speed clinically and culturally; whether it be the switch operator who calls with a patient enquiry every 15 minutes; whether it be the dinner lady who does not deliver the special meal; the medical officer who barks an order or the nurses failing a phone handover, you know how these scenarios usually end…with frustrated embittered parties who resentfully rub along to get work done. The consequences of failing to walk along can be far reaching affecting nursing culture and patient outcomes.

and embedded in our culture to be passed down generation to generation. Reciprocity and collegial generosity appear difficult the more pressure is in our health system, the more we empty our energy bucket to get the work done, and the emotional burden of nursing and midwifery work leaves little left for generosity towards each other. In October, I participated in our local Relay for Life with my daughter’s school team, a fundraising campaign for the Cancer Council –many are held across Australia throughout the year. It is the ultimate demonstration of arukimasu (walking with). Cancer patients, survivors, carers, community, health professionals, high school students and businesses walk together for 18 hours in relay, sharing ceremonies that celebrate survival, remembering those lost and building hope for a cancer free future. I was struck during the Relay how such walking occurs every time nurses and midwives share a moment with those in our care, that nurses and midwives are with patients and families during the small hours of the night, when people are at their most vulnerable, when there is sadness and happiness and hope. Nurses and midwives embody arukimasu as we walk with patients and families through birth, ageing, acute treatment, difficult decisions, making choices, and ultimately in death. As we commit to walk with patients this way, I encourage us to walk with each other more. Chōwa (harmony!)

It is often that you hear within nursing and midwifery professional folklore that we ‘eat our young’. Rather than being a breed of stalking carnivores, I think the problem is perhaps a product of our environment

IS YOUR INFORMATION ON DOSING FOR CHILDREN RELEVANT & UP TO DATE? 2016 Children’s Dosing Companion Print and Online Release The AMH Children’s Dosing Companion (CDC) is Australia’s national independent dosing guide for prescribing and administering medicines to children from birth to 18 years. The evidence-based and peerreviewed content provides detailed dosing information to assist nurses and midwives in hospitals and community settings. Clearly written and concisely laid-out, it now offers information for over 370 drugs. The 2016 Print and Online release has expanded its coverage on doses for drugs used in hospital and in neonates. This update includes a number of new monographs and other changes, some of those that may be of interest include:

DC The C f the rt o is pa cy Board • new monographs for ezetimibe, mannitol, micafungin, ma Phar ustralia’s A propofol and a range of antiretroviral drugs for HIV. of tial Essen nces e • a review of antifungal uses & doses, including amphotericin, Refer st i L caspofungin, fluconazole, flucytosine and voriconazole.

• dosing regimens for vancomycin together with advice regarding therapeutic drug monitoring. • details regarding name changes to some drugs in Australia. For more information go to

AMH Pre-Publication Promotion

COMING SOON! Last year our pre-publication promotion was a great success, with many winners around the country sharing in $1000’s worth of educational conferencing, travel, accommodation & office equipment. So we’re doing it again this year. To support you. The nurse, the midwife, the doctor, the pharmacist. Purchase during the pre-publication period to be in the running to receive some fantastic rewards. Stay tuned for more information.

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ANMJ November 2016  

November issue of the Australian Nursing & Midwifery Journal

ANMJ November 2016  

November issue of the Australian Nursing & Midwifery Journal