AMMJ September 2015

V O LU M E 2 3 , N O. 3 / S E P T E M B E R 2 0 1 5

NO PLACE LIKE HOME nurses and midwives tackling homelessness

www.anmf.org.au

Clinician Fact Sheet:

Acute Stroke The goal of the Acute Stroke Clinical Care Standard is to improve the early assessment and management of patients with stroke to increase their chance of surviving the stroke, to maximise their recovery and to reduce their risk of another stroke.

Clinicians and health services can use this Clinical Care Standard to support the delivery of high quality care.

UNDER THIS CLINICAL CARE STANDARD A person with suspected stroke is immediately assessed at first contact using a validated stroke screening tool, such as the F.A.S.T. (Face, Arm, Speech and Time) test.

FACE: Check their face. Has their mouth drooped?

ARMS: Can they lift both arms?

SPEECH: Is their speech slurred? Do they understand you?

TIME: Time is critical. If you see any of these signs call 000 straight away.

A patient with ischaemic stroke for whom reperfusion treatment is clinically appropriate, and after brain imaging excludes haemorrhage, is offered a reperfusion treatment in accordance with the settings and time frames recommended in the Clinical guidelines for stroke management.

A patient with stroke is offered treatment in a stroke unit as defined in the Acute stroke services framework.

A patient’s rehabilitation needs and goals are assessed by staff trained in rehabilitation within 24–48 hours of admission to the stroke unit. Rehabilitation is started as soon as possible, depending on the patient’s clinical condition and their preferences.

A patient with stroke, while in hospital, starts treatment and education to reduce their risk of another stroke.

A carer of a patient with stroke is given practical training and support to enable them to provide care, support and assistance to a patient with stroke.

Before a patient with stroke leaves the hospital, they are involved in the development of an individualised care plan that describes the ongoing care that the patient will require after they leave hospital. The plan includes rehabilitation goals, lifestyle modifications and medicines needed to manage risk factors, any equipment they need, follow-up appointments, and contact details for ongoing support services available in the community. This plan is provided to the patient before they leave hospital, and to their general practitioner or ongoing clinical provider within 48 hours of discharge.

More information on the Clinical Care Standards program is available from the Australian Commission on Safety and Quality in Health Care website at www.safetyandquality.gov.au/ccs.

Acute Stroke Clinical Care Standard Clinician Fact Sheet, June 2015.

EDITORIAL

Editorial Lee Thomas, ANMF Federal Secretary It’s been a bitterly cold winter in most parts of Australia this year. No more so than in my home town of Canberra. Unsurprisingly, it’s been a struggle most mornings to leave the warmth and comfort of my home to brave the icy elements, albeit for a short walk to my car.

NURSES WORKING IN COMMUNITY SERVICES ARE DOING AN INCREDIBLE JOB IN ADDRESSING THE HEALTHCARE NEEDS OF THE HOMELESS AND DISADVANTAGED, OFTEN UNDER TRYING CIRCUMSTANCES.

Yet as I feel that blast of cold, fresh air on my face each morning I often think about those who have slept rough overnight. I wonder what kind of night they have had and if they managed to find any warmth or shelter.

A few years ago I slept rough on the banks of Lake Burley Griffin along with 150 other people involved in the St Vinnies CEO sleep out. Armed with three pieces of cardboard and my sleeping bag I struggled to find a spot that would protect me from the wind, rain and cold. It was a tough night, but it was only one night with a hot shower, food and clean clothes awaiting me at the other end.

Each night over one hundred thousand people sleep rough in Australia because they are homeless. More than 10,000 of them are kids under 18 - a staggering statistic that I find hard to comprehend.

Yet as the number of homeless people continues to grow, I can’t help but think that the actions and recommendations our country is putting in place to ‘apparently’ boost our economy will actually only exacerbate this situation.

Last month’s draft Productivity Commission recommendation to cut penalty rates in the retail and hospitality sectors is one such example. The report advocates for the reduction of Sunday rates to the level of Saturday rates along with the removal of public holiday rates for workers in this sector. While retail and hospitality workers have been singled out there is no guarantee from the government that nurses and midwives won’t be next.

@AustralianNursingandMidwiferyFederation

anmf.org.au

@anmfbetterhands

It’s fairly clear this blatant threat to Australia’s current IR system does not consider the basic and essential living needs of the individual. Should these recommendations be implemented they will only serve to drive more people living on the brink of financial survival into poverty and onto our streets.

In this month’s feature on homelessness experts believe the number of Australians facing homelessness will double unless there is serious intervention from our government.

While finding enough affordable long-term housing for our most vulnerable is a major issue, so too is the desperate need for support programs particularly in relation to health. Despite this, nurses working in community services are doing an incredible job in addressing the healthcare needs of the homeless and disadvantaged, often under trying circumstances.

It came as no surprise last month when the Australian Institute of Health and Welfare (AIHW) report released its latest nursing and midwifery workforce 2014 figures, that read of 323,700 registered nurses and midwives in Australia, 9,100 were unemployed. That’s an increase from 8,200 in 2013 and 4,500 in 2011.

Of great concern to the professions has been the lack of secure employment for graduate nurses and midwives for the last three years. It’s estimated that between 30 to 40% of nurse and midwife graduates, in varying proportions across all states and territories, have been unable to find permanent jobs.

Addressing this issue has been a major priority for the ANMF over the past 12 months and consequently we have been working with key stakeholders to improve employment opportunities for graduate nurses and midwives. However to make genuine improvements we need more political commitment and we will continue to lobby the government to this end to ensure it happens.

www.anmf.org.au

September 2015 Volume 23, No. 3 1

Canberra

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

FRONT COVER: HOMELESS PERSONS PROGRAM NURSE JO GIAMPETROME AND HOMELESS PERSON JUSTIN.

Editorial

Melbourne & ANMJ

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

Federal Secretary Lee Thomas

Assistant Federal Secretary Annie Butler

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

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Victoria

Branch Secretary Yvonne Falckh

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

The Australian Nursing & Midwifery Journal is delivered free monthly to members of ANMF Branches other than New South Wales, Queensland and Western Australia.

Subscription rates are available on (03) 9602 8500. Nurses who wish to join the ANMF should contact their state branch. The statements or opinions expressed in the journal reflect the view of the authors and do not represent the official policy of the Australian Nursing & Midwifery Federation unless this is so stated. Although all accepted advertising material is expected to conform to the ANMF’s ethical standards, such acceptance does not imply endorsement.

All rights reserved. Material in the Australian Nursing & Midwifery Journal is copyright and may be reprinted only by arrang­ement with the Australian Nursing & Midwifery Federation Federal Office Note: ANMJ is indexed in the cumulative index to nursing and allied health literature and the international nursing index ISSN 2202-7114

Moving state? Transfer your ANMF membership

If you are a financial member of the ANMF, QNU or NSWNMA, you can transfer your membership by phoning your union branch.

Don’t take risks with your ANMF membership – transfer to the appropriate branch for total union cover. It is important for members to consider that nurses who do not transfer their membership are probably not covered by professional indemnity insurance.

New South Wales

Queensland

Tasmania

Western Australia

Branch Secretary Brett Holmes

Branch Secretary Beth Mohle

Branch Secretary Neroli Ellis

Branch Secretary Mark Olson

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

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

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

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

2 September 2015 Volume 23, No. 3

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

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Based on ANMJ 2014 member survey pass on rate Circulation: 98,970 BCA audit, March 2015

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News 4

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World 15 Issues 16

NO PLACE LIKE HOME

industrial 17

NURSES AND MIDWIVES TACKLING HOMELESSNESS

Education 18 Ethics 19 Feature 20 Issues 26 Wellbeing 27 Clinical Update

28

Research 32 Focus – Wound / Infection control 33 Calendar 45 Mail 46 Maree 48

FEATURE

NURSES AND MIDWIVES TACKLING HOMELESSNESS

04

19 NEWS

ETHICS

27

33 WELLBEING anmf.org.au

MINDFULNESS

FOCUS

WOUND / INFECTION CONTROL

September 2015 Volume 23, No. 3 3

NEWS

in the honour of Australian nurses who served in World War I. Lemnos was home to the first overseas deployment of 130 Australian nurses in war.

Four years in the making, the memorial is part of the 2015 ANZAC Centenary. The unveiling on 8 August marked the day the nurses arrived on the island of Lemnos 100 years ago.

The bagpipes blew as a reenactment of the arrival of Australian nurses and soldiers led the formal proceedings at the memorial site in the

City of Port Phillip, Melbourne.

Many deployed to Gallipoli left from the nearby Port Melbourne port and pier.

Matron of No.3 Australian General Hospital on Lemnos, Grace Wilson’s great-nephew Dr David Weedon, was at the unveiling, along with 23 other descendants. Grace Wilson was 35 years old when she left in 1914 for Lemnos.

She died in 1956, aged 77 years. “This memorial raises awareness of a legacy far too important to remain untold,” Dr Weedon said. “Nurses worked in the most challenging conditions beyond words; they were tearing up their own clothes to dress the wounded.”

In days of their arrival, nurses attended to 200 wounded; within two months there were 37,000 casualties in the field hospitals. Nurses faced lack of sanitation, with typhoid and dysentery rife.

Despite the lack of resources and primitive conditions, wound infection rates were low and the treatment regarded high back in England, Dr Weedon said. “They treated over 100,000 patients in 12 months.”

The ANMF Federal Office and ANMF Victorian Branch contributed to the memorial.

records, analysis led to collaborative evidence-based changes. Professor Barclay said what the top 10 NHMRC funded projects all seemed to have in common was ‘engagement’. “I think people are starting to realise the engagement approach to research is very valuable.” The research was also productive - with 18 papers, including two PhD studies and a third underway.

The project delivered improvements in clinical effectiveness and quality of care for women, including through midwifery group practice.

However it is very clear there was still much work to be done in infant health, Professor Barclay said, particularly around low birth weight. “The concern here is how we can do maternal and infant care better in these communities.

Babies are still born anaemic and of low birth weight; these babies are evacuated to hospital within the first year of their life at a far greater proportion than other Australian children: it is not good enough.”

The percentage of Aboriginal and Torres Strait Islander babies born with a low birth weight is 11% (2007-2011) compared to the rest of Australia at 4.8%

(2009-2011). The Northern Territory has the highest rates of infant and young child mortality in Australia at 9.2 deaths per 1,000 live births.

Professor Barclay said there had been a decline in the numbers of child and family health nurses to monitor maternal and infant health, including growth charts. While the midwifery profession had fought to retain its identity and status, there had been less focus on child and family health which had led to a decrease in skills and numbers in rural and remote areas.

Professor Barclay and her team are now working on The Australian Regional Birthing Index, based on a Canadian model. The tool estimates the level of maternity service required for a given regional population based on its characteristics and isolation. “It can be applied across every birth service across Australia for providers to plan how services could be provided and where, to make better decisions,” Professor Barclay said.

As a clinician and political activist, Professor Barclay said she had tried to use research to improve systems. “It (research) is a very powerful tool. Nurses really can improve systems - the quality and the calibre of work nurses are doing is of the highest possible standard and can change systems.”

RE-ENACTMENT OF NURSES AND SOLDIERS ARRIVING ON LEMNOS.

World War I Lemnos nurses memorial A bronze memorial in recognition of Australian nurses and the role of the island of Lemnos in World War I was unveiled in Melbourne last month.

The life-size memorial features a sculpture of a nurse protecting a weary, injured soldier.

The Melbourne Lemnos Gallipoli Memorial is the first major memorial

Nurse researcher in Australia’s top 10 A nurse and midwifery researcher has been recognised in a top ten list of Australian research projects.

Professor Lesley Barclay, Director of the University Centre for Rural Health, was recognised for the ‘Top End’ project working with Aboriginal women, clinicians and policy makers to improve maternal and infant health in disadvantaged communities in the Northern Territory.

The Ten of the Best Research Projects 2014 were among thousands of National Health and Medical Research Council (NHMRC) funded projects.

Professor Barclay’s research stemmed after identifying low uptake of services

by Aboriginal women in the NT largely due to not being culturally appropriate.

“Women evacuated to services to birth were returning home frightened. It is very difficult for Aboriginal women to leave their families and their children to go to hospital to give birth,” Professor Barclay said.

After collection of baseline data, lengthy observations and interviews and the study of hundreds of mother-infant 4 September 2015 Volume 23, No. 3

anmf.org.au

NEWS ANMF FEDERAL SECRETARY LEE THOMAS, AND ASSISTANT SECRETARY ANNIE BUTLER WITH KAY CROWLEY, ELLEN MCRAE AND CELENE MCMULLAN (FROM L-R)

Penalty shootout looms as slashing of rates begins The Australian Nursing and Midwifery Federation (ANMF) has reiterated its commitment to fighting for the retention of penalty rates across all sectors following the release of the Productivity Commission’s contentious draft report into workplace relations in early August.

The interim report recommends Sunday penalty rates be cut to Saturday rates for Australians working in hospitality, entertainment, and retail.

Penalty rates for health and emergency services, including nurses and midwives, have been safeguarded under the proposed changes but fears remain over the long-term implications of the new landscape.

ANMF Federal Secretary Lee Thomas said the proposal would create a ‘twotiered’ workplace relations system and that any cuts to penalty rates opened the door to nurses and midwives being targeted in future. “The penalty rates of retail and hospitality workers have been singled out this time round and there is no guarantee from the government that

Jobless rise worrying trend More than 9,000 Australian nurses and midwives are looking for work in the professions, the latest statistics show.

An Australian Institute of Health and Welfare 2014 workforce report shows of the 323,700 registered nurses and midwives in Australia, 9,100 are unemployed and looking for work – an increase from 8,200 in 2013 and 4,500 in 2011.

“The number of jobless nurses and midwives has doubled in three years, and that’s a worrying trend,” ANMF Federal anmf.org.au

nurses and midwives won’t be next.”

Ms Thomas said the first attack on penalty rates was merely the tip of the iceberg and that nurses and midwives should remain resolute in campaigning to protect the warranted and crucial financial compensation that most staff rely upon.

Mental health nurse Kay Crowley, a single mother with two teenage children and a mortgage, said penalty rates were vital to her livelihood. “Finances are very tough. I’m working as a nurse with reasonable rates. I can’t imagine what it would be like to be working in hospitality where the rate is lower and if you’re a single mum dependent on those penalty rates on the weekend to bring in that little extra buck to pay for the kids’ education or extra-curricular activities.

Secretary Lee Thomas said. “And it’s not just concerning for the ANMF and our members, if we’re not getting our newly qualified nurses and midwives into the workforce, that’s very concerning for the future of healthcare in Australia.”

The ANMF has raised concerns about the lack of secure employment for graduate nurses and midwives for the past three years. The union estimates between 30-40% of nurse and midwife graduates across all states and territories have been unable to find permanent jobs. A recent Graduate Careers Australia report of higher education graduates indicated almost 20% of 2014 graduate nurses and midwives had not found

“If you’re away from your children on the weekend you need to be getting paid for that.”

Anaesthetic recovery nurse Celene McMullan acknowledged nurses and midwives had been spared from the first round of cuts to penalty rates but suggested now was not the time to relax. “I think as nurses we should be concerned. Just because we’re not being targeted doesn’t mean that we will not be targeted.”

“We are a professional group.

We study hard. We take on a lot of responsibility to carry out our jobs. We work very unpredictable hours. We do a 24 hour job. People are sleeping; we’re working. People are having their Christmas dinner; we’re working. We like to be valued for that and attacking penalty rates is an attack on our worth.”

Registered nurse Ellen McRae said the removal of penalty rates would force her to rethink her future in the profession. “They [nurses] would love to be able to continue their work if penalty rates were impeded but the reality is, having such back-breaking work, they might not continue.”

Along with cuts to penalty rates, other key recommendations of the report included scrapping public holiday pay for any new holidays implemented by governments, the ability for employers and workers to negotiate swapping public holidays to other work days, and the introduction of enterprise contracts.

The final report is due to the federal government in November following public hearings and submissions.

full time employment. “It’s still hard to comprehend that we have 9,000 nurses and midwives looking for work when it’s estimated that Australia faces a shortage of more than 80,000 nurses by 2025,” Ms Thomas said.

The report found Australia on track with supply; the number of registered nurses has risen 7%, from 330,680 in 2011 to 353,000 last year.

The ANMF called on the government for political commitment for sustainable solutions to improve employment opportunities for Australian graduates.

“Without sustainable solutions, we will not have a sustainable nursing and midwifery workforce for the future,” Ms Thomas said.

September 2015 Volume 23, No. 3 5

Great jobs for nurses and midwives (you won’t find anywhere else) Registered nursing opportunities UK. Leading NHS Trust in England

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Clinical Nurse Consultant - Aged Care Adelaide. Excellent career development opportunity

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HealthTimes.com.au

NEWS THE HON CURTIS PITT MP AND CRAIG CRAWFORD MP WITH HESTA EXECUTIVE,

HESTA first for Indigenous reconciliation Superannuation fund HESTA launched its reconciliation action plan last month aimed to increase equity between Aboriginal and Torres Strait islander people and non-Indigenous Australians.

HESTA is the first industry superannuation fund to develop a Reconciliation Action Plan (RAP), which has been endorsed by Reconciliation Australia.

Flying start for two country students

The RAP sets out steps to show HESTA’s commitment to reconciliation with Aboriginal and Torres Strait Islander peoples and organisations.

HESTA Executive - People Strategy,

Sophie Sigalas said. “We seek to build respect through understanding and shared learnings, increase confidence and choice in retirement for the first Australians; and achieve equity in the treatment of non-Aboriginal and Aboriginal peoples.”

Through implementation of the RAP, HESTA aims to also capture data on how many of its current workforce identifies as having an Aboriginal or Torres Strait Islander background.

HESTA announced commitment to completing actions within the RAP over 2015 and 2016. Future RAPs will identify relationships, respect and opportunities for actions.

GRACE THOMPSON

Work experience with a local maternal and child health nurse while in secondary school inspired Nikita Bell’s desire to work in health.

“I definitely think I’ve picked the right career,” she said after completion of her first midwifery placement recently at Warrnambool Base Hospital.

Nikita is one of two nursing and midwifery students awarded four coveted country Victorian health scholarships for 2015.

Nikita, from Horsham, and Grace Thompson, from Benalla were the lucky recipients of this year’s Give Them Wings scholarships. Worth $2,500, the scholarships are provided by the Royal Flying Doctor Service (RFDS) Victoria and Rural Health Workforce Australia to encourage the next generation of nursing and allied health professionals from rural communities.

Nikita is in the first year of a nursing and midwifery course at Deakin University in Warrnambool. “I can’t see myself working in the city. I love the people here, it’s safe and everything is close.”

Indigenous health is a field she is keen to explore on graduation. “I have some Aboriginal cousins in Queensland and I’m interested in how I could make a difference to those communities.” anmf.org.au

NIKITA BELL

Grace, a first year nursing and midwifery student at Deakin University in Geelong, just completed her first maternity ward placement. “I got to care for one of the mothers and babies – and it was just so beautiful being there at such a special time in that family’s life. I think new life is just incredible and to experience that every day would be wonderful.”

Grace is also keen to work in a rural community on graduation. “I want my family to grow up in the country. When I was younger, I loved exploring around here with my brother. I want my kids to have the same kind of experiences.”

The $2,500 covers the costs of Grace’s first year university studies; and the scholarship includes a Royal Flying Doctor experience funded by volunteers at the

Bayside Auxiliary of RFDS Victoria.

Grace’s uncle was evacuated to Cairns by the RFDS for treatment after a horse kicked him and broke his leg while working on a cattle station in the Gulf of Carpentaria. “It’s an honour to receive this scholarship from them,” she said.

The scholarships recognised the importance of country students in helping to reduce Australia’s rural health workforce shortages, Rural Health Workforce CEO Greg Mundy said. “We need more nurses and allied health professionals in the bush.”

The two other 2015 winners were a medical imaging student at RMIT University in Bundoora and a physiotherapy student at La Trobe University in Shepparton.

September 2015 Volume 23, No. 3 7

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NEWS DR ALESSANDRO DEMAIO

Reducing the burden of noncommunicable diseases Leading academic Dr Alessandro Demaio has called for greater urgency in the fight against non-communicable diseases, which account for two thirds of global deaths.

Four key non-communicable diseases (NCD) include diabetes, heart disease, cancers and chronic lung diseases.

Speaking at the NSW Nurses and Midwives’ Association’s (NSWNMA, ANMF NSW Branch) 70th Annual Conference, Dr Demaio, a Visiting Fellow in Global Health at Harvard Medical School and co-founder of NCDFREE, a global social movement against NCDs, stressed the importance of addressing the critical health issue.

“When we have a political system that runs on three year grabs it’s very easy for these diseases to be put aside,” Dr Demaio warned. “NCDs are not a small problem.

NCDs are not a problem of tomorrow.”

Dr Demaio said NCDs were wideranging and could be triggered by

New national practice standards released for nurses in general practice New national practice standards for nurses working in general practice have been released.

The project to develop standards, which was funded by the federal Department of Health, was led by the Australian Nursing and Midwifery Federation (ANMF) Federal Office in partnership with the University of Wollongong’s School of Nursing and Midwifery.

The 22 standards articulate best practice for registered and enrolled nurses working in a general practice setting and are intended to be applied in conjunction with the professional practice framework developed by the Nursing and Midwifery Board of Australia.

The standards cover professional practice, nursing care, general practice environment, and collaborative practice.

The standards aim to present the nursing role in a unique context anmf.org.au

risk factors such as nutrition, environment, socio economic status, physical activity and unhealthy habits including smoking and alcohol consumption.

Contrary to some attitudes, Dr Demaio said NCDs were not merely the domain of rich, white, lazy American males, but an issue that touched poorer populations with insufficient access to healthcare and sport. About 85% of NCDs occur in the world’s poorest populations, he said.

Dr Demaio is demanding governments do more to tackle the issue, suggesting strategies such as people remaining resilient in the war against tobacco and its harmful effects, and lobbying governments to seriously look at implementing a tax on fast food.

He said it was imperative nurses and doctors set the right example and promote positive healthy eating and living habits whenever possible. “Although NCDs are a huge threat to our health, they are also an opportunity to rethink a whole number of different systems where our society can build a healthier future for our country.”

S tA N d A r d 2

18

S tA N d A r d 3

Provides nursing care consistent with current nursing and general practice standards, guidelines, regulations and legislation.

Actively builds and maintains professional relationships with other nurses and regularly engages in professional development activities.

Performance Indicators

Performance Indicators

Enrolled Nurse

Registered Nurse

Registered Nurse Advanced Practice

2.1

Identifies current NMBA EN standards for practice

2.1

Identifies current NMBA EN standards for practice

2.9

2.2

Practises within individual scope of practice.

2.2

Practises within individual scope of practice.

2.3

Undertakes delegated clinical tasks under the supervision of an RN.

2.3

Provides appropriate supervision and delegation of clinical tasks to ENs.

2.4

Seeks advice from the supervising RN when faced with situations outside of their scope of practice.

2.5

Uses general practice specific standards to guide nursing practice.

2.6

Applies evidence-based guidelines and policies when providing nursing care within the EN scope of practice.

2.7

Understands and uses relevant Commonwealth, State or Territory legislation to inform nursing practice.

2.4

Seeks advice from other RNs, or health professionals, when faced with situations outside of their scope of practice.

2.5

Uses general practice specific standards to guide nursing practice.

2.6

Practise is consistent with evidence-based guidelines and policies within the RN scope of practice.

2.7

Understands and uses relevant Commonwealth, State or Territory legislation to inform nursing practice.

2.8

Identifies and communicates changes in standards, guidelines, regulations and/or legislation to members of the general practice team.

Enrolled Nurse

Registered Nurse

Registered Nurse Advanced Practice

Critically evaluates how standards, guidelines, regulations and/ or legislation can be translated and integrated into practice.

3.1

Maintains professional relationships with other nurses in general practice, including networking and mentoring relationships.

3.1

Initiates and maintains professional relationships with other nurses in general practice, including networking and mentoring relationships.

3.9

2.10 Mentors other nurses and health professionals in the application of specific standards, guidelines, regulations and/or legislation.

3.2

Maintains relevant professional nursing and/or general practice memberships.

3.2

Engages with relevant professional nursing and/or general practice organisations.

3.10 Acts as a mentor or professional role model for other nurses in general practice.

3.3

Participates in regular clinical performance appraisal with the supervising RN.

3.3

Discusses and plans continuing professional development with the supervising RN.

Engages in peer appraisal with other RNs and undertakes regular selfassessment of clinical performance.

3.11 Undertakes and facilitates peer appraisal of nursing in general practice.

3.4

3.4

3.5

Actively participates in professional development activities relevant to nursing in general practice.

Plans own continuing professional education based on areas identified for development.

3.5

Actively participates in professional development activities relevant to nursing in general practice.

2.11 Evaluates the impact of standards, guidelines, regulations and/or legislation on service delivery, clinical care and/ or health outcomes.

2.12 Provides feedback to reviews of standards, guidelines, regulations and/or legislation.

ANMF National Practice Standards for Nurses in General Practice

ANMF_Standards for Nurses_2014_v7.indd 18

distinct from nurses working in other clinical settings. A snapshot of key principles in the document advocates providing consistent nursing care, actively building and maintaining professional relationships, illustrating nursing leadership, and empowering consumers to be active participants in their own healthcare.

Despite the growing employment of nurses in general practice both in Australia and internationally, the potential role and scope of practice of nurses in this setting is considered poorly understood.

3.6

Regularly participates in the activities of relevant professional nursing and/or general practice organisations.

3.7

Takes responsibility for the clinical performance appraisal of ENs under their supervision.

3.8

Discusses and plans continuing professional development with ENs under their supervision.

Leads networks of nurses in general practice, facilitating orientation to general practice and networking and / or mentoring relationships.

3.12 Critically reflects on own clinical performance and actively seeks external critical review of clinical practice.

19

3.13 Contributes to the professional development of other nurses in general practice.

3.14 Participates in the delivery of local continuing professional development opportunities.

ANMF National Practice Standards for Nurses in General Practice

4/12/14 11:35 PM

ANMF_Standards for Nurses_2014_v7.indd 19

4/12/14 11:35 PM

While the standards focused on the registered nurse and enrolled nurse workforce, it acknowledged further work is required to articulate the scope of nurse practitioners, midwives, Aboriginal healthcare workers, and assistants in nursing working in a general practice setting.

There are a limited number of hard copy standards available to members from ANMF Federal Office, Melbourne. The document is also available on the ANMF website: http://anmf.org.au/pages/ professional-standards September 2015 Volume 23, No. 3 9

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NEWS

The missing links in patient care A lack of resources, deteriorating patients, and unpredictable surges in patient numbers on the ward have been singled out as the chief reasons behind New South Wales nurses and midwives missing care, a new survey has found.

The study, run by Flinders University in Adelaide, was released during the 70th Annual Conference of the NSW Nurses and Midwives’ Association (NSWNMA) in Sydney and follows previous investigations in South Australia and New Zealand.

Missed care is defined as required patient care that is omitted or delayed due to multiple demands and inadequate resources.

The survey received responses from 4,431 nurses and midwives working in public and private hospitals and aged care facilities.

The study found increased workloads due to factors such as staff shortages, sudden changes in patient volumes, and an inadequate number of assistants, significantly triggered missed care by nurses and midwives.

Communication issues contributed to 37% of missed care, and access to resources 45%.

“They’re spending a tremendous amount of time just to find the resources to provide the care,” said lead researcher Dr Julie Henderson. “The care that gets missed is basic nursing care or interpersonal care.”

Missed nursing care was also attributed to a lack of managerial support and fewer senior staff on duty and

ANMF Vic Branch land knockout High Court decision

registered nurses being replaced by nurse assistants.

Missed care most frequently occurs during day shifts and was also influenced by the type of worksite (rural or metropolitan and private and public) and job satisfaction and levels of teamwork.

Respondents also pointed to having to manage older and more complex patients with multiple needs as the main cause of heavier workloads.

The biggest reason behind missed care in aged care was insufficient staff.

The study also found nurses and midwives associate missed care with poorer patient outcomes and satisfaction, unpaid overtime, and staff attrition.

The Missed Care study has also been undertaken in Victoria and Tasmania, with results expected shortly.

Queensland will also be examined next year.

FROM L-R ANMF VIC BRANCH ASSISTANT SECRETARY PAUL GILBERT, LEGAL REPRESENTATIVES AND ANMF VIC BRANCH INDUSTRIAL OFFICER BARRY MEGENNIS.

A three-year fight led by the Australian Nursing and Midwifery Federation (ANMF, Vic Branch) against a private hospital operator’s attempts to quash multiple enterprise agreements sealed with its Victorian workforce has ended in triumph following a knockout decision at the High Court of Australia in August.

The rejection handed down by Australia’s foremost court now paves the way for 200 registered and enrolled nurses to recoup $1.7 million in owed wages from the employer, Independent Private Hospitals of Australia (IPHOA).

The saga dates back to August 2012 when ANMF Vic Branch negotiated three 2012-2016 enterprise agreements on behalf of its members employed at three sites across Victoria - Essendon Private, Melbourne Eastern Private, and Malvern Private Hospitals.

After the Fair Work Commission’s Deputy President Hamilton approved the agreements in July 2012, IPHOA’s Chief Executive Officer claimed the State Manager for the hospitals in Victoria did not have the authority to approve the agreements and subsequently launched a challenge within the Commission to have the agreements overturned.

IPHOA’s first challenge proved successful following a Full Bench of the Commission ruling that IPHOA’s private bargaining representative did not have written approval to act as a bargaining agent.

Despite the decision, the ANMF Vic Branch resubmitted the agreements for approval in the knowledge that the state manager had signed all three agreements and also submitted a statutory declaration in support of the anmf.org.au

agreements.

On 20 December 2012, Deputy President Hamilton repeated his initial assessment that all of the relevant agreement making provisions under the Fair Work Act had been undertaken lawfully, and accordingly approved the agreements for a second time.

A unanimous decision in favour of employees was handed down by a full bench of the Federal Court in March this year, but IPHOA chose to persist with its case by pressing on to the High Court.

The High Court’s decision to reject IPHOA’s sixth and final appeal available officially concludes the dispute.

ANMF Vic Branch Industrial Officer Barry Megennis said the ANMF’s decision to defend the legal challenges was extremely important in terms of upholding the Fair Work Act’s agreement making provisions, and preventing employers from unilaterally deciding they no longer wanted the Agreement to apply the day after it was approved by the Commission.

“We were ecstatic,” he said of the decision. “We were always extremely confident that the unanimous judgement of the Federal Court to uphold DP Hamilton’s approval of the agreements would stand up against the rigours of any legal challenge.”

Victorian nurses employed by IPHOA

were initially notified of the victory by the ANMF Vic Branch via social media.

Soon after the decision, the employer contacted staff to inform them of their intention to immediately honour the terms and conditions of the agreement.

ANMF Vic Branch Secretary Lisa Fitzpatrick, Assistant Secretary Paul Gilbert, and Industrial Officer Barry Megennis met with IPHOA in early August to discuss the retrospective wage entitlements dating back to June 2012.

At the time ANMJ went to print, the ANMF’s legal representatives were waiting for IPHOA to provide a formal position on resolving all claims with the ANMF Vic Branch.

“From our perspective, we say the agreements must be honoured from the date they were certified from,” said Mr Megennis.

Mr Megennis said the satisfying victory will result in wage rates for IPHOA nurses falling into line with industry standards for nurses working in the private sector across Victoria.

Employees working at IPHOA have not received any wage increases since 2010.

September 2015 Volume 23, No. 3 11

NEWS

Registered nurses essential in aged care, NSW inquiry told The New South Wales Nurses and Midwives’ Association (NSWNMA ANMF NSW Branch) has defended current laws that require at least one registered nurse be on duty at all times across the state’s highcare nursing homes during an Upper House Inquiry in August examining the future of the regulation.

Conducted by the General Purpose Standing Committee, three public hearings took place last month to investigate the role registered nurses play in aged care facilities.

NSWNMA General Secretary Brett Holmes said registered nurses provided a level of care that was critical to the welfare of residents and one which was unable to be carried out by less qualified staff. “These nurses have a broad knowledge and understanding of their area of expertise plus a capacity to deliver complex care needs and, importantly, assessment and supervision of staff.

“We stand firm that we believe the state legislation should continue to protect the residents of NSW aged care facilities and protect those people with high and complex care needs.

“People do not become sick when the nurse is available. Accidents, injuries, falls do not occur just because someone is rostered on duty, so the importance of 24-hour coverage is to try to provide the best quality of care.”

Joanne Russell, a nurse practitioner in aged care, addressed the hearing,

detailing her role providing advanced nursing care to residents.

Questioned over the impact of potential changes to the legislation, Ms Russell said it would pose an increased risk in delivering quality care to a patient cohort with changing and unpredictable needs.

“Without registered nurses there is no-one to make a decision,” she said.

QUESTIONED OVER THE IMPACT OF POTENTIAL CHANGES TO THE LEGISLATION, MS RUSSELL SAID IT WOULD POSE AN INCREASED RISK IN DELIVERING QUALITY CARE TO A PATIENT COHORT WITH CHANGING AND UNPREDICTABLE NEEDS.

“Often it is on a knife’s edge and the fully trained registered nurse can make an informed, intelligent decision.”

Ms Russell told the hearing registered nurses have the ability to recognise complex issues and provide appropriate support.

She also said assistants in nursing faced with high-care residents often felt compelled to undertake roles

outside their scope of training and feel unprepared for the duties they are asked to perform. “I think carers who were asked to look after frail older people – for example on a weekend or night duty when there are no registered nurses available – feel compelled to provide care at a level higher than their qualifications, which are very minimal, enable them to do safely.”

The NSWNMA has been calling on the NSW government to retain nurses in aged care facilities with high-care residents, following changes to the Commonwealth Aged Care Act 1997, which came into effect in July, 2014, and impacted upon definitions within the NSW Public Health Act 2010.

In June last year, the NSW government introduced an interim measure to keep the current requirement until it conducted consultations with the sector via a Steering Committee.

A final decision rests with the NSW Minister for Health and is expected by the end of the year.

Mr Holmes acknowledged that many aged care providers abide by the laws, but added he was fearful new commercial operators entering the sector could exploit the diminished regulations.

He said it was imperative residents accessing high-care facilities receive what they paid for. “Our contention is that if they [aged care operators] are receiving money from the Commonwealth, which is classed as for high care and complex care, then they have an absolute obligation – and we should absolutely hold them to account for that – to use taxpayers’ dollars to deliver that care.”

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NEWS

Breast checks down Almost half of Victoria is below the statewide average for accessing free breast cancer checks.

Rally against China Free Trade Agreement Nurses and midwives in the ACT joined others in a rally against the China Free Trade Agreement in Canberra last month.

The federal government signed off on the China-Australia Free Trade Agreement (ChAFTA) in Canberra on 17 June. Rallies against ChAFTA organised by unions were held across the country in July and August.

ANMF ACT Branch Secretary Jenny Miragaya spoke at the rally of the union’s concerns that qualifications other than Australian standards may be acceptable under the agreement. “I am concerned that it is Australian nurses who will be required to care for workers hurt or injured on these sites, and it is home grown and educated Australian trained nurses and midwives who may be left unemployed or under-employed if an acceptance of ‘alternative qualifications’ becomes entrenched within the Australian health and aged care sectors.”

Ms Miragaya said the ANMF had always supported national and international movement of nurses and midwives. While there was a place for temporary skilled migration programs to meet short term and unexpected skill shortages, overseas trained nurses and

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midwives must meet Australian nursing and midwifery accreditation and regulation standards, she said. “The ANMF is concerned that while currently there is no recognition of alternative credentials in the absence of a skills and competency assessment undertaken by the Australian Nursing and Midwifery Accreditation Council (ANMAC) what happens to the high standards of nursing and midwifery care available within Australia, if ‘alternative credentials’ other than those required by ANMAC, become acceptable under the China Free Trade Agreement.”

This was of extreme importance to all Australians who expected service providers to be licensed, regulated and qualified to meet Australian work, health, safety and professional standards, Ms Miragaya said.

Unions have raised concerns that currently Australian workers looking for jobs face the highest unemployment rate in Australia since 2003. “Currently there are over 3,000 nursing graduates who cannot find jobs,” Ms Miragaya said.

In 2012-2014, Victoria’s average participation rate in the free two-yearly breast screen checks for women aged 50-69 was 54%.

Data released last month shows 47 electorates were above the average, 33 electorates were below, while eight were on par. Bellarine had the highest participation rate in Victoria at 63%, with Niddrie next at 61%. Women in the electorates of Bendigo East, Essendon and Geelong had participation rates of 60%. The inner city suburbs of Prahran had the lowest participation rate at 45%, followed by Albert Park at 46%, with the city of Melbourne at 47%.

Victorian Parliamentary Secretary for Health, Mary-Anne Thomas encouraged women, particularly those over the age of 50, to have their breasts screened regularly. “This data reminds us that we have more to do to raise awareness of the importance of regular breast screening.” www.breastscreening.org.au

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NEWS FROM L-R ANITA STIRLING WITH ANGUS, ANMF ASSISTANT FEDERAL SECRETARY ANNIE BUTLER AND PHOEBE MCDONAGH HOLDING TWINS SUMMER AND SYDNEY.

Inquiry into paid parental leave moves ahead The Australian Nursing and Midwifery Federation (ANMF) is ramping up the fight against drastic cuts to paid parental leave that threaten to strip away access to 18 weeks of government funded parental leave for almost 80,000 parents.

The widely condemned plans, announced by the Abbott government earlier this year, presented a glaring backflip from previous election promises committing to a 26 week policy.

The inquiry into the Fairer Paid Parental Leave Amendment Bill 2015 is being heard this month at a public hearing to the Senate Community Affairs Committee after the period for submissions officially closed in July.

In its submission to the committee, the ANMF underlined the importance of maintaining the current paid parental leave scheme, citing health benefits to mothers and newborns and an increased sense of security as privileges all parents should be able to enjoy.

An ANMF survey conducted in June received strong opposition to the plans.

Key findings included more than 35% of people reporting that they had accessed the government’s PPL scheme, with 85.7% of respondents reporting they had accessed both employer based and government funded schemes in a bid to spend more time at home with their newborn. Significantly, 90% of people listed financial pressures as the key factor in their decision to return to work, while 71% of prospective parents indicated the government’s plans to slash paid parental leave would directly influence their decision to start a family.

Part of the ANMF’s submission drew on real life experiences from working nurses and midwives across the profession. Registered nurse Phoebe McDonagh, who works in the neonatal intensive and special care unit at the Royal

Women’s Hospital in Melbourne, is the mother of four, including six month old twin girls Summer and Sydney. Currently on parental leave, Phoebe said having access to both employer and government provided paid parental leave entitlements had supported her ability to raise a family and stay connected in her industry.

“Pretty much as soon as the leave runs out I have to be back to work,” she said.

“I have had the benefit to see how good this scheme is.”

Phoebe believes the government is targeting women and dismissing the wideranging contributions they could make to society. “If you put that money in you’re going to reap the rewards later. It’s not about women individually getting an extra $11,000. We’re paying them, for the work that they do longer term to set up our communities as a whole.”

Clinical care nurse and advanced life support paramedic Anita Stirling, is mother to three, her youngest is just three months old.

All of Anita’s children were born prematurely and required various lengths of stay in hospital following their births.

Anita said without the current paid parental leave arrangements she and her partner would not have been able to cope. “Angus is my third premature baby so we knew there would be a very good chance we would have another small person. So if there wasn’t that support there, and that safety net, there’s no way that we could afford it.”

Anita revealed some of her colleagues have brought forward their plans to start a family in the hope of accessing the current scheme before it potentially gets wiped out for good. “It’s really sad that you have to plan to try and fall pregnant for that.”

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WORLD

KENYA: Rural village health centre awarded for skilled births A community health centre in Western Kenya, with the support of Australian nurses, has taken out first position for skilled birth deliveries in the region.

The Odede Community Health Centre has been awarded first position for skilled deliveries in Rarieda Sub County for 2014.

World Youth International (WYI) opened the centre in the extremely poor area in March 2013 to provide vital health and medical services to the community.

“This is a great win for the health centre as it acknowledges the high standards of care given to patients and the hard work that has gone into creating a highly skilled service,” WYI Major Projects Manager of Kenya Celia Boyd said. “For women, there are not that many places to go to give birth. Many women have to travel 30km to hospital. While 30km may not seem that far, most people live on less than $1 a day they cannot afford the trip there and back.”

One woman who had gone into labour attempted to walk the 30km distance to the nearest hospital, ended up at the steps of the Odede Health Centre before it had opened. A nurse, who was being interviewed for a position, delivered the baby.

Health promotion and education was paramount, Ms Boyd said. “People often arrive too late, a woman may be 20 hours in labour before she goes to the hospital, there are complications for the mother and

baby; we need to convey to people the benefits of healthcare.”

WYI aims at development of community-led, sustainable projects.

It’s Nurses in Action (NIA) program has volunteer nurses assist and help educate local staff to deliver quality care in their communities. Ms Boyd said local ownership of the Odede Health Centre, overseen by a respected local leader, was seen two and a half years on through the villagers’ passion.

“This is an extremely poor area with very low education and literacy levels, most people have not gone to high school.”

Everyone employed under the professional level of nurse is from the village. “They come from the same area and all speak the local tribal language,” Ms Boyd said. “This is the first facility in this village that has provided stable employment; for many it has been the first opportunity for employment,” Ms Boyd said.

The expectation of standards, including hygiene and quality of care, of volunteer nurses had raised the bar for the community, Ms Boyd said. International volunteer nurses gained skills working in a developing country with limited resources.

“The biggest problem is malaria and typhoid. There are also a lot of STDs. In terms of specialty areas, the biggest factor is maternal and infant health, with immunisations and mother and children clinics etc. There is also one day HIV screening and counselling.”

For more information on volunteering or donation, visit www.worldyouth.org.au

IRELAND: Trolley waits peak Ireland has reached its highest ever level of emergency department overcrowding, with a stark warning issued ahead of winter.

The Irish Nurses and Midwives Organisation (INMO) found a 21% increase on 2014 figures, with a record 6,715 patients waiting on trolleys, in its Trolley/Ward Watch figures for July. The top four hospital EDs that experienced the highest overcrowding, saw increases from 50 to 111% on figures from last year.

The INMO warned the unprecedented level of overcrowding raised serious concerns ahead of the autumn/ winter period. The INMO sought an immediate meeting with the Health Service Executive and Department of Health. “The health service must be given an additional funding allocation which will allow it, without waiting for the coming winter period or the next financial year, to open additional beds, with extra staff, immediately,” INMO General Secretary Liam Doran said.

Student nurses in mobile clinics Forget sightseeing in Bangkok. A group of nursing students and their lecturer worked in mobile health clinics in remote mountain villages of Thailand recently delivering primary healthcare.

It was the first trip to Thailand for Charles Sturt University (CSU) Bachelor of Nursing students undertaking studies in child, adolescent and family health.

The student nurses worked alongside Thai nursing teams assessing patients, providing care and assisting with medications. They also delivered health education and promotion, including basic hand washing. Tackling humidity and little sleep, they became adapted to ‘bucket showers’ and ‘squat toilets’. anmf.org.au

Academic Advisor for the Bachelor of Nursing program in the School of Nursing, Midwifery & Indigenous Health at CSU in Dubbo, Cathy Maginnis said the students saw the importance of the mobile health clinics, which may only visit an area once a month. On one day, two cases seen at the clinic were rushed to hospital by car - one a reaction to a bite and the other a severe case of jaundice. Both were potentially life-

threatening. “It was an eye-opener for students – what happens on those days when the clinic is not there?”

The experience gave students a better concept of nursing and local and Indigenous culture; and how it related back to nursing in Australia, Ms Maginnis said. “It’s an important part of a curriculum to have this opportunity. We often take for granted our health system in Australia.”

September 2015 Volume 23, No. 3 15

CSU NURSING STUDENTS IN THAILAND WITH LOCAL STAFF AND DIGNITARIES

THAILAND:

WORKING LIFE ISSUES

Respiratory rate: overlooked but vital Catherine Taylor Respiratory rate is well documented as an important signal of clinical deterioration, yet is the most common poorly documented vital sign (Hillman et al. 2005). If respiratory rate is such an important marker of a patient’s physiological change, then why does this discrepancy occur? What impact does it have on patient care and what can be done to change?

What makes respiratory rate so important?

An alteration outside of the ‘normal’ parameters of respiratory rate is usually due to the body’s attempt to correct physiological disturbances to homeostasis such as hypoxia, hypercapnia and blood pH abnormalities (Parkes, 2011).

It is often the first of vital signs to show a variance to ‘normal’ values, yet its importance is undervalued by clinicians, both nursing and medical.

A major factor is the ability of clinicians to measure and document respiratory rate appropriately.

Not only is respiratory rate the most commonly omitted vital sign from documentation, it is also guessed, estimated and repeated from previous entries by clinicians, doctors and nurses alike (Cooper et al. 2014).

Respiratory rate is measured in only approximately one fifth of all sets of vital signs each day (Mitchell and Van Leuvan, 2008).

When 58% of respiratory rates documented are incorrect (Semler et al. 2013), this equates to one correctly documented respiratory rate 0.5 times per day. This poor statistic for patients in the acute 16 September 2015 Volume 23, No. 3

hospital environment demonstrates neglect for patient monitoring, with potentially disastrous consequences.

Despite this, 80% of clinicians consider respiratory rate as a ‘very good’ indicator for a sick patient (Philip et al. 2013).

Incorrect data collection can lead to the prescription of medications, treatments or therapies which is not required and may be detrimental to a patient’s condition.

Legal complications of inaccurate documentation also should be considered.

Early detection Nurses and doctors report respiratory rate is not assessed accurately due to lack of time, laziness and lack of training/ knowledge (Philip et al. 2013).

Poor patient assessment can have a marked impact on decisions which affect patient care. Medical Emergency Teams (MET) are activated due to disturbed physiological parameters such as blood pressure, pulse, temperature and respiratory rate with the aim of early detection and prevention of adverse or sentinel events (Hillman et al. 2005). With inaccurate or missing vital sign data, it alters

foundations of early detection and patient status over time, making it difficult for MET to assess.

Another influence is the introduction of automated observation machines which provide measurements for blood pressure, pulse, pulse oximetry and temperature, however not for respiratory rate (Philip et al. 2013).

Unless a patient is ventilated, there is no automated device to measure respiratory rate in a ward setting. It is extensively documented that oxygen saturations are a poor and late indication of respiratory deterioration (Jacques et al. 2006): respiratory rate is the primary technique to measure respiratory status.

Clinicians are often time poor and, particularly within the nursing profession, practice has become task orientated due to high workloads and task allocation practices (Hogan, 2006). With the high acuity of hospitalised patients, the routine task of observations and what they indicate may be overlooked or not recognised as a high priority.

The teaching of patient observations may be distorted between university learning and hospital practice as respiratory rate may not be taught in conjunction with other vital signs, but alongside oxygen therapy (Hogan, 2006).

This has implications on students who may view respiratory rate only relevant for patients receiving oxygen therapy. The alignment of methods in education with clinical practice should be considered a priority for both education providers and hospitals to educate nursing students at the grass roots level.

If clinicians consider the importance and repercussions of respiratory rate assessment and documentation, it can be postulated the number of accurate and complete vital sign recordings would increase. This can be achieved through various methods at all stages of learning from student to advanced practice clinician.

Respiratory rate is a simple skill to perform which can identify early patient deterioration and is a critical vital sign.

Acknowledgments Monash University - Berwick Campus, Victoria Catherine Taylor is a Graduate Registered Nurse Eastern Health, Victoria

58% 58% OF RESPIRATORY RATES DOCUMENTED ARE INCORRECT

References Cooper, S., Cant, R. and Sparkes, L. 2014.

‘Respiratory rate records: the repeated rate’, Journal of Clinical Nursing, 23,1236-1238.

Hillman, K., Chen, J., Cretikos, M., Bellomo, R., Brown, D., Doig, G., Finfer, S. and Flabouris, A. 2005. ‘Introduction of the Medical Emergency Team (MET) system: a Cluster-Randomised Controlled Trial’, Lancet, 365,2091-2097.

Hogan, J. 2006. ‘Why don’t nurses monitor the respiratory rate of patients?’ British Journal of Nursing, 15(9), 489-492.

Jacques, T., Harrison, G., McLaws, M. and Kilborn, G. 2006. ‘Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting’, Resuscitation, 69(2),175-183.

Mitchell, I. and Van Leuvan, C. 2008. ‘Missed Opportunities? An observational study of vital sign measurements’, Critical Care and Resuscitation, 10(2),115118.

Parkes, R. (2011). Rate Of Respiration: The Forgotten Vital Sign.

Emergency Nurse, 19(2), 12-18.

Philip, K., Richardson, R. and Cohen, M. 2013. ‘Staff perceptions of respiratory rate measurement in a general hospital’, British Journal of Nursing, 22(10),570-574.

Semler, W., Stover, D., Copland, A., Hong, G., Johnson, M., Kriss, M. and Rice, T. 2013. ‘Flash mob research: a singleday, multicenter, resident directed study of respiratory rate’, CHEST, 143(6),1740-1744.

anmf.org.au

INDUSTRIAL

Productivity Commission draft report In the lead up to the next federal election, Australians will be experiencing ‘Groundhog Day’ following the release of yet another report containing proposals for ‘industrial relations reform’.

Andrew McCarthy, Federal Industrial Officer

anmf.org.au

Since the Howard government was defeated in 2007 largely as a result of its WorkChoices laws, the conservative parties have been considering alternative ways to finally achieve lasting ideological reforms to Australia’s industrial relations system. As part of this strategy, the Abbott government earlier this year commissioned the dryly economic Productivity Commission (PC) to undertake yet another inquiry and produce a suitable report which the government can use to make its case for changes at the next election.

The PC duly delivered in early August with its 1,000-page draft report into Australia’s Workplace Relations Framework. While the PC’s public take is that the IR system just ‘needs repair not replacement’, its recommendations if taken up by the government would clearly and significantly tilt the playing field towards employers away from employees.

Of most obvious concern are the PC’s recommendations regarding penalty rates, socalled ‘enterprise contracts’, and changes to the composition and independence of the Fair Work Commission.

The PC makes some positive comments about penalty rates and generally does not recommend changes in rates, stating that there are compelling grounds for penalty rates for overtime, night and shift work and notes the proven adverse health effects from night shift and rotating shift work.

The PC however makes a dubious distinction between work in retail and hospitality and other industries (including health) and goes on to recommend that Sunday rates in retail and hospitality be reduced to the level of Saturday rates. While it is encouraging that the PC supports the concept of penalty rates more widely, it does not take too much a leap to wonder what other industries will next be seen as an ‘exception’ to the general rule if workers in retail start having their penalty rates cut. No doubt the argument then will be that it is a precedent that should be extended more widely.

THE LATEST PC PROPOSAL THEN IS SIMPLY THE LATEST IN A LONG LINE OF ATTEMPTS TO RESURRECT THE CONCEPT. Another PC proposal is to introduce something called an ‘enterprise contract’. One of the key reasons WorkChoices was so unpopular was its introduction of a form of individual contract called an AWA (Australian Workplace Agreement). AWAs enabled employers to offer wages and conditions that were worse than the minimum standards contained in awards. The public backlash against

them, resulting in the Howard government’s loss of power in the 2007 election, meant that the Coalition has ever since proclaimed that it “heard the message loud and clear” (as it did again last month after the release of the PC report). However the Coalition, and the economically dry Productivity Commission, are still wedded to the concept of individual bargaining.

The latest PC proposal then is simply the latest in a long line of attempts to resurrect the concept. The PC proposes that the contract be able to be offered to prospective employees on a take it or leave it basis (ie. sign or no job), and no negotiations over the terms of the contract with new or existing employees (or their union) would be required. The contract would not need to be approved by the Fair Work Commission; rather an employee would be obliged to ‘stick their head up’ and make a complaint to the Commission about the agreement if they thought the contract was worse than the safety net. While there are laws prohibiting taking ‘adverse action’ against someone for complaining, the PC also makes recommendations that these laws should be amended; in any event, most people are understandably reluctant to take legal action due to the time and expense involved.

The independent umpire (the Fair Work Commission), which among other things makes decisions on minimum wages and conditions, ensures that agreements are better than minimum conditions and determines unfair dismissal claims is criticised by the PC for a ‘legalistic approach’ and relying too much on history and precedents. Currently most members of the Commission are appointed until the age of 65, ensuring their independence from government. The PC recommends that appointments would be for periods of five years instead, with possibility of reappointment subject to ‘performance review’.

This may lead to subtle pressure on Commission members to be more cautious in their decision making for fear of not being reappointed by a government that does not like their decisions.

The final report is due to be provided to the federal government in November 2015 following public hearings and submissions.

September 2015 Volume 23, No. 3 17

EDUCATION

Benefits of conferences In this increasingly complex healthcare environment, our careers and the level of care we provide depends on our ability to further our education, skills and knowledge. One way of extending our knowledge and enhancing our skills is through attending and participating in professional conferences.

Jodie Davis, ANMF Federal Education Officer

Conferences are offered in a variety of ways including symposiums, forums, web based and organisational conferences, many of which often occur annually.

Nursing and midwifery associations also provide annual meetings where members are invited to attend to hear speakers of general and specialised interests.

There are numerous conferences available at a national level, often these are large and attract prominent professional speakers ready to share their clinical expertise, research findings and technological and system breakthroughs.

International conferences, such as the conference held by the International Council of Nurses bring nurses and midwives together from a multitude of countries; an event that benefits the nursing and midwifery professions as a whole. There are many advantages to attending these activities. The most obvious of these is the opportunity to learn.

MEMBERS ATTENDING THIS YEAR’S CONFERENCE WILL ACQUIRE 14 HOURS TOWARDS THEIR ANNUAL CPD REQUIREMENTS.

FOR FURTHER INFORMATION ON THE NENA CONFERENCE PROGRAM INCLUDING REGISTRATION, GO TO THIS WEBSITE WWW. NENA.ORG.AU

The quality of speakers and presentations, and often the conference in general, can vary - some of them may not provide the information you are looking for. Conferences will also differ in price. Some can be quite expensive, particularly when you travel afar to attend.

Yet when you choose the one/s of interest and relevance to your practice, then they can be worth the investment in contributing to your ongoing education.

Additionally, attending a conference with a colleague that you can discuss the information shared afterwards, can help you to retain the knowledge and even possibly give you additional evidence to implement changes to your work area based on your recent learning.

Conferences can also contribute significantly to the attainment of Continuing Professional Development (CPD) that the Nursing

18 September 2015 Volume 23, No. 3

and Midwifery Board of Australia (NMBA) requires all nurses and midwives to achieve each year so as to maintain registration.

It is recommended a certificate of attendance with preferably CPD hours attained is provided at the conference you attend so that you have evidence of participation.

Documenting the reason for choosing the particular event and the influence it has had on your professional practice is also important so as to comply with the NMBA CPD Standard.

Participating in professional conferences can give opportunity to meet, interact with colleagues and experts in your area of work. Most conferences will have presenters who are authors, researchers, educators and clinicians that are recognised as experts in their field. Other opportunities include networking and developing new professional relationships with nurses and midwives from other Australian and overseas locations.

Attending professional conferences can offer the chance of learning about several relevant topics in one place. Keeping up with new advances in your profession can assist in career advancement and provide professional networking and relationship opportunities. New skills obtained can be shared with colleagues in the work place and positively affect the care received to the public.

As the peak professional and industrial organisation for nurses and midwives, the ANMF state and territory Branches provide either annual or biennial conferences, and at many of these conferences members have the opportunity to attend the professional days associated with them. Check with your Branch to see if this is relevant to you. These conferences allow for the exchange of experiences and discussion about clinical, professional and social issues that attendees feel professionally and personally passionate about.

The ANMF Federal Office also holds a Biennial National Conference for delegates from each state and territory branches to attend. The conference this year will be held in Adelaide 22 and 23 October.

This conference provides a forum for the consideration and debate of national policy of the ANMF for the ensuing two year period. As the NMBA considers membership of a professional organisation eligible CPD, members attending this year’s conference will acquire 14 hours towards their annual CPD requirements.

Preceding the ANMF Biennial Conference is the 12th Biennial National Enrolled Nurse Association (NENA) Conference. NENA is an ANMF Special Interest Group (SIG). The group’s membership is open to all enrolled nurses and student enrolled nurses in Australia.

It provides a forum for sharing information and ideas between members, raising the public profile of enrolled nursing and increasing awareness of the value of the role.

This year’s conference is open to all professionals who engage with enrolled nurses due to the dynamic speakers presenting and the recent changes to the enrolled nurse practice standards. Enrolled nurse educators and assessors and those who regularly delegate to enrolled nurses should attend if possible.

The program includes presentations from the NMBA, Australian Health Practitioner Regulation Agency (AHPRA) and Australian Nursing and Midwifery Accreditation Council (ANMAC), including the new enrolled nurse practice standards and changes to codes and guidelines affecting the practice of enrolled nurses. Ethical and legal considerations surrounding the recently introduced Border Force Act will be addressed along with the ANMF’s involvement with the Luke Batty Foundation. Enrolled nurses working in specialised areas including volunteering overseas will also be presenting, which will provide great insight into the valuable role of the enrolled nurse.

The ANMF Federal Office website offers an extensive events calendar providing nurses and midwives with information and links to multiple conferences, courses, workshops and events in every state and territory including national conferences. To access the events calendar go to http://anmf.org.au/ events-calendar. anmf.org.au

ETHICS

‘Moral panics’ and asylum seekers Megan-Jane Johnstone

Megan-Jane Johnstone

References Cohen, S. 2002. Folk devils and moral panics.

Routledge: New York.

Cohen, S. 2011. ‘Whose side were we on? The undeclared politics of moral panic theory’, Crime Media Culture, 7(3):237-243.

Goode, E. and BenYehuda, N. 2009.

Moral Panics: the social construction of deviance. WileyBlackwell: Southgate, Chichester.

Leach, M. 2003.

‘Disturbing practices: Dehumanizing asylum seekers in the refugee ‘crisis’ in Australia, 2001-2002,’ Refuge, 21(3):25-33.

Martin, G. 2015. ‘Stop the boats! Moral panic in Australia over asylum seekers’, Continuum: Journal of Media & Cultural Studies, 29(3):304-322.

Orwell, G (1946/1984edn).

‘Politics and the English language’ in G. Orwell Why I write (p102-120).

Penguin Books: London.

Megan-Jane Johnstone is Professor of Nursing in the School of Nursing and Midwifery at Deakin University in Victoria.

Professor Johnstone has extensive interest and expertise in the area of professional ethics in nursing. anmf.org.au

Desperate human beings – men, women and children – seeking asylum in Australia have been portrayed by conservative politicians and a cadre of equally conservative journalists as ‘illegals’, ‘immoral queue jumpers’, and a ‘threat to our cherished way of life’ when in reality they are none of these things (Leach, 2003).

Equally worrying is the politically motivated conflation of the world’s refugee crisis with the rise of Islamist sponsored terrorism and the recasting of Australia’s asylum seekers as ‘folk devils’ – specifically as ‘Muslin-terrorist-refugees’ – and thus as ‘suitable enemies’ who should justifiably be denounced and detained by Australia’s border protection authorities (Martin, 2015).

This overreaching mischaracterisation of asylum seekers as a threat to Australia’s societal values and interests must, however, be seen for what it is: a classic ‘moral panic’ engineered for questionable political purposes. (Recall the moral panic kindled by Prime Minister Abbott’s widely reported dog whistling hyperbole that Da’esh (IS) ‘is coming after us… is coming, if it can, for every person and for every government’ and the subliminal link of this statement to images of ‘boat people’ – read ‘Muslim-terroristsrefugees’ – invading our borders).

A question of nursing ethics Contemporary use of the notion ‘moral panic’ dates back to sociological discourses of the late1960s and a growing concern among scholars about the role of mass circulation media in misrepresenting and amplifying the occurrences and impact of social deviance (Cohen, 2002). In nursing, however, moral panic discourse has been used in commentary relating to ‘more immediate’ nursing concerns such as the management of epidemics (eg. swine flu, Ebola) and recidivism by adolescents sexually abused as children. Here it is reasonable to ask: What is moral panic? And what is its relevance to nursing discourse on the asylum seeker issue?

What is moral panic?

Moral panic may be described as a condition whereby individuals or groups feel a sudden, disproportionate and exaggerated sense of fear or alarm in response to an issue or situation they perceive as threatening to their societal

values and interests (Cohen, 2002).

The primary factors driving moral panics include: the mass media, the public, law enforcement agencies, politicians and legislators, and social movement activists. Although a ‘contested notion’, it is generally accepted that moral panics have five distinct elements: • concern (eg. as measured by media attention, opinion polls, proposed legislation, social movement activity, arrests and imprisonment, and the capacity of these things to generate widespread anxiety); • hostility (expressed via stereotypes; entails a split between ‘us’ and ‘them’ and positions outsiders as ‘folk devils’ and the enemy); • consensus (there is substantial or widespread agreement that the threat is real, serious and caused by the wrongdoing group); • disproportionality (the conduct or threats posed are exaggerated and incommensurate with ‘actual’ risks of harm); and • volatility (depending on whether a ‘folk devil’ is located and shared, panics can occur and subside in varying degrees over time) (Goode & Ben-Yehuda, 2009).

Locus of moral panics Historically moral panics have occurred in many contexts ranging from the European witch hunts of the 16-17 centuries, to the AIDS epidemic of the 1980s and, more recently, to ‘welfare cheats and single mothers’ (portrayed as ‘ripping off the system’ by making bogus or fraudulent welfare claims) (Cohen, 2002). Young, violent working class males, portrayed as hoodlums, vandals, loiterers, joy riders, etc. have also been the locus of moral panics (Cohen, 2002). Of all the sites of moral panics studied, however, anything to do with ‘immigration, migrants, multicultural absorption, refugees, border controls and asylum seekers’ have been identified as probably the most important. A key reason for this relates to these being ‘more political, more edgy and more

amenable to violence’ as well as being the most ‘politically ambiguous and intellectually difficult’ to deal with (eg. what is to be made of legal bans on women wearing a burka or hijāb – is it a victory or a defeat for advocates of multiculturalism?)

(Cohen, 2011 p242).

Relevance to the nursing profession The nursing profession prides itself on being informed, socially relevant, and passionately committed to humanitarian and social justice concerns. Even so, nurses need to be mindful that our world has changed dramatically in recent decades and arguably requires a much more sophisticated reading of the politics shaping it than has perhaps been undertaken previously.

To this end nurses need to read beyond the headlines, hoopla and hysteria about asylum seekers peddled in the media. In keeping with their professional responsibility to be well informed about and to uphold the human rights of vulnerable populations, nurses must also engage with a broader based interdisciplinary scholarship and narrative on the issue. This will enable them to better understand and interpret more reliably the political language of the day which, as George Orwell (1946/1984 edn, p120) has famously asserted, ‘is designed to make lies sound truthful and murder respectable, and to give an appearance of solidarity to pure wind.’ Drawing on Cohen (2011, p 242), it will also enable nurses to peel back the layers of the political hyperbole promulgating moral panic about Australia’s asylum seekers and to make informed judgments about how serious the perceived threat of asylum seekers ‘really’ is to our moral order, the extent to which this threat is amenable to social control, and ‘how far it invites ethical selfformation’ and indeed action on the part of the nursing profession.

September 2015 Volume 23, No. 3 19

FEATURE FEATURE

NO PLACE

HOMELESS PERSONS PROGRAM NURSE JO GIAMPETROME AND HOMELESS PERSON JUSIN.

20 September 2015 Volume 23, No. 3

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FEATURE

LIKE HOME nurses and midwives tackling homelessness

On any given night in Australia around 105,000 people will not have access to a safe and secure place to call home. Specific triggers for homelessness are varied and complex but what is certain is that it can touch anyone. Raising awareness is crucial to driving change and all Australians, including nurses and midwives, can step up to make a difference. Robert Fedele reports.

J

ustin puffs away on a cigarette while delicately clutching a mug of green tea.

He is sitting on a worn couch planted in the corner of his new home, a high-rise commission flat in Kensington in inner-city Melbourne.

The modest space is fitted with basic comforts including a kitchen, bedroom, and adjoining bathroom.

It might not look like much but it is the first real home Justin has known in a long time and the satisfaction in his eyes reveal it is his definition of a castle.

“It’s awesome,” he says of having a roof over his head. “Not just because it’s been that long, but because it’s not sort of any roof- it’s where I want to be.”

Justin’s back story is patchy but for much of his adult life, and up until recently, he was homeless.

He tells of growing up in Adelaide and experiencing a rough childhood. He left school in year 9 and did bits and pieces of work to get by thereafter. “I left school and went to work and started getting things but already by then I had habits. Things weren’t quite right.

I’d try and quit but then I’d have these problems. They wouldn’t surface straight away.”

From the age of 16 Justin “bounced around” from place to place, from Tasmania to Queensland and back to Adelaide, picking up odd jobs, couch surfing or living in a car, and sticking around until he inevitably outstayed his welcome.

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He recalls working in a restaurant in Tasmania washing dishes, laying turf in Queensland, and even joining the Army for a couple of years when he was 19.

The period during Justin’s mid 20s was dogged by living on the streets.

He describes alcohol as “my first demon” but it was heroin that would eventually take hold of him. “It’s a real trap because you can’t get any rest until you switch yourself off with drugs or get blind.”

Justin says his lifestyle began taking its toll in his late 20s and he longed for change. “But I just didn’t have the support to pull up.

To straighten up you need to be in an environment where you can do that but I could only get to places where people didn’t really want me to do that.”

Along the way there were attempts to get clean or try different paths but things always seemed to turn pear-shaped. Like the time Justin turned to medicinal marijuana as a substitute for harder drugs. “In my heart I was trying to do the right thing but when you’re freezing in the middle of winter and you can’t relax because you’re worried about the very little you have got going missing you want something just to switch yourself off from the situation.”

The last few years ran a similar course until Justin’s turning point when he was referred to housing program Melbourne Street to Home after a stint in crisis accommodation at Ozanam House

in North Melbourne.

He was also partnered with the Royal District Nursing Service’s Homeless Persons Program (HPP), which involves a team of specialist community health nurses working with and on behalf of individuals or groups experiencing homelessness.

As Justin had been homeless for at least 15 years it allowed regulators to fast track him through the system and into appropriate public housing.

It’s been a couple of months since he has had a place to call home. Through it all, HPP nurse Jo Giampetrome has been by his side and Justin counts her unwavering support as crucial to his newfound mindset.

“I’m still young but you get to a certain age where people give up on ya,” Justin says. “A whole team of people got behind me, which was great. It’s been important because of where they got me but it’s also been important because Jo’s been with me long enough to see that what I do is what I say.

Her staying the whole distance and seeing me get things has changed me.”

What Is homelessness?

The Australian Bureau of Statistics defines homelessness as a situation where a person does not have suitable accommodation alternatives and if their current living arrangement is: • In a dwelling that is inadequate • In a dwelling that has no tenure or the initial tenure is short or

September 2015 Volume 23, No. 3 21

FEATURE HOMELESNESS PREVENTION EVENT.

not extendable • Where the living arrangement

does not allow them to have control of, and access to space for social relations The ABS’ definition differentiates between ‘homelessness’ and ‘rooflessness’ by pairing home with fundamental elements including a sense of security, stability, privacy, safety, and the ability to control living space.

Homelessness is therefore a lack of one or more of these elements.

Other definitions widely used throughout the homelessness sector and adopted by the Commonwealth Advisory Committee on Homelessness in 2001 follow a three-tiered approach when categorising homelessness.

• Primary homelessness is experienced by people without conventional accommodation such as those sleeping rough.

• Secondary homelessness is experienced by people who frequently move from one temporary shelter to another such as emergency accommodation, youth refuges, or couch surfing.

• Tertiary homelessness is experienced by people staying in accommodation that falls below minimum community standards such as boarding houses or caravan parks.

Latest figures show on any given night in Australia one in 200 people are homeless.

Of more than 245,000 people assisted by homelessness services last year, almost half were young people under the age of 18.

22 September 2015 Volume 23, No. 3

Alarmingly, 41,000 of them were children under 10.

A poll of people seeking support from specialist homelessness services found domestic violence as the biggest trigger to ending up without a home.

Other chief factors included financial difficulties, housing affordability, inadequate dwellings and relationship breakdowns.

Addressing a changing problem Tackling homelessness is no easy task but numerous support services across the country believe they can make headway.

In Victoria, independent Melbourne-based community organisation Launch was established in July and marked a merger between long-standing services with similar histories and missions, HomeGround and Hanover.

Some of Launch’s services include providing crisis accommodation, running drug and alcohol programs, managing about 600 transitional properties, supporting homeless youth, and running Melbourne Street to Home, a program that helps the most vulnerable rough sleepers access safe, secure, and affordable longterm housing.

Chief Executive Officer Tony Keenan suggests the face of homelessness is changing.

“When Hanover started in 1963 homelessness was an issue that affected middle-aged men with a drinking problem around the innercity. Nowadays about 68% of our clients are women and about a third

of our clients are children.”

Mr Keenan attributes the shift to the growing awareness of domestic violence and more women feeling empowered to leave abusive relationships. “Predominantly, the women and kids are still the ones forced to flee and when they are forced to flee there’s no affordable housing.”

MR KEENAN SAYS INCREASING AFFORDABLE HOUSING STOCK MUST TIE IN WITH GOVERNMENT INTERVENTION TO ENSURE IT IS PROTECTED FOR THOSE MOST VULNERABLE. Mr Keenan claims the housing affordability crisis is spiralling out of control. “Australia has an incredibly low level of social public housing stock. Victoria is appalling. In Victoria it’s about 3.5% of the total housing stock. That includes community and public housing. By way of comparison, in the UK, it’s 30%.”

Mr Keenan says increasing affordable housing stock must tie in with government intervention to ensure it is protected for those most vulnerable.

Launch’s South Melbourne base holds 50 crisis accommodation rooms where people can stay for up to eight weeks while suitable housing is found.

People from all walks of life tread through the doors, many which experience mental illness, drug and

1 IN 200 ON ANY GIVEN NIGHT IN AUSTRALIA 1 IN 200 PEOPLE ARE HOMELESS anmf.org.au

FEATURE alcohol issues.

“It’s a heavily rationed service so the last time we did a turn away count we were turning away nine out of 10. So the people with the greatest need get here,” Mr Keenan says.

Launch is backed via various streams of combined state and federal funding but a draft Green Paper for the Reform of the Federation released earlier this year is investigating operations.

Many in the sector fear the federal government is distancing itself from homelessness and shifting responsibility onto states.

He also singled out nurses as a vital partner for leaders working in the homelessness sector, adding that many committed nurses experience the day-to-day reality of the job and deserve significant credit for maintaining healthcare in often trying circumstances.

Nurses on the frontline Michele McCarthy is one such nurse.

For the past 23 years, Michele has been an integral part of the nursing team at the Haymarket Foundation, a specialised service in inner-city Sydney that provides primary health

WE ARE LOSING THE BATTLE AT THE MOMENT, WITHOUT A DOUBT. WE VERY UNASHAMEDLY WANT TO MAKE IT ONE OF THE KEY ISSUES IN THE COMMUNITY’S MIND AND THE GOVERNMENT’S MIND. YOU CAN’T HAVE A SITUATION IN ONE OF THE WEALTHIEST COUNTRIES IN THE WORLD WHERE YOU’VE GOT INCREASING HOMELESSNESS. WHAT MAKES SENSE ABOUT THAT?

The move could lead to more economically challenged states such as Tasmania and South Australia ultimately ending up with inferior services.

“That’s quite unsettling for the sector,” Mr Keenan says.

“Clearly, our biggest concern is the opportunity for an overall loss of effort and resourcing.

“In these processes you’re always worried that it’s essentially a money saving exercise rather than good policy.”

Mr Keenan is blunt about the homelessness crisis facing Australia and predicts figures will double in Victoria in the next ten years to 22,000 unless there is serious intervention. “We are losing the battle at the moment, without a doubt. We very unashamedly want to make it one of the key issues in the community’s mind and the government’s mind. You can’t have a situation in one of the wealthiest countries in the world where you’ve got increasing homelessness. What makes sense about that?”

Mr Keenan considers increasing awareness about homelessness and pitching housing affordability as a key political issue as strategic targets moving forward. anmf.org.au

care to support homeless and disadvantaged people.

The clinic also provides showers, mail collection, support from community service workers, and a needle and syringe program.

Michele, a registered nurse, was drawn to Haymarket while working at Sydney Hospital where she saw many of the foundation’s clients come through the doors.

Funded by the Commonwealth Health Department, Haymarket’s team currently comprises two nurses, two part-time doctors and two community service workers.

In over two decades Michele has seen times change at the wellknown institution.

“It was extremely busy in those days,” she says. “It was very different to what it is now. The area was much more of a red light district and it’s gentrified now. There were a lot of working girls around when you’d come into work at 6.30am in the morning.”

Michele says twenty years ago the clinic would treat around 150 people per day but today numbers have halved.

Intravenous drug use, also rife once upon a time, has fallen in line with trends around the country, says

Michele.

But the clinic still hands out around two thousand needles and syringes per month as part of its program.

Some of the problems associated with homelessness are complex but can include: mental illness, drug and alcohol addiction, gambling, and personality disorder.

Poor literacy is also common in Haymarket’s clientele.

Nurses at Haymarket come across a gamut of problems from small cuts or abrasions to infections, cellulitis, and foot problems.

Nurses help patients manage chronic conditions like diabetes and run smoking cessation programs.

Some diabetics use the fridge to store their insulin, while others with mental health issues visit the clinic to take their medications or help themselves to a multi-vitamin.

This winter the clinic administered 110 flu vaccinations. It also offers vaccinations for Hepatitis A, Hepatitis B, and Boostrix.

In addition homeless people can come in and have a shower or pick up a clean pair of socks.

Michele explains the care they give their clientele is allencompassing. “We like to let them know what’s available and offer them help and maybe build a rapport and when and if they’re ready, suggest some help with detox or rehab.”

Michele says in the community it is very difficult to look after chronic health conditions and in the homeless population it is so much more difficult because when you are homeless and your life is chaotic it is very hard to be interested in anything apart from your immediate needs that day.

Asked about her motivations behind maintaining a career in nursing working with the homeless, Michele says the reward derives from working within a great team of doctors and welfare workers, and more importantly, a grateful client base.

“The clients are just like everybody else. They’ve all got personalities and most of them are very nice and polite. They’re just like everybody else only they can’t manage modern life quite the way other people do.”

From street to home Jo Giampetrome is one of the specialist community health nurses who provide healthcare as part of the Royal District Nursing Service’s

WHO ARE THEY?

OF PEOPLE WHO STAY IN BOARDING HOUSES: 74.8% MALE, 25.2% FEMALE

OF PEOPLE WHO SLEEP ROUGH: 67.6% MALE, 32.4% FEMALE

OF PEOPLE STAYING IN SUPPORTED ACCOMMODATION FOR THE HOMELESS: 49% MALE, 51% FEMALE

September 2015 Volume 23, No. 3 23

FEATURE (RDNS) Homeless Persons Program (HPP).

A splinter program run by HomeGround Services called Melbourne Street to Home, provides support services and health intervention to the city’s most vulnerable rough sleepers and is run in partnership with the RDNS. Melbourne Street to Home clients are long-term homeless and measured using the vulnerability index, which identifies those most at risk by assessing mental and health conditions and the length of homelessness.

Jo says homelessness can make someone sick, but also prematurely age them, adding that the ethos of HPP is that all people should be able to access healthcare.

Lots of clients experience issues such as drug addiction and mental health problems that prevent them from accessing healthcare, so HPP attempts to step in and navigate the sector for them.

Jo has five clients on her caseload, including Justin, who until recently slept rough in North Melbourne, and a girl in South Melbourne, also recently housed.

Jo says the girl in South Melbourne had been homeless for a really long time. She had been housed on and off, with behavioural issues seeing her evicted. “She bounced in and out of St Vincent’s and the Royal Melbourne hospitals almost on a daily basis. But since being housed she doesn’t present to hospital anymore.”

With this client, Jo takes the client’s medication to her home and pops it on top of the microwave so she’ll remember to take it daily.

“That’s another thing about housing.

The level of chaos is so much less.

They’ve got a roof over their head.

They feel safer and that allows us to work with them a lot more easily.”

Jo says the role of a community nurse can include wound care, medication management, monitoring, and an overarching pledge to stay connected to clients, help them navigate the sector, and refer them to other services available. “I reckon they’re a really rewarding group to look after.

Particularly in this role, you see really great outcomes for them.”

Jo met Justin after he was referred on from Ozanam House following multiple hospital admissions. Given Justin’s battle with heroin, one of the first steps in his rehabilitation was linking him 24 September 2015 Volume 23, No. 3

with a suitable GP and placing him on a Suboxone program, an opioid medication designed to help addicts wean off heroin.

Justin was given respite at a motel for a few weeks before being stabilised in medium-term housing.

Fortunately, his public housing request came through soon after.

The Street to Home program has access to funding that helped provide Justin with some basic essentials to furnish his flat including a fridge, bed, linen, plates, and washing machine.

“He’s done really well,” Jo beams. “Our goals are to eventually exit him because he’s managing on his own. The beauty with Street to Home is that he can ring us anytime.

So he’ll no longer formally be a client but he knows he’s got our number.”

Jo says navigating the homelessness sector can be difficult and that easier access to housing for people in need would be constructive. “Housing is a huge thing. It gives them a lot of hope.

As a nurse, it gives me an anchor to be able to connect with them. But it also gives me a connection to be able to work with them in terms of their health issues.”

Research Dr Yvonne Parry is a Senior Lecturer in the School of Nursing and Midwifery at Flinders University in South Australia and holds a strong interest in homelessness, specifically families at risk of homelessness.

Her research has recently involved collaborating with UnitingCare Wesley Port Adelaide to assist vulnerable children, and the Inner Southern Homelessness Service to gauge what families and staff require most to achieve

progress.

Dr Parry says changes to state policy back in 2008 applied the requirement for children to be recognised in official homelessness figures.

Previously, families could present to a service and children were rarely taken into account. Dr Parry believes the new process is important in early prevention.“Children can end up very isolated with lots of ill health and that accumulates into their adulthood. They miss developmental milestones as well as things like immunisation.”

Dr Parry’s research centred on examining how the policy change impacted the workforce at Inner Southern and whether needs of families were being met.

Findings suggested children required separate referrals than those of their parents and needed linking with education, immunisation, and wellbeing checks.

“The thing that was missing was health and that came through from both the parents and the staff and other work from the past. Health and nursing seem to be missing from the picture. Nurses play a vital role in helping any vulnerable group of people at health services.”

The findings triggered a new research project where a nurse practitioner will be employed at Inner Southern to deliver healthcare to children and families.

“There is a great need to have a nurse to address those problems and also have a look at how the parents are feeling as well,” says Dr Parry.

Dr Parry is hopeful other services across the state will follow suit and implement a nurse practitioner.

“They [the children] are part of

FROM LEFT MS WENDY RADBONE, MANAGER INNER SOUTHERN HOMELESSNESS SERVICE, ASSOCIATE PROF JULIAN GRANT SoNM FLINDERS UNIVERSITY, AND DR YVONNE PARRY CHIEF INVESTIGATOR ON THE SA SOCIAL PAEDIATRIC INITIATIVE RESEARCH PROJECT FROM SoNM FLINDERS UNIVERSITY.

WHY ARE THEY HOMELESS?

23%

DOMESTIC AND FAMILY VIOLENCE

16% FINANCIAL DIFFICULTIES

15%

HOUSING CRISIS

11%

INADEQUATE OR INAPPROPRIATE DWELLINGS

6%

RELATIONSHIP OR FAMILY BREAKDOWN

5%

HOUSING AFFORDABILITY STRESS

20%

OTHER REASONS

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FEATURE families. So the whole family is homeless. Sometimes we see helping the children as a way of helping the entire family.”

Dr Parry says her passion for addressing homelessness stems from wanting to make a difference. “ When we think of homelessness we often think of single people being homeless or single men, either young or old, being homeless. But homeless families is very much an invisible thing in our society and it’s getting worse.”

Dr Parry says while housing affordability is a serious issue, so too is the need to focus on support programs like integrating nurses into homelessness services.

She says outcomes for homeless children are often dire and many can end up with mental health issues or poor physical and chronic health conditions. Therefore prevention is paramount.

Raising awareness In August, communities across Australia united to raise awareness during Homelessness Prevention Week.

Run by Homelessness Australia (HA), the national peak body charged with representing the homelessness sector, the annual event aims to illustrate that homelessness happens to ordinary people experiencing extraordinary circumstances.

More than 150 events were held across the country to help showcase the work of homelessness services and connect them with those experiencing homelessness.

HA Chief Executive Officer Glenda Stevens said it was heartening to see members of the community show they care. “We can all actually do something to help solve this national issue. We could all take big or small steps, which will make a difference in ours and other peoples’ lives.”

HA represents some 1,300 homelessness and domestic violence services across the country. Key responsibilities include advocating on behalf of services at a federal government level, conducting research, and analysing the effectiveness of programs running across different states.

Ms Stevens says HA receives new data each year from the Australian Institute of Health and Welfare.

“We do know that more people are coming to homelessness services.

Whilst the services do an incredibly anmf.org.au

good job, more people are having to be turned away because the services don’t have the resources,” Ms Stevens says.

Domestic violence, still the biggest trigger to homelessness, significantly contributed to 41,000 children under 10 presenting to homelessness services in 2013/14.

“About 41,000 children technically homeless is really quite frightening when you look at what happens to those children in the long-term if they aren’t suitably housed quickly.”

Ms Stevens concedes homeless is a broad and complex issue, but believes it can be addressed with appropriate government effort.

“First of all, we need to have more accommodation and to have that we just need political will to get it done.

It’s pretty simple.

“What we have now is lots of people coming in the front door but they’re getting caught in the system because there’s nowhere for them to go that’s affordably appropriate.

“There’s no point in finding accommodation for a family way out of the city where there’s no transport, no hope of getting employment, and no nearby schools or community.”

Ms Stevens acknowledges that the government has upped its attention on domestic violence and believes it will have a positive ripple effect. “As we know, children who experience homelessness are more likely to experience homelessness as an adult. So we’re stopping that

ABOUT 41,000 CHILDREN TECHNICALLY HOMELESS IS REALLY QUITE FRIGHTENING WHEN YOU LOOK AT WHAT HAPPENS TO THOSE CHILDREN IN THE LONG-TERM IF THEY AREN’T SUITABLY HOUSED QUICKLY. generational problem by addressing domestic violence.”

Ms Stevens says it’s important the structural drivers behind homelessness are continually tackled. She is hopeful the draft Green Paper will be corrected so it adequately confronts the issue.

Ms Stevens says the federal government has already begun decreasing its funding to Homeless Australia and other housing peak bodies. “It’s very disappointing because there’s many federal drivers to homelessness.

Immigration, taxation, employment, education, that all fits in with the federal government.

“They have a great deal of influence into what influences homelessness. We feel it’s something that needs a national framework and sitting within the national framework would be state and regional frameworks and local frameworks. So we eliminate any waste in terms of time and effort and money and we also don’t have any gaps.”

105,237

NUMBER OF PEOPLE

56% 48% 25%

INDIGENOUS (COMPARED TO JUST UNDER 3% OF THE POPULATION)

30%

BORN OVERSEAS

September 2015 Volume 23, No. 3 25

ISSUES

Psychotropic medication and the compliant patient Mick Hawkins There seems to be little available literature, except for opinion, as to why people with a mental illness who are heavy users of illicit substances refuse prescription medication. Yet, there is much research on compliance; and a mass of anecdotal literature on the use of illicit drugs.

One hypothesis is people with a psychiatric illness who self-medicate with illicit substances may deem themselves to be ‘in charge’ of the process; whereas acceptance of prescription medication may be seen as a loss of control or autonomy.

What does have some evidence is the contention that ‘psychiatric patients’ are less compliant than ‘general patients’ and the more symptoms present in a psychiatric illness, the lower the compliance.

A classic vicious circle follows. Poor compliance leads to an increase in symptoms which triggers less compliance. As symptoms increase, perhaps there is a greater motivation to try the ‘quick fix’ it is believed illicit substances will achieve.

Literature suggests mental illness provides the worst scenario for poor compliance, combined with the use of illicit substances.

Acknowledgement of mental illness is often harder to achieve than that of a physical illness. One reason is that symptoms may be less apparent to the person than to those around them. If a person does not accept he or she has an illness, then medication designed to help manage it is hardly likely to be accepted.

Much is written on the importance of the ‘doctor/patient’ relationship, that is, the person who determines the medication has the prime role in motivating the sufferer to accept it. In multidisciplinary mental health teams where the care coordinator/case manager is not the prescriber, this ideal is not possible. Put simply, the medical practitioner does not have adequate exposure to the patient so as to properly motivate and educate on compliance. Even in the private sector, neither GP nor consultant has the time to educate adequately.

Despite this, evidence shows that compliance, combined with the avoidance of illicit substances is best achieved by improved patient comprehension, improved patient recall, and improved patient motivation. How are these things to be achieved?

Clearly a care coordinator/ 26 September 2015 Volume 23, No. 3

case manager and possibly a practice nurse can play a role in comprehension, recall, and motivation. But an examination of each reveals some barriers.

Comprehension To achieve patient comprehension, a health professional needs to overcome: • reluctance to acknowledge there is a problem; • preconceived or past experience ideas about the effects of prescription medicine; • inability to accept that medication side effects are preferable to recurrence of symptoms; • inappropriate advice from relatives and other resources; and • advantages flowing from a continuation of the mental illness such as DSP (disability support pension) eligibility.

Recall Recall is largely dependent on a patient’s short and long term memory which are the very functions often associated with the mental illness. Another vicious circle is encountered. Until therapy (in this case, medication) is effective in restoring ‘normal’ capacity the patient’s recall will not be adequate to ensure proper compliance.

Motivation Without adequate comprehension and recall it seems unlikely that motivation will be achieved. Before motivation exists there needs to be: • Acknowledgement by a patient that there is a problem; and acceptance that medication is the ‘lesser evil’.

• Understanding that the long term use of illicit drugs is detrimental because she/he is able to recall bad effects from the past; and information on how medication works as well as its advantages.

Questions There are a number of questions healthcare professionals need to ask themselves in terms of barriers

to gaining medication compliance for those with a mental illness.

• Are any of the barriers described attributable to the organisation or system of governance?

• If they are, why and what changes are possible at various levels?

• If not, what can be done to minimise the effects of these barriers?

Compulsion to achieve compliance Reliance on community or involuntary treatment orders to meet a medication schedule as prescribed may be perceived by a patient as eroding autonomy. Additionally, such reliance makes no contribution to enhancing comprehension, recall, and motivation; in fact it is regressive in that respect.

Other approaches There are a number of practical questions that arise in addressing medication compliance for a person with a mental illness. Below outlines some questions and possible approaches to take.

• Is it possible to press for a more flexible schedule from medical prescribers and give the patient choices?

• Can we offer the first medication to the patient as an ‘ambit claim’ so that the final solution is seen as part of her/his initiative?

• How often do we start the non-medication therapy and general support first so that the patient has some trust in us before we start modifying his bodily functions?

• How do we help the patient discern that there are no advantages from being perceived as mentally ill?

• Do we really understand that from the perspective of some patients, medication side effects are worse than the symptoms of their illness?

• Do we concentrate too much on trying to counter the influence of alternative therapies rather than attempting to have clients acknowledge these as complementary therapies?

Mick Hawkins graduated from Flinders University School of Nursing in 1998. He has worked in mental health nursing since 2001 predominantly within the community anmf.org.au

WELLBEING

Mindfulness in practice Natalie Dragon Five minutes a day of mindfulness can increase focus, decrease stress and improve resilience and wellbeing after six weeks, says Monash University’s School of Nursing and Midwifery Senior Research Fellow Jill Beattie.

There are a lot of misconceptions about what mindfulness is, says Jill, which is a sort of mental training or discipline, aimed at training attention and emotional regulation.

Mindfulness is an approach to daily life and includes the more formal practice of mindfulness meditation.

“It’s about paying attention with openness and curiosity to both internal experiences such as your thoughts, emotions and body sensations, and to external experiences going on around you, and accepting them in a nonjudgemental way. “If you know you are going to have a busy day, your mind has already started worrying which can lead to stress or anxiety.

When you are anxious or ruminating, you lose the ability to perceive and see what’s around you accurately”.

“One of the biggest roles for nurses is their organisational ability and flexibility; and the need to change midway to adapt to changing situations. This is very difficult to do when stressed and anxious”.

The wandering mind An untrained mind, in ‘default mode’, is a wandering mind, and research has shown that a wandering mind can be an unhappy mind says Jill. The research showed that when people were focussed on what they were currently doing, even if the work was hard - they were happier. “When our thoughts wander, we can think about things over and over again which can lead to stress and depression”.

Mindfulness increases our awareness What’s very crucial is that things are still going to happen – emergencies are going to happen, it’s about how we react to them. “If a patient doesn’t look well, we can start to panic and feel constricted – these are body sensations. Behaviour therapy shows that it’s actually our body sensations, anmf.org.au

such as constriction and tenseness in gut that influences how we react.

We can have similar body sensations in a variety of situations, yet react in similar ways without realising it.

When we are on ‘automatic pilot’, we do not pay attention to body cues.

Through mindfulness we can learn to recognise and pay attention to these early and take a mindful breath – focus on your breath as it comes in, and out, feeling it as it enters and leaves your nostrils; this only takes a few moments and will bring you into the present, increase your assessment ability and appropriate management of the situation. Mindfulness is about accepting things as they are and paying attention to what’s happening in the present experience, says Jill.

This is a really important message for nurses who work on a busy ward.”

Improving sleep One exercise that can be done to relax between a late/early is to lie down in bed, take a few breaths and just be aware of the body, says Jill.

“Scan your body. What am I feeling? What are the body sensations? Feel if there are any places of tension. Take a few normal, regular breaths and focus on the air entering and leaving the nostrils. Feel your body start to slow down quite quickly.”

People lie down ready to go to sleep, but often wake up during the night unable to get back to sleep because of their intrusive thoughts, says Jill. “This is why it’s beneficial to practice mindfulness of breathing before you go to sleep - to accept those thoughts without judgement, just keep returning to the breath. When we do not ‘feed’ the thoughts, they subside – this is how the brain works. If you’re trying to get back to sleep, recognise those thoughts - let them come and go - but don’t engage with or have a conversation with them.

“One of the things I found is that once you start living more mindfully, especially making time for mindfulness meditation, sleep is one of the first things that improve”

Daily habit Living mindfully changes how we go about our daily lives, says Jill.

“When we wake up, we usually shoot out of bed, instead of noticing how the body is feeling – putting our feet on the ground, noticing how we are standing – bringing our body into the present as we brush our teeth, shower and

before we go about the day.”

The key in mindfulness meditation and mindfulness in daily life is to decrease emotional reaction and increase awareness and acceptance, not push uncomfortable thoughts and emotions down, says Jill. “Our thoughts and emotions are transitory - they will pass. We can observe our thoughts, without having to change with them. Pay attention and accept them and our emotional body sensations, do not engage with them and they go quite quickly.”

Ideally people should take some time out for mindfulness, at least five minutes in the morning and evening, says Jill. Mindfulness can be seen as a mental discipline, she says. “It’s like being physically fit – you need to exercise regularly and properly and with adequate practice to experience its full benefits. Once a person gets into the practice, they start to see the benefits. With practice, you are able to recognise earlier and earlier when you are stressed and uptight; once you recognise this you take a breath now, instead of getting to the panic stage.”

One of the things nurses find after starting mindfulness is awareness of their body, says Jill.

“Most health professionals do not live in their own body. When they become more aware, more present, and more compassionate towards themselves, their self-care increases – this is important if we are caring for others.”

This has added benefits for the workplace, Jill says. “It enables you to assess patients more accurately.

You are more aware, able to respond rather than react, and patient and medication errors decrease.

Reference Killingsworth, M. and Gilbert, D. 2010. ‘A wandering mind is an unhappy mind,’ Science, 330:932.

Dr Jill Beattie is an Adjunct Senior Research Fellow in the School of Nursing and Midwifery, Monash University, Victoria. She is also a mindfulness-based emotional fitness consultant and has delivered mindfulness education to doctors, nurses and families of defence force personnel.

September 2015 Volume 23, No. 3 27

CLINICAL UPDATE

The barriers and enablers related to the early recognition of delirium in older palliative care patients - An integrative literature review Mary Bozzo Delirium is a complex neuropsychiatric syndrome which is often under-recognised by nurses. Studies have shown that nurses do detect changes but these are not linked with an understanding or recognition of delirium.

This integrative literature review aims to explore barriers and enablers raised by nurses which impact on the timely recognition of delirium in older palliative care patients.

Methods Studies from 1988-2014 were identified using an inclusion/ exclusion criteria reporting on nursing assessment and recognition of delirium in older palliative patients. ProQuest and Google Scholar were the databases used in addition to Medline/PubMed using the “delirium” filter from CareSearch.

Results Three studies met the selection criteria. Similar results emerged despite the heterogeneity of the studies related to methods, design and patient population.

Conclusion This integrative literature review has identified that nurses working in different healthcare settings, including palliative care, have similar views, practices and experiences related to barriers and enablers believed to impact assessment and recognition of delirium. However more studies are needed, in settings other than inpatient palliative settings, in a variety of countries and in older palliative patients.

Introduction Delirium is the most common neuropsychiatric complication in advanced cancer (Brietbart & Alici, 2011). It is characterised by: • A. Disturbance in attention (that is a reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment); • B. the disturbance develops over a short period of time (usually 28 September 2015 Volume 23, No. 3

hours to a few days) represents an acute change from baseline attention and awareness and tends to fluctuate in severity during the course of a day; • C. an additional disturbance in cognition (eg. memory deficit, disorientation, language, visuospatial ability, or perception); • D. the disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as a coma; and • E. there is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (ie. due to a drug of abuse or to a medication) or exposure to a toxin or is due to multiple aetiologies, (Diagnostic Statistical Manual of Mental Disorders - DSM-5 European Delirium Association and American Delirium Society 2014).

Based on eight different screening and assessment tools, the incidence in palliative care inpatients, ranges from 3 – 45% (Hosie et al. 2012). Prevalence rates: 13.3 – 42.3% at admission, 26 – 62% during the length of stay in hospital, increasing to 58.8 – 88% weeks to hours preceding death has been reported (Hosie et al. 2012).

What is known about nursing assessment?

As nurses provide 24 hour care at the bedside, they can be better utilised in the early recognition of delirium. However, all the evidence so far stresses nursing assessment have been based on rapid informal assessments contributing to missed delirium incidences (Dahkle & Phinney, 2008, Agar et al. 2012). When directly comparing nurse clinical assessment with gold standard definitions, nurse recognition of delirium ranged from 26 - 83%, highlighting 17 - 74% missed delirium incidences (Steis &

Fick, 2008).

Through rapid assessment, however, it has been proven that nurses detect change (Dahkle & Phinney, 2008, Agar et al. 2012), but these changes are not linked with delirium (Dahkle & Phinney, 2008, Steis & Fick, 2008, Agar et al.

2012, Hosie et al. 2014b). Nurses recognise that delirious patients are distressed, confused, that their behaviour is inappropriate and they need help (Steis & Fick, 2008).

Barriers to the comprehensive assessment of delirium The literature has clearly highlighted that nurses have a poor knowledge of the Diagnostic Criteria for Delirium (DSM-5) included in the Diagnostic Statistical Manual of Mental Disorders (Hosie et al. 2014a, Agar et al. 2012).

Nursing assessment is based on behavioural and cognitive changes rather than monitoring for key symptoms (Dahkle & Phinney, 2008, Steis & Fick 2008).

Signs and symptoms such as acute onset, fluctuations of symptoms, inattention, disorganised thinking, memory impairment, perceptual disturbances, psychomotor agitation/retardation and changes in circadian cycle and the hypoactive variant are not recognised (Agar et al. 2012).

Early detection of delirium particularly in the context of hypoactive delirium, which can easily be mistaken for either depression or profound fatigue with its characteristics psychomotor retardation, paucity of speech with or without prompting, lethargy and reduced awareness of surroundings, has been clearly shown in the literature as one of the four major predisposing factors for delirium in addition to age (80 years and older), visual impairment and dementia (Inouye et al. 2001, Spiller & Keen 2006, Brietbart & Alici 2011, Hosie et al. 2014b).

It has also been proven that the under-recognition by nurses increases the number of risk factors present. If patients have three or four of these, under-recognition by nurses increases by 20-fold (Inouye et al.

2001, Steis & Fick 2008).

References Agar M, Draper B, Phillips P. A., Phillips J, Collier A, Harlum J & Currow D (2012) Making decisions about delirium: A qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry and oncology Palliative Medicine Vol.26 pp: 887-896 American Psychiatric Association (2013) Diagnostic Statistical Manual for Mental Disorders, Fifth Edition [Electronic version] Retrieved 16th November 2013 from Google web site: www. dsm5.org Brietbart W & Alici Y (2011) Delirium in Supportive Oncology [Electronic version] Retrieved 8th September 2013 from Google web site: www. sciencedirect.com.pp: 541- 554 Bush S., H., & Bruera E., (2009) The Assessment and Management of Delirium in Cancer Patients The Oncologist Vol.14 pp: 1039-1049 CareSearch (2013) Palliative Care Network Retrieved 25th October 2014 from Google web site: www.caresearch. com.au Crane K (2012) Cancer in the Developing World: Palliative Care Gains Ground in Developing Countries [Electronic version] Retrieved 13th February 2015 from Google web site: www. scholar.google.com. au Journal of National Cancer Institute pp:1613-15 Dahlke S & Phinney A (2008) Caring for Hospitalized Older Adults at Risk for Delirium Journal of Gerontological Nursing Vol. 34, No. 6 pp: 46-47 Delirium Clinical Guidelines Expert Working Group (2006) Clinical practice guidelines for the management of delirium in older people Retrieved 23 August 2013 from Google web site:

anmf.org.au

CLINICAL UPDATE Implications for nursing practice Under-recognition leads to undertreatment and poor outcomes (Inouye 2006, Irwin et al. 2008).

This is evidenced through longer institutionalisation at a greater cost to the healthcare system (Milisen et al. 2004), increased patient functional decline, greater risk of falls, increased risk of morbidity and risk of dementia, contributing to increased patient and carer anxiety and or distress (Milisen et al. 2004, Agar et al. 2012, Mir et al. 2014).

Therefore the aim of this integrative literature review is to explore the barriers and enablers voiced by nurses that may potentially impact on the timely recognition of delirium in older palliative care patients.

Methods The search was undertaken in June 2014. Articles published 1988-2014 were sought. Databases searched ProQuest and Google Scholar and the website CareSearch (www. caresearch.com.au) was also included as part of the search strategy.

Keywords, “delirium” and “nursing assessment” and “older patients” and “palliative care” formed the basis of the broader search underpinning nursing assessment related to the patient population in question. The Medical Subject Headings (MeSH) ‘confusion’ [MeSH Terms] AND ‘advance care planning’ [MeSH Terms] OR ‘attitude to death’ [MeSH Terms] OR ‘bereavement’ [MeSH Terms] OR ‘terminal care’ [MeSH Terms] OR ‘hospices’ [MeSH Terms] OR ‘life support care’ [MeSH Terms] OR ‘palliative care’ [MeSH Terms] OR ‘terminally ill’ [MeSH Terms] OR ‘death’ [MeSH] were added.

Nine thousand and eighty-six

papers were retrieved. To ensure quality articles reflected sound argument and methodology as well as objective evaluation by experts in the field, peer-reviewed papers were only included (Dixon 2001).

Papers written in languages other than English could not be found using the selected databases and website. After excluding articles not related to humans, 55 articles were retrieved from ProQuest.

Subsequent to applying date limits in Google Scholar (1988-2914) 7640 articles were sourced.

Based on the inclusion criteria 24 papers from ProQuest and 37 from Google Scholar were relevant.

CareSearch, with its predefined palliative care filters yielded 52 articles. These were the strongest evidence of all citations. In addition a reference list of articles/abstracts papers resulted in an overlap leaving 48 articles. After reading titles and abstracts 16 papers were related.

Through using the two databases and the CareSearch website, a total of 77 articles met the general inclusion criteria. However, after reading each of these articles, while contributing to a greater understanding of delirium, 74 were not specifically related to a palliative population, exclusively to nursing, only focused on the phenomenology of delirium or delirium assessment tools with only three relevant papers remaining that met the selection criteria (Figure 1 and Table 1).

Analysis The broader search revealed a large body of information related to delirium based on the most current empirical and theoretical literature. From these papers, a thematic analysis, consistent with an integrative review approach (Whitemore & Knafl, 2005) was conducted to categorise the many

different aspects of delirium and implications for nursing clinical practice. Studies exploring nursing recognition and assessment, older patients and palliative care were included. Three studies were found to capture the context, processes and pertinent subjective elements related to nurses, their assessments of delirium, incorporating barriers and enablers highlighting similarities across many areas of nursing including palliative care.

(Hosie et al. 2014a, Hosie et al.

2014b, Agar et al 2012).

Results Settings and demographics While Agar et al. (2012) did not define the number of sites, healthcare settings included: palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Hosie et al. (2014a) focused on 30 participants working in palliative care inpatient units (n=9) within acute or subacute hospitals and the third study (Hosie et al. 2014b) comprised of 30 participants from nine specialist palliative Figure 1 : Flowchart of articles from search to inclusion of relevant data Records identified through database searching: ProQuest (n=652) & Google Scholar (n=8,130) + Records identified via other sources: CareSearch (n=48) (n=8,830)

3 primary studies

Table 1 Inclusion and exclusion criteria Inclusion

Exclusion

peer-reviewed articles

articles not peer-reviewed

articles written in English palliative care focused papers

papers not focused on palliative care

papers related to older patients

papers related to children and young adults

papers related to nursing assessment or recognition of delirium

articles unrelated to: nursing/assessment/recognition of delirium

all papers including studies, guidelines and expert opinion papers related to humans anmf.org.au

papers unrelated to humans

Dixon N (2001) Writing for publication – a guide for new authors International Journal for Quality in Health Care Vol 13 No 5 pp: 417-421 European Delirium Association and American Delirium Society (2014) The DSN5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer Biomedical Central Medicine Vol. 12 No.141 pp: 1-4 Retrieved 1st November 2014 from Google web site: www. biomedcentral. com/1741-7015/12/141 Gaudreau J., D., Gagnon P., Harel F., Tremblay A., & Roy M.,A., ( 2005a) Fast, Systematic and Continuous Delirium Assessment in Hospitalized Patients: The Nursing Delirium Screening Scale Journal of pain and symptom management Vol. 29 No.4 pp: 368-375 Hosie A., Davidson P., M., Agar M., Sanderson C., R., & Phillips J., (2012) Delirium prevalence, incidence and implications for screening in specialist palliative care inpatient settings: A systematic review Palliative Medicine Vol. 27 pp: 486-498 Hosie A, Agar M, Lobb E, Davidson P. M & Phillips J (2014 a) Palliative care nurses’ recognition and assessment of patients with delirium symptoms: A qualitative study using critical incident technique International Journal of Nursing Studies Vol 51 Iss:10 pp: 13051420 Retrieved from Google web site: http:// dx.doi.org/10.1016/j. ijnurstu.2014.02.005 Hosie A, Agar M, Lobb E, Davidson P. M & Phillips J (2014b) (Article in Press) Identifying the Barriers and Enablers to Palliative Care Nurses, Recognition and Assessment of Delirium Symptoms: A Qualitative Study Journal of Pain and Symptom Management Retrieved from Google web site: http:// dx.doi.org/10.1016/j. jpainsymman.2014.01.

008

September 2015 Volume 23, No. 3 29

CLINICAL UPDATE care inpatient services across three Australian states. The two studies undertaken by Hosie et al. (2014) required participants to be registered or enrolled nurses, currently working in a clinical role in Australian specialist palliative care inpatient units with a minimum of three months palliative experience.

In the study undertaken by Agar et al. (2012), all participants worked rostered shifts, including night duty, except those in aged care, who only worked days with reported experience in the clinical areas from six months to 37 years.

Study characteristics, design and focus Hosie et al. (2014a) and Agar et al. (2012) focused on recognition, assessment based on the DSM-5 and the DSM-IV-TR respectively. The latter study also addressed barriers and enablers impacting on delirium recognition and nursing assessment and how nurses managed delirium, which is outside the scope of this paper. Hosie et al. (2014b) focused on barriers and enablers of recognition of delirium palliative care patients.

Semi-structured interviews were used, in all three studies, to gain insight into nurses’ views regarding difficulties in recognising and assessing delirium across many areas of healthcare including palliative care. A grounded theory perspective

was utilised by Agar and colleagues (2012) to better understand how palliative nurses may differ from nurses working in other areas. The remaining two studies utilised a critical incident technique in conjunction with using a vignette of a hypoactive patient to prompt their recollection of a similar incident.

Study quality The study conducted by Agar et al.

(2012) consisted of a heterogenous sample of participants in terms of experience and areas of nursing. In order to demonstrate the nurses’ views and practices that were rich in experiences related to delirium, the small sample size (n=40) needed to be considered in terms of quality related to validity and generalisabilty.

This also applied to the studies conducted by Hosie et al. (2014a and 2014b) with sample sizes of (n=30). Because these participants were self-selected, results may have represented nurses’ views who were most interested in palliative care and not representative of those who were less interested in palliative care and who may have responded with less curiosity.

Barriers and enablers By comparing the three final studies, common views based on nurses’ knowledge, experience and practice emerged. These were categorised

into barriers and enablers.

Poor knowledge of the Diagnostic Statistical Manual Criteria for delirium became evident in the interviews (Agar et al. 2012, Hosie et al 2014a, Hosie et al 2014b). In addition, nurses’ lacked awareness of the hypoactive variant, which contributed to missed incidence of delirium (Agar et al. 2012).

Limited knowledge of predisposing factors of delirium such as sensory impairment, dehydration, prior cognitive impairment and precipitating factors such as hypoxia, infection and treatments such as narcotics, steroids, anticholinergic drugs antineoplastic agents were also noted (Inouye 2006, Agar et al. 2012). Witnessing the distress of patients and their loved ones and difficulty balancing competing interests of delirious patients with other patients equally in need of attention, particularly those at the end of life, was of deep concern, especially if a peaceful death was unable to be achieved (Agar et al. 2012).

In trying to balance challenging needs and heavy workloads, nurses believed support strategies from management were lacking (Steis & Fick 2008, Agar et al. 2012). Nonpharmacological interventions such as one-on-one nursing were suggested as potential enablers, as this was viewed as a valued support mechanism allowing nurses more

Inouye S. K, Foreman Marquis D, Mion Lorraine C, Katz K. H, Cooney M. Jr (2001) Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researchers ratings Archives of Internal Medicine Vol. 161. No: 20 pp: 24672473 Irwin S, Rao S, Bower K A, Palica J, Rao S. S, Maglione J. E, Soskins M & Betterton A. E (2008) Psychiatric issues in palliative Care: Recognition of delirium in patients enrolled in hospice care Palliative and Supportive Care Vol. 6 pp:159-164 Milisen K, Steeman E, Foreman M. D (2004) Early detection and prevention of delirium in older patients with cancer European Journal of Cancer Care Vol. 13 pp:495-500

Table 2 Relevant Primary Studies Author

Design/ DSM criteria

Agar et al.

(2012)

Setting/population

Outcome

qualitative/ to explore nurses’ views re: defining semi-structured interviews/ delirium/ assessing/ managing DSM -IV-TR delirium ( the latter, which is out of the scope of this review). Also provides information on potential barriers and enablers and some potential interventions but does not study interventions per se

nurses in inpatient palliative care, geriatric, aged care, geriatric psychiatry & oncology Patients cared for had cancer, or were older adults

nurses demonstrated limited knowledge of features of delirium with implications for education and knowledge translation

Hosie et al.

(2014a)

qualitative/ critical incident technique / semi-structured interviews and data analysis/using a vignette/ DSM-5

to explore the experiences, views and practices of in- patient palliative care nurses in delirium recognition and assessment

30 nurses from nine Australian specialist palliative care inpatient services

a greater insight into potential ways of enhancing early recognition of delirium from a palliative care nurse’s perspective

Hosie et al., (2014b)

qualitative critical incident technique based on semi-structured interviews and data analysis/using a vignette /DSM-5

to identify nurses’ perceptions of the barriers and enablers in recognising and assessing delirium symptoms in inpatient settings

30 nurses from nine Australian specialist palliative care inpatient services

in order to support palliative care nurses in the early recognition of delirium barriers and enablers need to be addressed at the patient family, health professional and system levels

30 September 2015 Volume 23, No. 3

Objective

anmf.org.au

CLINICAL UPDATE time to clinically assess and address the complex care needs of delirious patients (Agar et al. 2012). Hosie et al. (2014a) highlighted that the participants also identified a gap in their own delirium knowledge.

Strengthening collaborative multidisciplinary team relationships and a proactive communication based on trust between nurses, patients, family members and doctors were also recounted as potential enablers.

Concerns related to a lack of access to guidelines or integrating systems translating delirium knowledge into the workplace were raised. Admission delirium assessment, demonstrated to improve clinician recognition of delirium (Rao et al. 2011) were not in place, while nurses’ perception that cognitive and delirium assessments were lengthy and burdensome for palliative care patients were other barriers raised. To address this, a patient centred approach was suggested. (Hosie et al. 2014b) Further learning was embraced by all participants. In-services with a case study focus relevant to nursing and to the multidisciplinary team were proposed. Furthermore, debriefing was seen as beneficial ‘to break things down’ (Hosie et al.

2014b). Finally most participants believed a care plan or delirium ‘clinical pathway’ would provide a constructive method to assist in delirium screening assessment and management (Hosie et al. 2014b).

wide experience in delirium and worked in diverse roles in a range of locations, essentially all the studies were undertaken in Australia and as such reflected views and experiences of Australian palliative care nurses. Furthermore, the data is based on the provision of palliative care in inpatient palliative care units.

Therefore, the data may not be representative of nurses working in other settings such as community nursing or in countries, where palliative care is still developing and where most cancers are diagnosed at late stages, which ultimately may impact on early recognition delirium by nurses (Crane 2010).

Conversely, two different methodologies were used, yielding similar results. This adds validity to the findings in terms of nursing possessing, an incomplete delirium knowledge and reliance on a non-formalised assessment approach to delirium recognition and assessment, rather than using a structured delirium screening and assessment, based on the Diagnostic Statistical Manual Criteria for Delirium (Dahkle & Phinney, 2008, Steis & Fick 2008, Agar et al.

2012, Hosie et al. 2014 b, Hosie et al.

2014a) which was consistent with the practice of nurses caring for older, hospitalised patients with delirium in previous studies (Dahkle & Phinney 2008, Steis & Fick 2008, Agar et al.

2012, Hosie et al. 2014a, Hosie et al.

2014b).

Discussion

This integrative literature review has highlighted a dearth of evidence related to nursing assessment in the early recognition of delirium in older palliative care patients.

However, from the scant information available, nurses working in a variety of healthcare areas, including palliative care, voice similar concerns related to barriers and enablers which are believed to impact timely recognition of delirium. More studies are needed in relation to nurses recognising delirium in older palliative patients, in settings other than inpatient palliative settings and countries other than Australia.

This literature review has highlighted the paucity of high-quality evidence related to the barriers and enablers which impact early recognition of delirium, particularly in older patients who are receiving palliative care, despite age being one of the major independent risk factors which is under-recognised by nurses (Inouye et al. 2001). In the three studies found, 75% of the participants in one of the studies worked in areas other than palliative care (Agar et al. 2012).

This may have impacted the results, as the oncology nurses, who all possessed post graduate qualifications, demonstrated the greatest understanding related to oncological, medical precipitants, which may have limited comparability with the rest of the studies undertaken purely in palliative care settings.

Although the participants had anmf.org.au

Conclusion

Implications for nursing practice Gaps in clinical practice have been identified despite nurses being well placed to detect delirium and its fluctuating symptoms (Agar et al.

2012, Hosie et al. 2014a, Hosie et al.

2014b). This paper highlights more education and training is needed (Tabet & Howard 2006). An essential part of this learning is knowledge of the Diagnostic Criteria for Delirium in the Diagnostical Statistical Manual 5 (DSM-5) (Agar et al. 2012, American Psychiatric Association 2013, Hosie et al. 2014a, Hosie et al.

2014b) and a greater understanding of the predisposing factors risk factors (Inouye et al. 2001, Agar et al. 2012) In the clinical setting, to further assist nurses in detection of early delirium, training is needed in the use of a validated delirium screening tool such as the Nursing Delirium Screening Scale (NuDESC), which still needs validation for use by nurses to assess palliative patients (Gaudreau et al. 2005a).

Clinical guidelines for the prevention, detection and management of delirium, in terms nurses can understand and engage (Delirium Clinical Guidelines Expert Working Group 2006, Steis & Fick, 2008, National Institute for Health and Clinical Excellence (NICE 2010)) were also believed to enhance nursing assessment in the early recognition of delirium.

However, it is vital that guidelines are not followed blindly and that nurses’ practice holistically, therefore consider the individual circumstances (Bush & Bruera 2009).

Implications for future research More research is needed related to nursing assessment and recognition of delirium in the older patients in palliative care, including in settings other than inpatient palliative care units such as in community settings. More studies based in other countries are also needed to determine if the Australian experience is reflected in other countries. Follow up studies are essential to trial proposed enablers in terms of interventions, including delirium education using contextual learning such as case studies and trialling an assessment/ screening tool such as the Nu-DESC administered by nurses to older palliative adults.

Conflict of interest The authors declare that there is no conflict of interest.

Mary Bozzo MPalCare, Flinders University, Registered Nurse, North Wing, University Hospital Geelong

Mir F., Zafar F., & Rodin M., B., (2014) Falls in Older Adults with Cancer [Electronic version] Retrieved 4th July 2014 from Google web site: http:// link.springer.com/ article/10.1007/s13670014-0090-9#page-1 from Current Geriatric Reports pp:1-7 DOI 10.1007/s13670-0140090-9 National Institute for Health and Clinical Excellence (NICE) (2010) Delirium Diagnosis Prevention and Management [Electronic version] Retrieved 5th October 2013 from Google web site: http:// guidance.nice.org.uk/ CG103/NICEGuidance/ pdf/English pp:1-33 Rao S, Ferris F D, & Irwin S A (2011) Ease of screening for depression and delirium patients enrolled in inpatient hospice care Journal of Palliative Medicine Vol. 14 No.3 pp: 275-279 Spiller J. A & Keen J. C (2006) Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care Palliative Medicine Vol. 20 pp: 17-23 Steis M. R & Fick D. M (2008) Are Nurses Recognizing Delirium? A Systematic Review Journal of Gerontological Nursing Vol. 34 No. 9 pp: 40-48 Tabet N & Howard R( 2006) Prevention, diagnosis and treatment of delirium: staff educational approaches Expert Rev. Neurotherapeutics Vol. 6 No.5 pp:741-751 Whittemore R & Knafl K (2005) The integrative review: updated methodology Journal of Advanced Nursing Vol. 52 No. 5 pp: 546-553

September 2015 Volume 23, No. 3 31

RESEARCH

Is work-related stress affecting nurses and midwives?

By Sadie Geraghty and Kim Oliver Stress within the nursing and midwifery professions has been documented worldwide, with the perceived stressors nurses and midwives report varying from country to country (Schluter et al. 2011).

Two PhD studies are being conducted through Edith Cowan University in Western Australia, which are concerned with nurses’ self-reported perceived stress and cortisol levels found in hair; and midwives’ workplace stress and career decisions.

Nurses and midwives are describing their working environments as becoming increasingly stressful and being permeated by a culture of fear (Hood et al. 2010).

Perceived stressors within nursing and midwifery are not limited to the hospital environment, but are found in community, rural and remote clinical workplace settings.

The aim of the Nurses’ selfreported perceived stress and cortisol levels found in hair study is to explore the perceived occupational stress levels amongst novice nurses through to experienced nurses; and to explore if there is a correlation between hair cortisol levels and the perceived occupational stress.

This study will use a written questionnaire to identify the workrelated stress perceived by nurses (n=420), and participants will also be asked to consent to a small hair sample being taken from the posterior vertex region of the head, as close to the scalp as possible without including the hair follicle.

This will equate to approximately 32 September 2015 Volume 23, No. 3

15-20 strands depending on the thickness of the hair. Human hair grows approximately 1cm per month, so taking a 2cm sample will enable a sufficient sample to record the previous months’ cortisol concentrations within the hair, which will then be correlated with the written questionnaire which focuses on the last months’ perceived occupational stress.

One source of work-related stress for nurses and midwives is the role itself, which has become multifaceted due to increased patient acuity. It also includes insufficient work resources, poor skill amongst staff, shift work, lack of peer support and heavy workloads, which can lead to burnout and attrition of the professions (Mollart et al. 2013).

The Midwives’ workplace stress and its implications for their emotional wellbeing and career decisions study is focused on experiences of midwives located in Western Australia. A grounded theory methodology is being used to investigate whether midwifery practice impacts on the emotional wellbeing of midwives and influences their career decisions to stay working within midwifery.

The potential impact of these research studies are that new and robust ways of monitoring and understanding workplace stress levels within the nursing and midwifery professions will be enabled, which are accurate, valid and non-invasive. These two studies hope to build on the body of knowledge and add further insights into the perceived stress of nurses and midwives working within the clinical environments and how this will impact on the nursing and midwifery workforce of the future.

References Hood, L., J. Fenwick, and J. Butt. 2010. ‘A story of scrutiny and fear: Australian midwives’ experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice’, Midwifery, 26(3):268-285.

Mollart, L., Skinner, V., Newing, C. and Foureur, M. 2013. ‘Factors that may influence midwives work-related stress and burnout’, Women & Birth, 26(1):26-32.

Pugh, J., Twigg, D., Martin, T. and Rai, T. 2013.

‘Western Australia facing critical losses in its midwifery workforce: a survey of midwives’ intentions’, Midwifery, 29(5):497-505.

Schluter, P., Turner, C., Huntington, A., Bain, C. and McClure, R. 2011. ‘Work/life balance and health: the nurses and midwives e-cohort study’, International Nursing Review 58(1):28-36.

Sadie Geraghty is a Nursing & Midwifery Lecturer and Kim Oliver is a Nursing Lecturer. Both are at Edith Cowan University

Monkey-bars not so fun Monkey-bar injuries account for almost one fifth of paediatric fracture admissions, with more than half causing severe injury, research in the latest ANZ Journal of Surgery shows.

More than half of monkey-bar related injuries recorded in an audit of 211 fracture admissions to a Melbourne hospital over two years were caused from children aged one to 13, either attempting to skip a rung or from sitting or standing on top of a monkey bar and falling. “Monkey-bar and play equipment falls can result in injuries that are significantly more likely to require a trip to the operating theatre,” Co-author and orthopaedic trainee Dr Sina Babazadeh said. Aside from the stress involved, injuries could have long standing repercussions, she said.

Alcohol consumption at conception increases baby’s diabetes risk in middle age Babies conceived by women who drink alcohol around the time of conception face significantly increased risk of type 2 diabetes and obesity in early middle age.

The equivalent of five standard drinks around time of conception altered foetal development, the University of Queensland (UQ) study found. “Before the egg implants, before any organs start to develop, alcohol consumption somehow causes changes to the embryo,” UQ Associate Professor Karen Moritz said.

Exposure to alcohol at conception presented a similar risk to consumption of a high fat diet for a major part of life, the research found.

Dr Moritz said the findings were significant with 50% of Australian pregnancies unplanned.

Future research will focus on preventative treatments, including a nutrient given to the mother in later pregnancy to combat the effects of early alcohol exposure on baby. anmf.org.au

Wound / Infection Control

Healthy healing and wound prevention

By K Price, A Dyer, T Rando and P Hickman Critical to achieving best outcomes in any clinical setting is ensuring decision making in wound prevention and healthy healing of a wound, has successful client centred outcomes.

The Wound Management Innovation CRC (WMI CRC) was formed on 1 July 2010 to: alleviate suffering of people with chronic wounds; improve wound prevention; deliver clinical resources of national importance; develop next generation wound management products; educate researchers and healthcare providers; and reduce the cost of healthcare to people with wounds. www.woundcrc.com/ Among the critical indicators of quality services and resident satisfaction in residential aged care as legislated in the Aged Care Act 1997 is the prevalence of pressure injuries and skin tears.

A service delivery model is under anmf.org.au

evaluation that incorporates healthy healing and wound prevention approaches. The model is aimed to provide near zero incidences of preventable pressure injury or skin tears resulting in significant benefits in resident quality of life, staff productivity, cost savings and accreditation processes.

In collaboration with Southern Cross Care (SA&NT), the WMI CRC is working with the University of South Australia undertaking a research project. The project uses descriptive methodology to identify processes implemented by staff to increase the focus on ensuring healthy healing and wound prevention of residents; and to deliver quality outcomes in an efficacious manner in aged care settings. The research is not focused on any one specific staff member or resident, rather on the value of the processes being used to collect information and improve resident outcomes. www. southerncrosscare.com.au/ As an inaugural member of the South Australian Innovation Hub funded by the Commonwealth government, Southern Cross Care (SA&NT) acknowledges healthy healing and wound prevention as an essential component of its service delivery model. Involvement

with the Wound CRC may assist other approved providers in the implementation of a systematic approach to wound prevention and healthy healing for all residents, informed by best available evidence.

The research project has four phases: Phase 1: What is happening now? A descriptive account of everyday activities that involves a triangulation of data collection methods including: Wound Prevalence Survey; Wound Prevention and Management Audit; and EQ 5D Quality of Life survey.

Phase 2: Education, training and service provision where SCC staff have access to wound experts and wound products, online education resources and access to a telehealth Wound Advisory Service (Wounds West).

Phase 3: A repeat of data collection tools from Phase 1.

Phase 4: Analysis, reporting and sustainability of the approach.

Findings will be available in early 2016. www.dss.gov.au/ ourresponsibilities/ ageingandagedcare/ ensuring qualitythesouthaustralian innovationhubtrial

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Associate Professor K Price and T Rando are in the School of Nursing and Midwifery at the University of SA A Dyer is Research Director, Wound Management Innovation Collaboration Research Centre P Hickman is Group Manager, Strategy (Research and Development), Southern Cross Care (SA&NT)

September 2015 Volume 23, No. 3 33

FOCUS

Wound / Infection Control

References Anderson, D. 2011.

‘Surgical site infections’, Infectious Disease Clinics North America, 25(1):135-153.

Wound healing in obese women following caesarean section

By Helen Stapleton on behalf of the DRESSING Trial team Almost 2.1 million elective surgeries were performed in Australian hospitals in 2013-14. Around 30% of all surgical procedures are associated with surgical site infections (SSI), and are the third most common hospital acquired infection (Mangram et al. 1999).

SSI increase the risk of death and rates of hospital readmission, prolong hospitalisation and greatly increase overall costs of healthcare (Friedman et al. 2007; de Lissovoy et al. 2009; Andersson et al. 2011).

Obesity, defined in our study as a body mass index (BMI kg/ m2) ≥30, is a growing global public health problem; it is an independent predictor of SSI. Obese pregnant women are more likely than their healthy-weight counterparts to require a caesarean section (CS), and to suffer higher rates of postnatal complications, including SSI. The impact on family life is substantial as postnatal recovery is slower, with women experiencing more pain, feeling more fatigued, and less likely to breastfeed. Post-operative infection is a potential complication of all surgeries including CS, however overweight and obese women are at particular risk. A meta-analysis of

six studies showed the odds ratio for overweight or obese CS women having an infection was 3.3 (95% CI 2.7 – 4.1) compared to women within the normal BMI weight range (Heslehurst et al. 2008).

The application of Negative Pressure Wound Therapy (NPWT) devices in high-risk populations (including obese pregnant women undergoing CS) has become increasingly popular in Australia and internationally. This is despite the added cost and lack of empirical evidence for efficacy. Whilst it is understandable health services may use NPWT to reduce the incidence of SSI and associated economic burden, the absence of high quality research is problematic (Webster et al. 2014).

Our research team and project A five-year $2.3 million project grant was awarded by the National

Health and Medical Research Council to undertake the aDding negative pRESSure to improve healING (DRESSING) randomised controlled trial. It will address an important research gap and provide much needed clinical and economic evidence in a rapidly developing and costly area of healthcare. Four Queensland maternity hospitals will each recruit just over 2,000 women undergoing CS, who will be randomised in theatre to receive either NPWT or a standard surgical dressing. The primary outcome is SSI. Secondary outcomes include: length of hospital stay, readmission, wound complications and healthrelated quality of life. Economic outcomes include direct healthcare costs.

In the absence of compelling evidence, the clinical trial is timely, as it will provide evidence needed to guide future practice, nationally and internationally.

What is negative pressure wound therapy (NPWT)?

NPWT is based on a sealed system that applies negative pressure to the wound surface; pressure is typically maintained at 50-125 mm Hg. Intermittent or continuous suction is maintained by connecting suction tubes from the wound dressing to a vacuum pump and liquid waste collector. Wound healing is thought to occur more rapidly due to changes to the microenvironment of the wound resulting from increased blood flow and tissue granulation, and reduced oedema and bacterial contamination.

AN EXAMPLE OF AN NPWT DISPOSABLE DEVICE (PICO ™ SMITH & NEPHEW)

34 September 2015 Volume 23, No. 3

de Lissovoy, G., Fraeman, K., Hutchins, V., Murphy, D., Song, D. and Vaughn, B. 2009.

‘Surgical site infection: incidence and impact on hospital utilization and treatment costs’, American Journal of Infection Control, 37(5):387-397.

Friedman, D., Bull, A. and Russo, P. 2007.

‘Performance of the national nosocomial infections surveillance risk index in predicting surgical site infection in Australia’, Infection Control and Hospital Epidemiology, 28(1): 55-59.

Heslehurst, N., Simpson, H., Ells, L., Rankin, J., Wilkinson, J. and Lang, R. 2008. ‘The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis’, Obesity Review, 9(6):635-83.

Mangram, A., Horan, T., Pearson, M., Silver, L. and Jarvis, W. 1999.

‘Guideline for prevention of surgical site infection’, Infection Control and Hospital Epidemiology 20(4):247-280.

Webster, J., Scuffham, P., Stankiewicz, M. and Chaboyer, W. 2014.

Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention (Review). The Cochrane Library, JohnWiley & Sons, Ltd.: 46.

Dr Helen Stapleton is Senior Research Fellow, CoDirector: Mater Midwifery Research Unit in the Faculty of Health and Behavioural Sciences at MRI-UQ School of Nursing, Midwifery and Social Work in Queensland anmf.org.au

Wound / Infection Control

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Michelle Gibb

The Australian wound registry

By Michelle Gibb, Xin-Yi Chua, Dominique Gorse and Douglas Queen Wound management poses a significant challenge to the healthcare system.

More than 433,000 people suffer from chronic wounds such as leg ulcers, pressure injuries or nonhealing surgical wounds at any one time. However the actual incidence is unknown as many people never seek help for their wound problems.

Wounds cost the Australian healthcare system more than $2.6 billion a year which equates to almost 2% of the national healthcare budget. Given wound care is a high cost area of healthcare, capturing the costs associated with patient care is essential.

The Australian Wound Registry (AWR) is a key strategic objective of the Wound Management Innovation Cooperative Research Centre (WMI CRC). Working collaboratively with healthcare organisations, key objectives include: • Enhancing understanding of clinical and health outcomes for patients with wounds; and measuring the prevalence of anmf.org.au

wound aetiologies nationally.

• Yielding important health

economics data to inform health policy; and reimbursement mechanisms.

The AWR is modelled on the registry used in Canada and Wales. It incorporates a flexible approach to data capture, namely using digital pen and paper and removing traditional barriers to data collection. The AWR has the capacity to extract de-identified data from organisations with existing databases. The power of a registry is the ability to be able to generate reports that can be used at the individual, unit, local, state, national and international level for benchmarking and quality improvement.

The WMI CRC conducted a pilot study from December 2014 to May 2015. The study was divided into three components: • to assess digital pen usability; • data relevancy; and • data integration processes.

Technical investigations into

the policies and strategies for data privacy and ethics, data governance, data integration, data security, registry hosting, risks and funding models were also conducted in parallel. The results of the pilot project were extremely positive, confirming the usability of this approach within Australia.

The AWR is a clinical register hosted in-the-cloud and will collect de-identified patient information.

The AWR will adopt an opt-out consent model. Periodical reports will be generated from the data collected.

The AWR will provide rich data to enhance evidence based practice in the management and prevention of wounds; inform healthcare policy and reimbursement; and generate a valuable industry database for product and marketing information.

The AWR will be a resource of national and international importance.

Organisations interested in participating in the AWR are invited to contact the WMI CRC.

Michelle Gibb is a PhD Candidate and Clinical Director, Wound Management Innovation Cooperative Research Centre Dr Xin-Yi Chua is Head of Informatics and Dr Dominique Gorse is General Manager, both are at QFAB Bioinformatics, University of Queensland Dr Douglas Queen is CEO at TraxMedica in Toronto, Ontario Canada

September 2015 Volume 23, No. 3 35

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Wound / Infection Control

FOCUS

Paula Foran

References AORN Guidance Statement. 2007.

‘The value of clinical learning activities in the perioperative setting in the undergraduate curricula’, American Operating Room Nurses Journal, 86(2):265-269.

Australian College of Operating Room Nurses. 2015. Asepsis Competency Standard.

South Australia: ACORN,1-9.

Blomberg, A., Bisholt, B., Nilsson, J. and Lindwall, L. 2015.

‘Making the invisible visible: operating theatre nurses’ perceptions of caring in perioperative practice’, Scandinavian Journal of Caring Sciences, 29(2):361-368.

Bull, R. and Fitzgerald, M. 2006. ‘Nursing in a technological enviroment: nursing care in the operating room’, International Journal of Nursing Practice, 12:3-7.

Foran, P. 2013. The value of guided operating room experience for undergraduate nurses.

Doctor of Philosophy Faculty of Arts and Education, Deakin University.

National Health and Medical Research Council. 2010.

Australian Guidelines for the Prevention and Control of Infection in Healthcare. www.nhmrc. gov.au/guidelinespublications/cd33 [Accessed 17 July, 2015] Zegers, M., de Bruijne, M., de Zeizer, B., Merten, H., Groenewegen, P., van der Wal, G. and Wagner, C. 2011. ‘The incidence, root-cause, and outcomes of adverse events in surgical units: implication for potential preventable strategies’, Patient Safety in Surgery, 5(13):3-11.

anmf.org.au

Perioperative nursing: preventing infection behind closed doors

By Paula Foran There is an assumption that perioperative nursing is more technical than nursing in nature (Richarson, 2008 as cited in Blomberg et al. 2015; Bull and Fitzgerald 2006).

The modern day perioperative nurse not only provides thoughtful nursing care but advocates for patients while at their most vulnerable and are unable to speak for themselves (AORN Guidance Statement 2007).

One vital nursing advocacy role lies in the prevention of infection during surgical procedures. There are approximately 200,000 hospital acquired infections each year in acute Australian healthcare settings (National Health and Medical Research Council 2010), with surgical site infections one of the most common. Such infections accounted for almost 40% of all surgical patient adverse events (Zegers et al. 2011). This shows the importance of good aseptic technique in the operating suite where there is potential for infection.

Asepsis is a term meaning free from additional pathogenic microorganisms (Owen 2008, as cited in Australian College of Operating Room Nurses 2015).

‘Aseptic technique’ is the practical method applied to ensure asepsis in an operating suite.

Perioperative nurses take their

PERIOPERATIVE NURSES TAKE THEIR INFECTION PREVENTION ADVOCACY ROLE SERIOUSLY AND WILL SPEAK UP, OFTEN WHEN IT MAY NOT BE EASY TO DO SO, TO PROTECT PATIENTS WHEN THEY SEE A POSSIBLE BREECH IN ASEPSIS OR INFECTION PREVENTION GUIDELINES. infection prevention advocacy role seriously and will speak up, often when it may not be easy to do so, to protect patients when they see a possible breech in asepsis or infection prevention guidelines.

The Australian College of Operating Room Nurses (ACORN) is the national governing body that

oversees nursing practice within this specialty area and provides evidence based standards and guidelines from which best practice is guided.

In the past 12 months three standards have been released that involve the prevention of infection at its conception. These are: • infection prevention; • perioperative attire; and • aseptic technique.

Perioperative nurses are firstline fighters in the war against surgical wound infections and the operating suite the perfect environment to learn about asepsis.

One of the salient skills Australian undergraduate nurses learn through guided operating room experience is an understanding of asepsis and infection prevention, taking this knowledge back to the surgical wards (Foran, 2013).

Perioperative nurses will continue to teach the skills of asepsis and infection prevention, and advocate for patients behind closed doors.

Dr Paula Foran is the Education Officer at the Australian College of Operating Room Nurses (ACORN) September 2015 Volume 23, No. 3 37

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Wound / Infection Control

FOCUS

References Centers for Disease Control and Prevention.

2014a. ‘Tightened guidance for US healthcare workers on personal protective equipment for Ebola’. www.cdc.gov/media/ releases/2014/ fs1020-ebola-personalprotective-equipment. html (Accessed 26 June 2015)

Infection control: it’s not just what you wear – it’s how you take it off

By Gina Mata, Kim Oliver, Sara Geale and Elisabeth Jacob More than 240 healthcare workers providing care in West Africa had contracted Ebola and more than 120 of those died, as of February 2014 (WHO, 2014).

There are still active cases in the United Kingdom, Spain, and United States (WHO, 19 June 2015). This shows the need for all healthcare providers to continually update their knowledge and understanding of the importance of strict compliance with infection control protocols and be aware of simple procedures, such as how to don (put on) and doff (take off) Personal Protective Equipment (PPE).

Infection control programs rely on healthcare providers understanding the modes of transmission of infectious organisms and knowing how, when and why to apply basic principles of infection prevention (NHMRC, 2010a).

Differences in healthcare setting and functions require flexibility in setting policies and procedures, as the purpose of implementing infection control measures may differ (NHMRC, 2010b). For example, maintaining sterility and protection.

The first step and the last step in any healthcare interaction should always be hand washing. Donning of PPE is undertaken prior to entering patient care areas. Healthcare providers are advised to remember the basic rules of wearing PPE: keep hands away from their face; limit surfaces touched; change gloves if torn or heavily contaminated; and perform anmf.org.au

hand hygiene on completion of the interaction. PPE should not be removed, adjusted or exchanged in the contaminated area.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare (NHMRC, 2010b) recommend PPE forward based care should be donned in the following order: • gown; • face mask or respirator mask; • goggles or face shield; and • gloves pulled over the sleeves of the gown - in some situations such as Ebola double gloving is recommended.

Doffing of PPE is a high risk process when healthcare staff may be exposed to infectious diseases, such as Ebola (CDC, 2014a). Removal of PPE requires a systematised process, a designated area for doffing and in cases of diseases such as Ebola, a trained observer to oversee the procedure (CDC, 2014b). Recommendations for doffing of PPE include the following sequence (NHMRC, 2010b): • gloves; • goggles or face shield; • gown; • face mask or respirator; and • hand wash.

It is essential to remember when doffing PPE that everything is now contaminated and needs to be removed with care and disposed of appropriately. Note that PPE is removed at the doorway or in the anteroom of the patient care area. The exception to this is if a respirator is required such as in

INFECTION CONTROL PROGRAMS RELY ON HEALTHCARE PROVIDERS UNDERSTANDING THE MODES OF TRANSMISSION OF INFECTIOUS ORGANISMS AND KNOWING HOW, WHEN AND WHY TO APPLY BASIC PRINCIPLES OF INFECTION PREVENTION the case of respiratory diseases such as Middle Eastern Respiratory Syndrome Corona Virus (MERSCoV) and Swine flu. In these cases the respirator is removed after leaving the patient’s room and after closing the door.

Hand washing remains the mainstay of infection control (WHO, 2015). It is important that processes and procedures are in place to safeguard the patient, care provider and the facility itself.

Ms Gina Mata; Ms Kim Oliver and Dr Sara Geale are Lecturers and Dr Elisabeth Jacob is a Senior Lecturer in the School of Nursing and Midwifery at Edith Cowan University

Centers for Disease Control and Prevention.

2014b. ‘Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus disease in US hospitals, including procedures for putting on (donning) and removing (doffing)’. www.cdc.gov/vhf/ebola/ healthcare-us/ppe/ guidance.html (Accessed 26 June 2015) National Health and Medical Research Council. 2010a.

Australian Guidelines for the Prevention and Control of Infection in Healthcare, Summary Information.

Commonwealth of Australia: Canberra. www.nhmrc.gov.au/ guidelines-publications/ cd33 (Accessed 25 June 2015) National Health and Medical Research Council. 2010b.

Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Commonwealth of Australia: Canberra. www.nhmrc.gov.au/_ files_nhmrc/publications/ attachments/ cd33_infection_control_ healthcare_140616.pdf (Accessed 25 June 2015) World Health Organization. 2014.

‘Unprecedented number of medical staff infected with Ebola’ (Media release). http://www.who. int/mediacentre/news/ ebola/25-august-2014/ en/ (Accessed 23 June 2015) World Health Organization. 2015.

‘Infection prevention and control’. http://www.who. int/csr/bioriskreduction/ infection_control/en/ (Accessed 26 June 2015)

September 2015 Volume 23, No. 3 39

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Wound / Infection Control

Introducing the wellbeing in wounds network

By Dominic Upton, Penney Upton, Ann Marie Dunk and Judith Barker Wellbeing is related to, but separate from, Quality of Life (Upton et al. 2013).

While we agree identifying compromised Quality of Life (QoL) is important, our clinical and research work suggests giving more attention to wellbeing can further optimise patient outcomes.

The deficit model of health related QoL identifies negative emotions such as depression; whereas the asset model of wellbeing highlights positive emotions and psychological resources including resilience, hope and self-efficacy. These are important assets which can enable individuals with wounds to have better outcomes. Just as psychological difficulty (eg. stress and anxiety) can delay wound healing, the presence of positive psychological resources may support better mental health and speedier healing. Positive mental attitude and wellbeing have previously been associated with better outcomes in other conditions.

This belief in wellbeing, and a shared interest in improving patient outcomes, has resulted in an innovative collaboration, the Wellbeing in Wounds Network. The

References

THESE ARE IMPORTANT ASSETS WHICH CAN ENABLE INDIVIDUALS WITH WOUNDS TO HAVE BETTER OUTCOMES. partnership between ACT Health and the University of Canberra aims to improve outcomes for patients with wounds through translational research, education, and practice.

Although a recent venture, we have completed several projects (Upton and Upton, 2015) and have others underway. Of key interest is the construction and validation of the Wellbeing in Wounds Inventory (WOWI). Specifically developed for use with wound care patients, WOWI is a valid and reliable means of assessing a patient’s wellbeing. This unique measure allows clinicians (and researchers) to identify patients with limited psychological resources in order to develop suitable support and intervention packages. A webpage providing more information about wellbeing and the WOWI is under construction. www. wellbeingofwounds.info The website is designed to provide a one-stop-shop for information on wellbeing in wounds for both patients and clinicians.

It will include details on how to assess, manage, and intervene, with the aim of improving the quality of life for patients with wounds.

Upton, D., Andrews, A. and Upton, P. 2014.

‘Venous leg ulcers: what about wellbeing?’

Journal of Wound Care, 23(1):14-16.

Upton, D. and Upton, P. 2015. Psychology of wounds and wound care in clinical practice.

Springer International Publishing: London, United Kingdom.

Dominic Upton is Deputy Dean in the Faculty of Health and Penney Upton is Senior Research Fellow in the Health Research Institute. Both are at the University of Canberra Ann Marie Dunk is a Clinical Nurse Consultant – Tissue Viability Unit at the Canberra Hospital Judith Barker is a Nurse PractitionerWound Management at the Canberra Hospital and Health Services

Wound management: summarised evidence

By Keryln Carville and Robin Watts Lack of time is an oft heard cry from clinicians; certainly when it comes to reading professional journals and research articles. So are there reliable sources of evidence available that assess and summarise recent evidence on wound topics that clinicians can check to ensure their wound care practice is current and safe? The answer is ‘yes’.

Funded as part of the national Wound Management Innovation Co-operative Research Centre research program, a series of evidence summaries have and are being developed focusing on the effectiveness (or otherwise) of approaches to wound care. The project is being run by the Wound Healing and Management Node, part of the Joanna Briggs Institute’s (JBI) Collaborative Centre in Western Australia. Topics already addressed include four aspects of managing biofilms (definition, debridement, silver products, iodophors), PHMB dressings, and tea tree oil. A series on the assessment and management of lymphoedema is underway, together with six topics related to negative pressure wound therapy,

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Visit us online or contact 03 9903 9016 to find out how you can become a wound care expert. monash.edu/wound-care

CRICOS provider: Monash University 00008C

Take your nursing career to the next level.

Become a Wound Care Expert.

Wound / Infection Control four on radiation induced skin damage, two on biofilms, and several on bioengineered tissue therapy.

These evidence summaries are designed to be a quick reference to clinicians as what research is available, how good that research is in terms of quality and what the implications are for practice. Not only do these summaries provide a source of information for individual nurses but also for healthcare organisations to check their current wound care policies and procedures are up to date. What has become evident as the project has progressed is that the evidence base for a number of wound practices in respect to effectiveness is weak. These gaps need to be addressed by well-designed clinical studies.

The evidence summaries can be accessed through the JBI database in departments of health, hospital or university libraries. For nurses who are members of the Australian Wound Management Association, the summaries are published in the organisation’s journal Wound Practice and Research.

Professor Keryln Carville is Project Leader at Silver Chain House and Adjunct Professor of Primary healthcare & Community Nursing in WA Professor Robin Watts AM is Program Leader in the School of Nursing, Midwifery & Paramedicine at Curtin University in WA

Developing wound experts in tissue viability at Canberra Hospital

By Ann Marie Dunk Establishing systems for reporting and monitoring all wound types is essential in improving patient outcomes.

With an ageing population, chronic wounds pose a concern, especially in the management of costs associated with wound care. The ability to find clinical nurses with the required expertise is limited in our workforce (Mardsen and Reid-Searl, 2007). Evidence shows that new graduate registered nurses (RNs) have little preparation in wound assessment and management prior to commencement of the first placement in clinical practice (Mardsen and Reid-Searl, 2007).

This situation poses issues for an unprepared workforce in delivering expertise in this clinical specialty.

Coupled with this limitation, there is a need to obtain accurate data on wound management activities at all health service levels in order to provide improved monitoring of all wound types.

To achieve this, improved documentation and a higher level of expertise in wound assessment and management practices are required. The Tissue Viability Unit

A trusted source of specialist advice Palliative care advice on symptom and pain management and advance care planning for GPs, residential aged care and home care staff DECISION ASSIST LINE

(TVU) at Canberra Hospital has developed a unique mentorship program that enables registered nurses to develop the required wound expertise. This has led to improved outcomes for patients and a greater ability to measure and monitor healing outcomes.

Ann Marie Dunk The TVU provides an opportunity for two RNs to be assigned to the unit for a six month rotational period. Nurses who have participated in the program come from a variety of clinical specialities within the acute hospital. To underpin the development of the RNs, a conceptual framework was sought and the M-Strong Model (Gardner et al. 2013) of the Advanced Practice Nurse was found to be an appropriate fit to provide the foundation. The five domains References of this model incorporate: direct Gardner, G., Chang, A., Duffield, C. and and comprehensive care; support Doubrovsky, A. 2013. of systems; skill and decision‘Delineating the practice profile of advance making; education and research; practice nursing: a crossand professional leadership. sectional survey using the modified strong Clear expectations are set on model of advance commencement of the program; practice,’ Journal of Advanced Nursing, and measurable developmental 69(9):1931-42. outcomes are reviewed in each Mardsen, W. and domain on an ongoing basis.

Reid-Searl, K. 2007.

A major measurable outcome ‘Overcoming tradition: teaching wound has been a decrease in pressure management into the injury prevalence, from 19 to 7.7% 21st century’, Collegian, 14(4)7-10. and facility acquired pressure injuries from 15 to 3.5%.

Ann Marie Real time monitoring of all wound types and healing outcomes Dunk is a Clinical Nurse benefits not only patients but Consultant – health services. This model is now Tissue Viability demonstrating how increasing Unit at the wound care experts can fill the Canberra knowledge gap in our health Hospital service

Register now for free workshops for aged care staff in residential, home care and community settings These interactive workshops enhance skills and improve your understanding of advance care planning, talking through challenging topics and taking a palliative approach to care.

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Jonathon Greening Memorial Scholarship Fund 2015 Applications are invited from District Nurses who are planning to undertake further education, training or to conduct research related to district nursing clinical practice.

There is one award in the Jonathon Greening Memorial Scholarship Fund this year of an amount up to $5,000 however this award may be divided into several smaller awards if considered appropriate by the selection panel.

The closing date for applications is 23 October 2015 Application forms may be obtained from: Alison Killin RDNS – 31 Alma Road, St Kilda Vic 3182 Telephone: (03) 9536 5225 Email: akillin@rdns.com.au

Wound / Infection Control

AWMA Aseptic Technique Sub-Committee

By Lyn Thomas Australian Wound Management Association (AWMA) National Sub Committee Chair Terry Swanson published an article in the Australian Nursing and Midwifery Journal outlining the development of the ‘AWMA aseptic technique minimum standard for a wound dressing procedure in the home care environment’ in 2014.

The purpose of undertaking this work was discussed in the article and has since progressed. AWMA has provided funding to include a formal literature review by a consultant methodologist of the

Creating ‘pressure awareness’ in health services

By Meagan Shannon and Virginia Plummer

THIS IS A WEEK WHEN WE CAN ALL DO SOMETHING ABOUT POVERTY 11-17 OCTOBER 2015 For more informationa and ideas: www.anitpovertyweek.org.au apw@antipovertyweek.org.au 1300 797 290

42 September 2015 Volume 23, No. 3

There are many factors associated with the development of a pressure injury (PI) such as immobility, malnutrition, pressure, shear forces and underlying comorbidities.

These injuries are known to be debilitating, while also costly to manage and heal. Prevention is the principal aim for all patients in care, particularly the aged (Haesler et al.

2014; Norman and Young, 2014; Brem et al. 2010; Graves et al. 2005).

Nurses are increasing their commitment to reporting of data that relates to a hospital acquired PI that is largely preventable by nursing care (HSRG, 2013). The ACHS EQuIP criterion framework for improvement may be improving both the rate and willingness of nurses to contribute data according to the 2006-2013 Clinical Indicator Report, supported by specialised skin integrity nurses in hospitals. There are 373 public and private healthcare organisations contributing data on PIs each year, 100 more than the 263 when data was first captured for this hospitalwide clinical indicator in 2007 (HSRG, 2013). Pressure awareness is taking place at the bedside, the health

evidence which will strengthen the document recommendations. The AWMA Aseptic Technique SubCommittee has also expanded its approach to include development of documents to guide aseptic technique related to wound management procedures in the acute care setting, outpatient clinic and general practice settings.

A package to demystify the aseptic technique procedure related to wound dressings will be available together with the documents, when approved for publication

by AWMA. Health professionals will have the tools to improve the safety and healing outcomes for persons with wounds. It is envisaged this evidence based practice literature will facilitate clinicians and healthcare managers in addressing the National Safety and Quality in Health Service Standard 3 Healthcare Associated Infections. service and national levels.

The governance of pressure awareness programs by specialised nurses can drive multiple strategies to ensure pressure prevention is supported in patient care. Strategies may involve: • pressure risk assessment tools; • access to pressure relieving equipment, including a variety of specialty mattresses and cushions; • regular and comprehensive skin checks; and • specific documentation to support turning regimes and customised wound care documentation to ensure consistency in care (Haesler et al.

2014).

Pressure awareness involves clinicians, patients and carers which is critical for PI prevention and most effective when patients participate in this aspect of their care (Miles, 2014).

This is usually best achieved through education and information on a patient’s specific pressure prevention needs. At Peninsula Health, a formal questioning process to our ongoing skin integrity audits has been created: ‘Is the patient aware of pressure risks?’ This allows a simple interaction to raise awareness of pressure for clinician and patient, and allows education and/or update of a patient’s pressure prevention care. For example, the patient may be able to initiate small shifts which are very effective when full body repositioning is not required (Miles, 2014).

Lyn Thomas is Chair of the Australian Wound Management Association (AWMA) Aseptic Technique SubCommittee and an Endorsed NP Wound Management

References Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, B., Golinko, M., Yan, A., Lyder, C. and Vladeck, B. 2010. ‘High cost of stage IV pressure ulcers’, American Journal of Surgery, 200(4):473-477.

Graves, N., Birrell, F. and Whitby, M. 2005. ‘Modeling the economic losses from pressure ulcers among hospitalised patients in Australia’, Wound Repair and Regeneration, 13(5):462-467.

Haesler, E. (Ed.). 2014.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance and treatment of pressure ulcers: quick reference guide. Cambridge Media: Perth, Australia.

Health Services Research Group (HSRG). 2014.

Australasian Clinical Indicator Report 20062013, 15th Edition.

Australian Council on Healthcare Standards: NSW, Australia.

Miles, S., Nowicki, T. and Fulbrook, P. 2014.

‘Repositioning to prevent pressure injuries: evidence for practice’, Australian Nursing and Midwifery Journal, 21(6):32-35.

Norman, R. and Young Jr E. 2014. ‘Pressure Ulcers’ in Atlas of Geriatric Dermatology, p215-218.

Springer: London, United Kingdom.

Meagan Shannon is a Skin Integrity Clinical Nurse Consultant (SICNC) and Virginia Plummer is Associate Professor Nurse Research at Peninsula Health anmf.org.au

Wound / Infection Control

Importance of the microclimate in maintaining skin integrity

By Ann Marie Dunk The importance of maintaining skin integrity is to a large extent intertwined with pressure injury prevention and management.

Successful prevention strategies in prevention of pressure injury depend on a complex balance between external loads applied to the skin and soft tissues, and intrinsic ability of the skin and soft tissues to withstand prolonged or excessive loading. Evidence suggests one other key mechanism that leads to tissue damage and stage 1 and 2 pressure injuries development is microclimate (Haesler, 2014).

Microclimate has two key factors: • temperature (of the skin or soft

Infection surveillance in the home healthcare setting

By Raylee A Pandur In Australia, there is no national approach to surveillance for healthcare associated infections (HAIs).

There is wide variation in the methods, scope and resources used for surveillance, and in the publication and use of data. However the quality framework within which healthcare is delivered should include reliable, validated and standardised surveillance processes across all settings.

Infection prevention and control has traditionally been acute care focused, with home healthcare (HHC) relying on adaptation of existing acute guidelines. However delivery of healthcare continues to shift from hospitals to alternate settings, dictating the need for infection prevention and surveillance programs to respond. If valid data on the incidence of HHC associated infections is not available, how can appropriate targeted control anmf.org.au

tissues); and at the interface between the skin and support surface.

With an increase in humidity and temperature, the skin becomes weaker (more vulnerable) and less stiff (Clarke et al. 2011).

Improving these factors in clinical practice improves skin integrity and reduces the potential for pressure injury development.

Poor microclimate management is also linked with incontinence associated dermatitis (IAD).

Many clinical practices for nurses are often imbedded in culture, history or rituals of practice which show little evidence in improving patient outcomes. Historically ‘draw sheets’ served as providing a clean sheet next to the skin without having to change all bed linen.

The heavy rubber back plastic also served as lifter or turner device when a bedbound person required position change, but had a negative impact in terms of microclimate.

Modern clinical practice activities have moved towards the use

of supportive lifting devices and specialised incontinence management products.

Changing and improving practices for microclimate management requires a multipronged approach. The Tissue Viability Unit (TVU) at Canberra Hospital has developed quality projects with a microclimate awareness program, which is evidence based and changing clinical practice. It includes standardisation of PH cleansers, moisturising and barrier creams; use of incontinence management products; microclimate management systems in place; and removal of the traditional washable incontinent sheets.

Newer technologies need to be explored to improve traditional practices and reduce potential risk factors around skin damage due to microclimate. Health organisations need to support an evidence based approach to practice challenges and in parallel with education packages.

This leads to improved skin integrity in patients.

initiatives be implemented?

In the United States, the Association for Professionals in Infection Control and Epidemiology (APIC) Home Care Membership Section published draft definitions for surveillance of infections in home healthcare. These have since been accepted by the Hospital Infections Program and Centers for Disease Control (APIC, 2008). However these have neither been endorsed, nor alternatives developed in Australia, and therefore determination and comparison of agency rates is not currently possible.

Unique challenges exist in the home care setting which preclude the implementation of simple surveillance processes, even if nationally accepted and standardised definitions and methods are available. These include: the absence of trained infection control personnel; problematic capture of laboratory and other diagnostic data; lack of continuity of care; and limited capacity to collect numerator and denominator data.

It is evident the financial burden of implementing such a program would be a considerable barrier that cannot be ignored.

Although research on infections in HHC is sparse and the epidemiology of such infections

has not been described, a few researchers have identified that 4.5-11.5% of HHC patients had at least one episode of infection during their home healthcare stay (Shang, 2015; Manangan, 2002).

These studies highlight the need to investigate the infection risks associated with shifting patients of increasingly high acuity, and often with medical devices, from hospital to the community. Although the risk of infection transmission is less in the home compared to hospital through geographical separation, HHC patients are cared for in a completely uncontrolled environment inherent with infection risks.

Addressing this gap in the quality of care cycle will require substantial resources and infrastructure, accompanied by interagency collaboration, transparency, and data sharing. However the effort would appear worthwhile given the ultimate goal of surveillance is to improve patient care and minimise complications of infections that can have a deleterious impact on quality of life. The smallest effort towards this goal could make the greatest difference to the lives of people in our care, that often live with chronic illnesses or wounds in socially isolating circumstances.

• humidity or skin surface moisture

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References Clarke, M. and Black, J. 2011. ‘Skin IQ Microclimate manager made easy’, Wounds International, 2(2).

Haesler, E. (Ed). 2014.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Cambridge Media: Perth, Australia.

Ann Marie Dunk is a Clinical Nurse Consultant – Tissue Viability Unit at the Canberra Hospital

References APIC Home Care Membership Section 2000. 2008. ‘APICHICPAC Surveillance Definitions for Home Healthcare and Home Hospice Infections.’ Association for Professionals in Infection Control and Epidemiology (APIC). www.apic. org/Resource_/ TinyMceFileManager/ Practice_Guidance/HHSurv-Def.pdf (Accessed 25 June 2015) Manangan, L., Pearson, M., Tokars, J., Miller, E., and Jarvis, W. 2002. ‘Feasibility of national surveillance of healthcare associated infections in home care settings’, Emerging Infectious Diseases, 8(3):233-236.

Shang, J., Larson, E., Liu, J., and Stone, P. 2015. ‘Infection in home healthcare: results from national outcome and assessment information set data’, American Journal of Infection Control, 43:454-9.

Raylee A Pandur is an Infection Prevention & Control Consultant at RDNS Limited, Victoria

September 2015 Volume 23, No. 3 43

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SEPTEMBER Indigenous Literacy Day 2 September. http://matsiti.edu.au/ events/indigenous/ 5th International Conference on Health, Wellness and Society 3-4 September, Madrid, Spain. http://healthandsociety.com/theconference 10th Conference of the Australian College of Nurse Practitioners Celebrating the past and embracing the future 6-8 September, Pullman Albert Park, Victoria. www.dcconferences. com.au/acnp2015/ 6th Australian Emergency Nurse Practitioner Symposium Celebrating the past and embracing the future 9-10 September, the Mercure, Albert Park, Victoria. www. dcconferences.com.au/acnp2015/ Australian Disease Management Association 11th Annual Conference Count me in: Partnerships in chronic care?

9–11 September, Brisbane Convention Centre. www.adma.org. au/ E: b.shen@alfred.org.au P: (03) 9076 4125 Australian Nurses and Midwives Conference Hosted by the Australian Nursing & Midwifery Federation Victorian Branch 10-11 September, Melbourne Convention and Exhibition Centre. www.tiny.cc/2015abstracts

World STI & AIDS Congress 13-16 September, Brisbane, Queensland. This congress is being held in conjunction with the International Union against STIs (IUSTI, www.iusti.org), ensuring a vibrant event with delegates from around the world. The ISSTDR and IUSTI are the pre-eminent global bodies dedicated to research into STIs, HIV, vaccines and sexual health, from basic science through to population health. www.worldsti2015.com Lung Health Promotion Centre at The Alfred 16-18 September/14-15 October - Respiratory Course (Mod A & B) 16-18 September - Respiratory Course (Module A) P: (03) 9076 2382 E: lunghealth@alfred.org.au Australasian HIV&AIDS Conference 16-18 September, Brisbane Queensland. This conference is the major forum for the presentation of HIV research in Australasia. It is the annual conference of the Australasian Society for HIV Medicine (ASHM) which has represented medical practitioners working in the HIV sector since its incorporation in 1990. www.hivaidsconference.com.au - to be launched soon 17th Annual CATSINaM Conference The only way is up 22-24 September, Doubletree Hilton Hotel, Darwin. www.catsinam.org.au Nurses Christian Fellowship Australia - Victoria and Tasmania 25-26 September - Spiritual Care Course, Ashburton Baptist Church, Melbourne. For more information E: ncfavictoria@gmail.com or M: 0412 328 672

Australian College of Neonatal Nurses 10th Annual Conference and Skin Care and Skin Injury Symposium 10-12 September, Sydney NSW. www.acnn.org.au/news-and-events/ acnn-national-conference/

World Gastroenterology Organisation (WGO) and the Gastroenterological Society of Australia (GESA) International Congress 28 September-2 October, Brisbane, Qld. www.gastro2015.com/

Brisbane Practice Nurse Clinical Education Queensland’s leading event for nurses working in General Practice.

Earn 18 CPD hours.

11–13 September. www.pnce.com.au

David Unaipon Birthday 28 September. http://matsiti.edu. au/events/indigenous/

United Nations Declaration on the Rights of Indigenous Peoples 13 September. http://matsiti.edu. au/events/indigenous/

Lung Health Promotion Centre at The Alfred 5-6 October - Spirometry Principles & Practice 14-15 October - Respiratory Course (Module B) 22-23 October - Managing COPD P: (03) 9076 2382 E: lunghealth@alfred.org.au

OCTOBER

40th National Conference of the Australian Association of Stomal Therapy Nurses Proactive and Innovative Strategies in Stomal Therapy Nursing 5–7 October, Melbourne Convention Centre. www. stomaltherapy.com/conferences.php Australian College of Midwives 19th Biennial Conference Super midwives - making a difference 5-8 October, Gold Coast, Qld. www.acm2015.com/ International Indigenous Women’s Convention Our families, our communities: nothing about us without us 6-9 October, Sydney NSW. http:// dreamtimepr.com/save-the-dateinternational-indigenous-womensconvention-sydney-october-2015/ 13th International Conference for Emergency Nursing Emergency Care: Accept the Challenge, Lead the Change 7-9 October, Brisbane Convention & Exhibition Centre, Queensland. www.icen.com.au/2015/ Australian College of Nursing National Nursing Forum Advancing nurse leadership 14-16 October, Brisbane Convention & Exhibition Centre. http://acn.edu.au/forum_2015 12th Biennial National Enrolled Nurse Association of Australia (ANMF SIG) Conference 21 October, InterContinental, Adelaide SA. P: 1300 972 315 E: info@nena.org.au www.nena.org. au/2015NENAConference.html

NOVEMBER Lung Health Promotion Centre at The Alfred 11–13 November - Asthma Educator’s Course 19-20 November - Smoking Cessation Facilitator’s Course P: (03) 9076 2382 E: lunghealth@alfred.org.au Hospital In The Home Society, 8th Scientific Meeting HITH at 21: Maturity, Responsibility and Quality 11-13 November, Rydges World Square, Sydney. Early bird registration is now open and closes 25 September. http://conference. hithsociety.org.au/ Melbourne Practice Nurse Clinical Education Australia’s leading event for nurses working in General Practice. Earn 18 CPD hours. 13–15 November. www.pnce.com.au

NETWORK Royal Adelaide Hospital, Class of 756, 40-year reunion It’s our 40th and time to have a reunion! Keeping it simple so contact Karen Braithwaite or Frances Woodcock on M: 0422 812 187 or E: woodcock7@gmail.com Box Hill Hospital, Group 99, 30-year reunion For further information contact Clare D’Arcy-Evans E: clarebears21@icloud.com or M: 0416 399 881 St Vincent’s Hospital Melbourne, PTS October 1975, 40-year reunion 3 October. Contact Anna Martin M: 0412 235 666 E: amartinpoppins@optusnet. com.au The Alfred Hospital, group 3/75 40-year reunion 10 October. Contact Penny McCarthy (nee Jaffray) E: p.mccarthy@alfred.org.au or Mary Rhodes (nee Woods) M: 0438 897 578 E: rhodesmary@gmail.com 97th Annual General Meeting of the Alfred Hospital Nurses League 24 October at 1.30pm at the Mt Erica Hotel, Prahran following lunch at 12noon.

Contact Dorothy Owen E: dorothy@e-owen.com Royal Hobart Hospital, 4/75 PTS, 40-year reunion 30 October, 6.30pm, Janne Gordon’s, 94 Nelson Road, Mount Nelson, Tasmania 7007. BYO drinks and $20 towards pizzas, nibbles and cake. Contact: Janne E: gordies@southernphone. com.au, Alex E: therandalls3@ netspace.net.au, Heather E: hknichols@gmail.com or Sue E: susan.cunningham57@ hotmail.com by 30 September (let us know of any special dietary needs) LaTrobe University, LaTrobe/Bendigo Campus nursing group (19881991), 25-year reunion 20 February 2016, Bendigo.

Contact Steven Graham E: sgraham@bendigohealth. org.au or Sarah Shipp (nee Prudham) E: sshipp@ bendigohealth.org.au or search Facebook page LaTrobe 1991 reunion Email cathy@anmf.org.au if you would like to place a reunion notice

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September 2015 Volume 23, No. 3 45

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Parker by the behaviomidwife e, abs costs less in the Facilita days It is not the work , the earlyurs. financia proces As a I rememb tor, SA Education in rec in enteeism, thatjob we, our do but s of doi1990’s. lly, in what we do to er a ruit own staf newly graduat ment adv each other midwife ersetolyour health and edng our in her 20’s costs. f turnover and The aspiring younge affe was who 4 Cor and wellbe r workers that me thin stic, ners pro It isfeeds cted. enthusia ingpassion this disease. ate is supportive to gram what not the wor basedandk back to my us, who were made Bianca k that We are constan asp we do to eacintake themidwife Salter own hos applauds ofwe midwife the ear next do iring you h Canad about the bullying tly reading ly 199 ry trai s. One ning day l a’s pita er andto butry student dayoth embra nger wor I came ce of gradua 0’s. , this dise towork s in entase our to be and intimidation issues harassm euthan informe teddmid I rem emberasia s tha . thatker she (ANMJ Mail was had t fee We taken wife June a new d arethe ds her ownent middle manage identifie in her 2015). hus life, constanwere all shocked ly we about at iast suppor ment level 20’s , distress tly rea inthe numerous health tive to ic, passionate who ed and din intimid thebullying, in disbelie intake employ ee survey harass gf. ation r,and it is well docume of mid us, whoHoweve findings across wer issu mid me This nted day I cam the wifery that ine countrie experie nt andnce has es ide dleand manag in our studen the nexts whereBia professional journalscountry its mark e to on ntifi assisted me.ed ement thaleft It is ts.and atathe .numero legacy that tnever Oneeuthana Ca nca Salter she had work tosuicide What are we doing be sia finding us health emmyleve on l have app in will anyonewere watch nada’s info tak rme withs acro legalise ployee the who all shocke en herbeen results of these embra lauds euthigher profess the ss own life dd there are to work in disbcomes han surveys? andey rates ce d, I am aware ionalare the country surv There , we abuse, deaths no state or federal of, elie or I f.have distressedof elder journa heard of, Jun byasia (ANMJ of andorinjust What surveys ‘regularand ls. ’ suicide and casese 201 ourfeel thatThi s experie Mail track and monitor bullying results toare we doi is just not right ingnce euthana on mesometh of 5). and of Ho ng will aggress sia .

I never the has It wev without with incidences in no stat seion consent.er, it is Letter of left its a legacy my wat notisgo surveysand askthe the workpla e that in The ma well doc Daily do hearch will ? The RUOK? If Ito that nev rk Mail Online and moce.or federal cou re are again, work that anyone June, the month LeProfesso er survterrible tter ofr Farrell, ANMJ nito on reportedsuicide10 ntries whe umented 2010 21r March I want to eys to news and I 2014, incidenVol bullyin that we don’t know a studyand re ass hea am awa who comes there tracwas that the rd of, know found bee how effective isted n legalis euthanasia in the g and wemo ingorI just Profess ces are nth aggofress k not issometh of, or “A high proportion at addressing was fee re deaths aware The winner of just wor have and ed I rate or this could ion kplace classed the Farrell . havenot s of eld e as euthana said, right will l that som hav 2014, problem . and of the ANMJ TheIt is one thing to endorse iner abu re are higher we zero , ANMJor behaved ething Belgium ask RUOdone ‘regularsia in some I never win involved patients way Vol 21 se, dea toleranc that may we are adon ’t kno ’ terr have K? suic not best letter who made of the nere to aggress Ma ible w ths If I ide and did not euthan a difference tonew go ion at add rch by bullying ANon effe ressing how asia s again, do hear tha ask for their lives is one and that the that person.

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10 er to taken part in fou pap nd “A they enforce es aknow and d in e d and er, in it said ‘termina our a hav bul with not study some high how to effective $50 Col voucher.

It is lyin e made , donrequest wor ly a sad deaths tions without g day way tha when e act s; anothe kpl ace onhow we as a diff classed proportion that or it. ices per a ere how posted professi If you would vouche esSoMy son. Ma er do we change r Belconsent on of many of nce to t ma y as eut Elderly ever, it gium ’.” g alto and kno thinthis and frail patients r. ybe towith people that isintentionsthat good gether good like to submitIf you culture? outcom did not involved pat hanasia in hel w how are stand would to by collectiv e but ely p prevent the most vulnerab to effe Maybe I am naïve ients who So how orenf of all. individu orce itally incontribute for the a letter to thelike to ended.le ask definite Euthanasia ctiv but silence has do ely sub ir cult any to only ” Mo lives to we cha increase ly not act oning mitorganisation ure? someth in any It is a and itwitness ANMJ email a letterhealth re tha way vulnerability. admitted s their priatesad n “100 be to the about Maor department nge to thisone it. inappro profess happen day whe to ing . anmj@anmf.ANMJ thought ybe I embedd of our colleagu taken researchers nurses n we as In the publichad em healthca hea am into es. of alle good ion We must naïv percept lth org ing part in anmj@aourail find a way to speak that the ny goo ion org.au a re position with intentio ma out req descript ‘ter though anis d peonurses remain the most nmf. ationionsbut has or ind up professi any onally and uest or minations y ple honest n criteria Letters mayorg.au key selectio or persistently. ividuall ns stan about with professi d by colland Elderlyethical address our hea t that consen embed departm somBecause ify we in sile Letter our acknowledgem don’t, and this ent ectivel eth are theon, but be edited for disease will lthcof t’.” nce the areand s may nevering key seleent y most frail patien e of euthana beinap positio ding into to one managed and witn embrac ce to enforcin vulnera clarity and be editedadheren ts treated more n des and all of our propria ess severelyEuthanasiasia g nappropr our ack ctio te hap would criteriaiate cription ble find a efficient for ce behavio coll underm onl and clarity workpla pen eag nowled space. that addeffective this way to ly y increas of all. s ly. “Enoug ing ion. vulnerabilitine percept and With adhere urs? specific gem and perh is enough speak”... ues. We mu ress es space. criteria for our y. ent nce their unit manage up pro st sistent of and In the to enf position workpl public disease ly. Becaus fession ace beh r orc nurses ing app Anonymousthis anmf.org.au ally Triffett RN, RM criteria e if we Maree remain perception will avio and rop , RN anmf.or nev riat urs? trea and hon Tasman for our don theiamo er be g.au unit ma With specifice manag ’t, effectiv ted more the em est profess st ethical efficien ed nager ely. “En ion, but brace tly and positio ough would of eut n is eno hanasia Anony ugh”... July 2015per Volume sev 23, ere No. ly mous 1 underm ception 47 RN, RM ine this 46-47_ANMJ .

July15_Calendar_Mail 46-4 7_AN .indd 47 MJ July1 Maree 5_Ca lenda Triffet r_Mail.ind t, RN d 47 Tasma nia

Euthanasia could undermi the perceptio ne n of the professio n Euth an could asia the pe undermin e of the rception profes sion

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Thanks for publishing the letter in the July issue dealing with the difference between policy and practice in dealing with workplace bullying.

As I wrote about twelve months’ ago in the journal, the bully is insecure and frightened as well as generally incompetent. The bully copies the behaviour of those above her/him.

Your July writer is on the ball when she says that policies may be all very well, but unless they are backed up by essential requirements in the person specification for a job, they serve merely to protect the organisation after a crisis occurs.

It is a pity that anonymity is needed,

but the suggestion re. anonymous feedback will be relevant until the problem is better controlled. And the feedback needs to be horizontal as well as vertical because handovers and transfers abound with attempts to bully and bluff.

We have the best job in the world and we do need to do all we can to counter the disproportionate effects of the few pathetic bullies we have.

Mick Hawkins, MHN, SA

A nursing voice and vision

L-R MARISA BELL (SA BRANCH PRESIDENT), ANNABEL DIGANCE MP (MEMBER FOR ELDER), SA HEALTH MINISTER JACK SNELLING MP, ADJ ASSOC PROFESSOR ELIZABETH DABARS AM (SA BRANCH SECRETARY) AND NAT COOK MP (MEMBER FOR FISHER) AT THE 2015 SOUTH AUSTRALIAN CONFERENCE.

As a nurse I had the privilege to attend the ANMF (SA Branch’s) annual delegates’ conference in Adelaide. This forum is a place to hear what our profession is grappling with, the strengths and challenges we face.

There were some excellent speakers. The politicians, who have the opportunity to make real changes at a policy level, were the most adept speakers. Some also appeared to listen about amendments that were proposed to give nurse practitioners long overdue recognition and provider numbers.

One of the most inspiring voices came from a presentation on the Robin Hood Tax. Discussed was a viable alternative to raising other taxes, to help save our healthcare. These are big picture issues that relate directly to our

profession. As we are constantly being told that we are facing health budget disaster warnings.

The two day conference also provided research on advanced practice nurses, single room hospitals, the RAH transition and panel discussions in mental health and aged care. We also heard the anthem I am Woman (more than once!) as we relived Judith Lucy’s quest to uncover womanhood via her nursing shoes as well as her soccer boots.

There was not much more we

could have asked for, but Tim Costello rounded off a packed program with words on equity and the work of World Vision. Tim Costello noted that as a large union we have a considerable collective voice and power, which was evident by the union’s well organised, professional, and wide reaching conference.

I’m hoping many nurses from all specialties get a chance to participate next year.

Jenny Esots, RN , SA

NOTICE TO MEMBERS ANMF Federal Office Financial Report The ANMF Federal Office Financial Report for the year ended 30 June 2015 is now available at www.anmf.org.au Members without internet access may obtain a hard copy of the report by applying in writing to: Federal Finance Officer Australian Nursing & Midwifery Federation Level 1, 365 Queen Street Melbourne Victoria 3000

46 July 2015 Volume 23, No. 1

anmf.org.au

MAIL Education

: Part 2 Educ

FOCUS ation:

Reference

Part

2

FOC

US

s

Algoso, M., (2012). The & Peters, K. of underg experiences raduate Assistants in (AIN). Nurse Nursing Today, 32(3), Education 197-202.

Beckett, A., S., & Green Gilbertson, wood, S. (2007). Doing thing: Nursin the right g studen relational ts, practice, and moral agenc Of Nursin y. Journal g 46(1), 28-32.Education,

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Pet of und The exp ers, K. Assista ergraduateriences (AIN nts in Nur e ).

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Journal of Nursing the righ rela Advanced t tion stud Nursing, moral al practic ents, 62(1), 41-52.

Of Nur agency. e, and Jou Clark, T., 46(1 sing Edu rnal & ), 28cation, (2007). Fit Holmes, S. 32. for practic An explor e?

Beecro ation of the develo & We ft, P.C., pment of Dorey, newly qualifi Turnovnten, M. F., (200 using focus ed nurses new er intentio 8). gradua n in Internationalgroups. a mu Journal of ltivariat te nurses Nursing Jou : e ana Studies, rna 44(7), lysis.

1210-1220.

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Clark, d, Moxham, M., (200 T., & Hol 7).

L., mes, Broadbent, & An exp Fit for S. pra Graduate M. (2013). the dev loration ctice? registered newly elopm of nurse practic ent of in the Austra e readiness using qualified lian Internafocus gro nurses context: An issue ups worthyNursingtional Jou . of discus sion. The 1210-1 Studie rnal of Australian s, 44(7 Journal of 220.

Nursing ), Practice.

El Had Bachelor of Moxha dad, M., Mannix, Most unde Nursing students J., m, Beale, B., Faga, P., Broadb L., & . rgraduat ent & Jackso Gra are in aged e AIN posi with at least n, D. (2006) duate , M. (201 . Toward Bachsetti tions care s nurse pra registe 3). sustainable are perc experienc three months RN, elor ngs, whic red models for ctice in the clinical educa eiveMo of e rea h d to st prov tion in con Australian diness opportu employe who were previous rsing undeideNu nursing: limit An ongoin of text: An nitieare d ed as stu rg ly s issu disc unde to g conve rad inpractice ua de in aged e wor uss rsation rgraduat set of nurs thy a narro te wAI nts Education . Nurse Australian ion. The e . care facil are pe aged ing in PracticNursing Jou N ities. Part AIN Peters, 2012 skills (Algcare 6, 3 - 11. e, be required sition icipa Practicrnal of with oppo rceivedoso &settings powill e. to s at lea plete nts , whonlin rtubaug 2014). Howse; Stom Mannix prov nitiesh to & Judd ich e survey expe com Ong, G.L. st thr an ever ide t of, prev , Beale, , J., Fag (2013). Using to pr rieor ee mo has not dete to participaemand/ final placem a, P., ncbe B., & willin research actic limite e wh Peter nursiious ng ski ents toD. (200 d Jac te in plooneo g nths prepare studen s, ed undergra 20 rmin yedto-one sustain 6). Tow kson, lls (A e a nainter 20 whether , g Times t nurses ard rrowviews. in Nursin as un were prev RN duat lgo 14e). AIN 12; Sto Toag clinical. able mo s com ed plete , 109(3) prior to grad employm mbau so &survey, 12-14. care an de , educati dels for rgrad iou has no Howe nursing onlin ll be ver, pr ent gh & surv pleawise facilit e uate sly on follo n assis t de readines un uatio w uir convers : An ong in req the Ju ies ev eym ts AI on link: in ter dd iou oin Spenc . Pa s for Ne, D., Edu ation. onke liny.co dethis ed to www g mine works res for_, e rve Prep rg group. cati Nur Roud, D., Vallant d wh ea The aim comp .rticipa to pa sum/r/ prior rad 6, 3, S., on in Pra se uate nts & Aspina y an arat ether rch Clinical_ ion_ C. (2012) Prac ctice, ll,- 11. the rtictice AIN prop is to explrea ofto . Preparing grad ipate d/or be lete registe an Alternati osed interv em oredin stud uatio Ong, plo vely, red nurses the y ym the iew essperc one-t willing a papein G.L graduate n depends ent surveysucan for eptio r copy on fina rvey,be s. To co ol plac . (2013).

(NG Th this grnsasofsisnew ts Usin us mpletof one and all of us”.“us preand ple requ In 2001In whetheris to )enurs aimes g par ement suand oup. in wothe ase este Nursin , New rveym Praxis in of regarding rk author 2001Sout unde e an Nursingge student s to fol d from exrgra New Zealan will plore , Newh Wales duatethe (NSW)(N employm onbe prop 28(2), 5-13. 12Times, nurses grad maillow If youfoare AIN the lin onlin key.c Hea r_Clin ed out.

SWlth 14. d, e the pe entuainteaged So os 109(3), . develope ) He inte k: icarest impleme in prepwh rcept ed stupart (NG) care imple alth uth ed om Wales l_Pra in /r/Prep ww assis aring dy icipating eththem Stomb nted Alter Spence w.augh, A., deved and ted ion nu an me er in cti ince this rse ar s for na Bachelor , & work un D., of (eith the su emronm study ce Bachof nted ntivelop atA.ion Roud,Judd, (2014). Does s reg tively envi clinic edre ployment.dergthe an inc whe D.,g& Vallant, S., alarding new er in com Nurs elo nursin _ certific , a pa assistant plet C. (201 r of ing Asp were we ing undergra y ca or participa students en Explrad ua the au rve in pr entiv and a surv oring per co activ Nursi re ely n be increase reg ation2). Prepar inall, duat ey epari e wh activ ting aged te AIN recru thorin an e AINt in nursin iste py of reque ing ited ng Assistan or requ emp wo Assis ere in prep student’s depgendred nur ely rec stu an inte to work care rk en ng the aring ses tstan rview confidences ste in ts yo e infod wi Nursing m loyment on “us nts assis plea paireIfmor and ruited deas level of basic viron ing stud completi be ma ) d from the clinic all of unde nurs comp in Nu (AIN rmalltion ted se cont and the rticip u are ents ment. for Pranursin whils ng int alrg us work envi when enterin xis g us”. Nur lettheir rsing s) to wotrk eres , iled ouacare ing unde Exploforclinical (m.algos nursnu (eith actatMar in pr radua 28(2 in ing icris g New Zea sing rgraduat teso as the pote ingrsiprog t.nursing progra ), 5-1 te ronm d in IN e in thAlgo ntial ep er ws.e o@u ng prram.the ring has ir un (A land AIN ent m? 3. in Journal Of , The the cli aritongunite inceinc derg s) whilst and educ ogram HREC or em aim Professional ntive u).is study mplet parti codu.a entiv App Nursing, Sto rad was thisua ation rsithe servplo iceym mbaug nicalsectnu . Th of to supp 30(2), cip e wa l Num or re rova 162-16 delopm ent A. (201 deve or, ang h,7. te that the ating stuions work ber: ing A., & s to ortefurth velop aim is relat a H109 po cruc de su qu 4). ent er ial Judd, 15 tento envir assistan Doe nts supp of hip meof pleas ire mo in an int rvey Wolff, A.C., tiaprov nt clinic on ort for this nursan t B., s nursing l to iding Mar ingd educ incrPesut, of clial skills education ment for qual re inf icris e co ifica ervie Regan, S.stud ease cert & Algo ther (2010) nical fur ation. unite the ity nursing tion (m that nt or an.org. ha so . New anmf w) cand gradua is ac mf.orau .al ma s The ent a idat goso televe skills is t MarPhD tion, auth se nurse practic ’s con servi g.au readiness: l of bas fide HRECe from ciais seekcto for nursi cruor e @uthe ce Nursing ingr,NG perspe a relnurs Schoicr ws.ed care ic nur nce ng ed l to prov olisofAlgo on the contex Appro and whenctives ati sing Mid es on u.a a so our undersnursing t shapin ucati entg iding sh Universit vawife atu). ering The tandingpro the Journa quali ip y of Wes l Nury autho on. gram? expectations l Of and ty ternmb er: H1 Mar Nursing . Nurse r is se Pro Syd ney.0915 Education , 30(2 fessional eking Today cand icris Al , 30(2), 34-45_ ), 162 187-191. ida goso NG nu -167.

Wolff, ANMJ 34-45_ ANMJ Nursi te fro is a Ph Aug15_ Aug15 rses Regan, A.C., Pes m Augu _Focu st 2015 s.indd 35 Focus.i D Volum Unive ng and M the Scho gradua S. (201 ut, B., & ndd e 23, No. 0).

35 idwife rsity ol of readin 2 te nurse New 35ctic of W on the ess: per pra spectiv e este ry at the our undcontext rn Sy shapin es expecta erstand dney g .

Educati tions. ing and Nurse 187-19 on Tod Augus ay, 30(2 1. t 201 ),

Undergr aduate Assistant ergra employmUnd e en ptloin agduate in Nursing (AIN) graduatem gra ssisDo s for ymened caAre:

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By Maricri t inthiNs prepare tes cli wo sByAlg edrk en for th al ursme Moso aricris ing (A new Nursing e clin carevir Algo : Don edu Nu cati IN) oe nt? rsion mad the so ic

ng ed e transitio based trainthnefrom transhosuc at l- n itionpitaio ing mad seto the sector ove ba d tra e tertfro m sector yearsini ng iary ho Howeve r 20 overago.to the spitalr, Ho grav con 20 ye te the quality weeve cern s arsutag rtiary r, gr thand e ququa ave abo undergr o. alityntity adu unde an ofconcerns experience atergnurs quan radues’ dclini ex tity of about ate nu cal r to grad rienc remains re speprio rseon uati (Cla es main rk & Holm s’ cli Ong, 201 ior200 s (Clar pr nic es, to gr O3; ngSpe 7; ad al , 20nce & Ho raising issu etk al, 13; ,Sp raisies 201 es uation ngsurroun ence lm2), graduate ding gr prep issue , et al, , 2007; s surro new aredness practicepr aduate (Bec actickett,prepar forunding 2012), BeecrofBe et al, ed e (Bec ne t, ec 7;ss fo new etro al, kett,200 200 et al, 200 ft, 8; r Man et et al, 6). 20 et al, 20 nix, al, 06).

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Letter of the month

Constant clinical experience required I noticed there was no mail segment in the August 2015 edition of the ANMJ so I thought I would contribute considering my first contribution was in October 2002.

My attention was drawn to the article “Undergraduate Assistant in Nursing (AIN) employment in aged care: Does this prepare new graduates for the clinical work environment?” in the August issue of the ANMJ - 2015 (p35).

Given that I graduated as a new registered nurse (RN) in December 2014 places me in that transition phase from being an AIN to an RN as I am currently applying for RN graduate nursing programs for 2016.

I mentioned that my first contribution was in 2002 to the ANJ at which time I just became an AIN in aged care.

What I can say today from my own experience is that to some degree aged care has played an important role in providing me with clinical experience within my scope of practice as an AIN. However there is a difference between subacute care in aged care, and acute care in mainstream hospitals.

For some time now AINs have been able to work shifts in acute care settings in various hospitals which would no doubt be an advantage compared to AINs in aged care. That being said I have done some nursing shifts as an AIN through nursing agencies that has allowed me to work in various acute hospital wards.

In my opinion consistent practice in clinical nursing helps to strengthen ones confidence and competence, which I became aware of during my clinical placements as a student nurse.

If the nursing industry wanted better experienced new RN graduates I would suggest they explore the idea of endorsing second year nursing students to the equivalent qualification of an enrolled nurse (EN).

One of my biggest setbacks being

IN MY OPINION CONSISTENT PRACTICE IN CLINICAL NURSING HELPS TO STRENGTHEN ONES CONFIDENCE AND COMPETENCE, WHICH I BECAME AWARE OF DURING MY CLINICAL PLACEMENTS AS A STUDENT NURSE

a second and third year nursing student was not being able to practice in acute wards like an EN unless I was on clinical placements. I noticed as a student nurse that other student nurses who were ENs with medication endorsements were far more efficient than those of us who were not. The logic behind this was lack of exposure to ongoing clinical practice, and not related to one’s inability to provide efficient nursing care in acute care settings.

Peter Stevenson, RN, ACT

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

Qualification frustration I feel compelled to write this letter considering the lack of available opportunities to qualify as a mental health nurse.

I am an RN with nearly nine years general nursing experience. From the very beginning of my nursing career, I have had a passion for mental health nursing and now wish to complete my Masters in Mental Health.

Unfortunately I am unable to be accepted in any program because every university that I have asked wants me to anmf.org.au

be employed in a mental health facility so that I can complete the required modules.

Fair enough, but I am unable to gain employment in a mental health facility because I am not a qualified mental health nurse: a classic case of Catch 22?

Moreover, most places are full fee paying rather than CSP and are generally allocated to graduate nurses only.

How about catering to a whole range of nurses and not just new graduates?

Many of us already have several years of life experiences and surely that counts for something? I myself have worked as a high school teacher for 20 odd years, as well as a custodial officer for 5.5

years. Currently I work as a civilian nurse for the Australian Defence Force and this has renewed my interest in this particular area of nursing.

I am quite disappointed with the state of affairs: on the one hand, we are told that there is a dearth of mental health nurses but on the other, there are very limited opportunities to qualify as one. Can someone please explain why this is so?

And can someone please advise me how to gain a CSP spot in a Master of Mental Health course?

Manisha Sheorey, RN, Vic August 2015 Volume 23, No. 2 47

MAREE

Maree Burgess, ANMF Vice President

THIS IMAGE WAS ORIGINALLY PUBLISHED ON WWW. THECONVERSATION. COM

I have followed the Sydney Swans AFL team since their not so glorious days at the Lake Oval in South Melbourne.

I stood with my father in rain, hail and shine, watching our team give their all each week. More often than not, we lost, but the courage and commitment of those teams are reflected in the current team members.

I realise that the ‘back page’ of the ANMJ is not a sports column, however, the parallels between their team, your team and my team are similar. We pull together as a team to achieve the best outcomes for our patients, families, colleagues and our union. At times, we are called on to speak out, to advocate for the best and fairest interests of our team.

team, the Flying Boomerangs and was a tribute to them, a celebration of Indigenous heritage.

Comedian and social commentator Aamer Rahman wrote in newmatilda.com, that “white Australia is so terrified of Aboriginal people that an imaginary spear still has them crying three days later after it didn’t hit them”. I believe the imaginary spear did hit the mark just as Nicky Winmar’s actions did in 1993, when at the end of a close fought game against Collingwood in which St Kilda were victors, having been racially vilified during the game, he is reported to have “raised his arms over his head before lifting his St Kilda guernsey, pointed to his bare brown skin and declared “I’m black – and I’m proud to be black” (Michael Gordon, The Age, 16 April 2013). As a consequence of Nicky Winmar’s protest, changes were made to AFL codes of

cultures of our country – and constitutional recognition is part of achieving that”.

While support for the campaign is broad, ranging from members of the major Parliamentary parties, to business leaders and indeed the population as a whole, there has emerged a counter opinion from more conservative commentators, including Noel Pearson, the Indigenous Cape York leader. In an article in the Sydney Morning Herald newspaper on 14 April this year, Noel Pearson was reported by journalist Michael Gordon to have moved away from the general consensus on Constitutional reform and instead supporting a draft declaration on the place of Aboriginal and Torres Strait Islanders in the nation’s history and culture. Noel Pearson proposed that this declaration would need to be linked to constitutional changes.

HE LATER EXPLAINED THAT THE INDIGENOUS DANCE HAD BEEN CREATED

BY THE UNDER 16 INDIGENOUS TEAM, THE FLYING BOOMERANGS AND WAS A TRIBUTE TO THEM, A CELEBRATION OF INDIGENOUS HERITAGE.

FOR FUTHER INFORMATION AND TO SHOW YOUR SUPPORT FOR THE CAMPAIGN, VISIT WWW. RECOGNISE. ORG.AU/

In the recent Indigenous round, in which the players and the broader football community celebrate the Indigenous community, Adam Goodes, a dual Brownlow Medallist, former Australian of the Year and an outstanding Indigenous footballer was denigrated in sections of the media for performing an Indigenous war dance after he scored a brilliant goal in the game against Carlton at the SCG. The football media were divided and derisive in their opinions of Adam’s intentions in performing this dance. Should he not have been able to celebrate his Aboriginal heritage in this way? Was he too aggressive for our general liking? Are we more comfortable as a society if we espouse tolerance only on our terms?

He later explained that the Indigenous dance had been created by the under 16 Indigenous

48 September 2015 Volume 23, No. 3

conduct to prohibit racial/religious vilification.

The Australian Football League as a sponsor of the Indigenous Round of football is supportive of the RECOGNISE campaign. What is RECOGNISE? As reported on their website, RECOGNISE is the people’s movement to recognise Aboriginal and Torres Strait Islander peoples in the Australian Constitution. The goals include wanting to see fairness and respect at the heart of our Constitution, to ensure racial discrimination has no place in it, a chance for Australia to acknowledge the first chapter of our national story and to forge our future together in a more united nation. Adam is quoted on the RECOGNISE website – “I hope that future generations of Australians will grow up learning about the rich and impressive first

Of concern is that the declaration would sit outside the Constitution and have no legal force.

The ongoing debate around RECOGNISE reveals the complexity involved in amending our Constitution. Inherently, it is a document which has served Australians well, but which ignores the original inhabitants and thousands of years of history of Indigenous Australians. Adam Goodes as an Indigenous man, former Australian of the Year, spokesperson for RECOGNISE and a brilliant footballer and a dual Brownlow Medalist!

He should be acknowledged for the courage he brings not only on the sporting field, but his advocacy for Aboriginal and Torres Strait Islander peoples. In football terms, let’s not play the man. Go Goodsey, go Swannies. anmf.org.au

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Join the super fund that puts members first.

Call 1300 650 873 or visit firststatesuper.com.au Consider our product disclosure statement before making a decision about First State Super. Call us or visit our website for a copy.

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Caring for the people who care

2014 winners, left to right: Outstanding Graduate: Zoe Sabri, Nurse of the Year: Stephen Brown, and Team Innovation: Prof Jeanine Young representing the Pepi-pod® Program.

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