V O LU M E 2 4 , N O. 3 / S E P T E M B E R 2 0 1 6
ON TECH HOW DIGITAL TECHNOLOGY IS REDEFINING HEALTHCARE
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Directory 02 Editorial 03 News 04 World 12 Professional 13 Feature – Digital Technology 14 Viewpoint 20
ON TECH HOW DIGITAL TECHNOLOGY IS EDEFINING HEALTHCARE
Research 21 Clinical update
Legal 27 Education 28 Issues 30 Focus – Education Part 1 31 Calendar 45 Mail 46 Annie 48
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September 2016 Volume 24, No. 3 1
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Editorial Lee Thomas, ANMF Federal Secretary The four day festival was a truly uplifting occasion as many Indigenous Australians spoke passionately about innovations in social enterprises, outstanding partnerships and business ventures they are involved in. I left the festival feeling proud of their achievements and enthused about the future of all Aboriginal and Torres Strait Islander peoples. Yet despite feeling encouraged I also left with a sense of urgency knowing that these achievements were only the tip of the iceberg in ensuring equality for all Indigenous Australians, particularly in relation to health.
Last month I joined Aboriginal and Torres Strait Islander leaders, academics, policy makers and political and business leaders from across the globe at the esteemed Garma festival to discuss pressing issues facing our Indigenous population. The annual event, held by the Yothu Yindi Foundation, is an opportunity to learn about the economic challenges and openings for Aboriginal people as well as an occasion to share knowledge and culture, therefore creating greater understanding between Indigenous and non-Indigenous Australians.
The fact still remains that many Aboriginal and Torres Strait Islander peoples are socially disadvantaged, their issues including lower education and employment rates, higher smoking rates, poor nutrition, physical inactivity and poorer access to health services, all of which results in worse health outcomes for Indigenous people than for the rest of the population. One of the proven ways to tackle these issues is to provide a culturally safe Indigenous health workforce. The ANMF has been a strong advocate of Indigenous healthcare workers and has supported the work and initiatives of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), whose primary function is to implement strategies to increase the recruitment and retention of Aboriginal and Torres Strait Islander peoples into nursing and midwifery professions. This month I am also proud to announce the ANMF Federal Office has had its Reconciliation Action Plan (RAP) endorsed by Reconciliation Australia.
THIS MONTH I AM ALSO PROUD TO ANNOUNCE THE ANMF FEDERAL OFFICE HAS HAD ITS RECONCILIATION ACTION PLAN (RAP) ENDORSED BY RECONCILIATION AUSTRALIA.
The premise behind the plan is our commitment to address health inequities experienced by many Aboriginal and Torres Strait Islander peoples. The RAP is an important objective of ANMF’s strategic plan and articulates our vision to influence nursing, midwifery, health and social justice policy in order to improve health outcomes for Indigenous Australians. Coinciding with the RAP in the journal this month are a number of Indigenous health stories, including great achievements made by some of our Indigenous health workforce. Also in the ANMJ, the feature spread investigates the influence of technology and apps on healthcare and how this is changing the way we deliver health. The focus section addresses the latest from our education sector and the recent developments that have occurred to meet the needs of undergraduate and postgraduate nurses and midwives. Additionally, this month’s education tutorial helps identify elder abuse while Clinical Update looks at causes and better ways to treat Delirium. With the array of topics in the journal this month I hope you find the ANMJ an informative and enjoyable read.
September 2016 Volume 24, No. 3 3
AGED CARE IN CRISIS The residential aged care sector has reached crisis point with funding and staffing critical issues, according to an ANMF national survey. Findings show a systemic failure to ensure safe and adequate care to Australian aged care residents. Almost 2,500 people, including more than 1,700 aged care nurses and care workers took part in the ANMF online survey and national phone-in. The greatest concern raised by survey participants was federal funding cuts and staffing levels, ANMF Federal Secretary Lee Thomas said.“The lack of emotional and social care for residents described by participants was deeply disturbing.” Countless incidents were described of residents being “left wet, dirty, hungry, thirsty, dehydrated and in pain”, the survey report found. Residents were “bored, lonely, ignored, invisible, depressed, humiliated, belittled and dehumanised”. “Their accounts describe a situation of widespread substandard care which offers little or no dignity to the elderly at the end of their lives,” Ms Thomas said. “Resources are becoming so scarce that on many occasions it is just not possible for residents to be cared for safely or, as reported by many
TACKLING STRESS AND BURNOUT IN NURSES A pilot education program aiming to arm cancer nurses with the coping skills to deal with stress and burnout will soon be rolled out at two Western Australian hospitals. The innovative wellbeing project, led by Professor Anne Williams, Professor of Health Research at Murdoch University, was unveiled as part of the 17th International Mental Health Conference on the Gold Coast last month. The project, which has been in the pipeline for several years, is coming to fruition following a survey of cancer nurses which confirmed widespread high levels of workplace stress and importantly, substantial scope for improving resilience
4 September 2016 Volume 24, No. 3
participants, even humanely.” About 96% of aged care workers and 94% of community members considered current funding inadequate to meet the needs of aged care residents. More than 90% indicated the government’s $1.8 billion cuts forecast over the next four years would have a significant impact on levels of care provided. “Staff who are always rushing between tasks cannot give quality time and care to frail elders,” one survey participant said. An alarming 80% of those working in aged care said current staffing levels were insufficient to provide adequate care. Workloads were identified as the single greatest contributor to recruitment and retention for the aged care sector by almost half of survey participants. In some facilities on a pm or night shift there was one RN for 145-150 residents. Day shifts ranged from one RN for 28 residents to one RN for 120 residents; some facilities did not have a RN, or worked part-time. “I resigned last week as my pleas for one more hour of carer time on a pm shift were ignored…I can’t continue to see the neglect of the residents,” one aged care worker said. The overwhelming theme was that the elderly deserved much better care than they currently received, Ms Thomas said. “Despite multiple reviews, inquiries and investigations, there is simply a lack of will by governments and industry to address these matters seriously.”
“HAVING TO RUSH FRAIL, ANXIOUS, VULNERABLE, PERHAPS DEMENTED, PERSONS IN ORDER TO ATTEND TO THEIR MOST BASIC REQUIREMENTS…IS A DISGRACE AND POOR REFLECTION ON THE SOCIETY THAT IGNORES OR FAILS TO ADDRESS SUCH ISSUES.”
“MOST OF US ARE VERY STRESSED [WHICH IS] RESULTING [IN] POOR HEALTH…IT’S JUST IMPOSSIBLE WHEN YOU DON’T HAVE ADEQUATE STAFF, IT’S SO FRUSTRATING THAT NO ONE CARES ABOUT ADEQUATE STAFFING AND YET EXPECT QUALITY CARE? IT MAKES ME CRY.”
“WHILE STUDYING TOWARDS MY BACHELOR OF NURSING, I WORKED IN PRIVATE AGED CARE AS AN AIN. WORKING THERE WAS SOUL DESTROYING AND I WILL NEVER WORK IN AGED CARE AGAIN AS AN AIN OR RN DUE TO THE POOR LEVEL OF CARE, STAFFING RATIOS AND POOR PAY LEVELS.”
through a wellbeing education program.
demands of watching patients suffer.
The proposed education framework designed to increase wellbeing will target four key areas – knowledge and understanding, self-discipline and motivation, organisational culture and environment, and strategies and resources.
“The ongoing effect of that is it is not conducive to providing compassionate care to patients,” Professor Williams said. “It’s also a problem for the nursing profession because a lot of nurses get to the point where they just can’t cope anymore and leave. So the retention of skills and experienced staff is getting to be quite a problem, which then puts pressure on the younger ones that are left to cope.”
As the pilot education program has progressed, it has also pinpointed a need for a new component utilising the firsthand accounts of cancer nurses who have experienced stress and burnout. Professor Williams said recent years have seen a greater focus on acknowledgment of the stressful environment nurses work in and attempting to curb the problem. She said signs of stress, such as exhaustion or a negative emotional reaction to work challenges, could lead to poorer outcomes. Causes of stress specific to nursing identified include a high workload, lack of control, insufficient support, staffing levels, co-worker conflict and bullying, and the emotional
Professor Williams listed the high workload of nurses and increasing acuity of patients as factors contributing to stress across the profession. The new wellbeing education program will focus on empowering nurses with coping strategies they can use to selfmanage stress and burnout. A trial and evaluation of the program will then be undertaken next year. If successful, it is hoped the program will lead to further intervention studies in hospitals and possible inclusion within undergraduate nursing courses.
CENSUS TO INFORM ON AGEING
ABORIGINAL WOMEN CELEBRATED
This year’s Census will be the last before Australia has to make some stark choices on healthy ageing, an Australian academic has warned.
The strength of trail-blazing Aboriginal and Torres Strait Islander women was celebrated at Government House in Melbourne last month.
Central Queensland (CQ) University Director of Healthy Ageing and Dementia Programs Lisa Hee said it was vital for everyone to contribute to the Census so government and other policymakers were accurately informed of the true needs and abilities of the population.
The event hosted by the Victorian Governor, included a panel discussion organised by the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM).
There will be a significant increase in unmet needs of elderly people in their homes, Ms Hee said. “The funds for aged care facilities have been slashed making it far more difficult to care for residents who are unable to pay large bonds or extra daily care fees. “In addition, many self-funded retirees will be forced to go to Centrelink for additional funds to live as their interest rates are no longer providing enough to live on independently.” A nationwide priority of healthy ageing will require a community-wide effort, not just doctors and nurses, Ms Hee said.
2017 WA NURSE/MIDWIFE AWARDS OPEN West Australian nurses are encouraged to nominate outstanding colleagues for the 2017 WA Nursing and Midwifery Excellence Awards. There are 13 categories and a Consumer Appreciation Award voted by the public. A Lifetime Achievement Honour will also be awarded to a nurse or midwife. Nominations close 9 December. www.wanmea.com.au
Victorian Governor Hon Linda Dessau AM paid tribute to the work of CATSINaM in recruiting and retaining Aboriginal and Torres Strait Islander people to the health workforce. “What better contribution to helping deliver high quality culturallyappropriate healthcare services,” she said. CATSINaM has a membership of 3,100 Aboriginal and Torres Strait Islander nurses and midwives. While the largest Aboriginal health workforce, “we only make up 1% of the nursing and midwifery population; three percent of the population are Indigenous we have a long way to go,” CATSINaM CEO Janine Mohamed said.
WHILE THE LARGEST ABORIGINAL HEALTH WORKFORCE, “WE ONLY MAKE UP 1% OF THE NURSING AND MIDWIFERY POPULATION; THREE PERCENT OF THE POPULATION ARE INDIGENOUS WE HAVE A LONG WAY TO GO,”
Raising expectations of Aboriginal and Torres Strait Islander people, particularly children emerged a main theme. Ms Mohamed said results from the Health Care Heroes survey showed no Aboriginal or Torres Strait Islander child believed they could be a health professional. “They believed they could be an AFL footballer or run in the Olympics but they didn’t believe they were smart enough to be a health professional. “To Close the Gap, we need an Aboriginal and Torres Strait Island workforce and a
CATSINaM CEO JANINE MOHAMED AND DR JACKIE HUGGINS AM
culturally safe non-Indigenous workforce with good grounding on how to look after our people.” Panellist at the event, Aunty Gracelyn Smallwood said as one of 13 children it was inevitable she would become a midwife. “I had the most powerful background of lore, culture, politicisation but we also had to get a Western education to be able to advocate for our people.” The nurse, midwife and activist received a phone call from Wayne Goss on the night he was elected as Queensland Premier. “He said, ‘I want you to come in and work as an Indigenous Advisor. I’ve heard all the problems and would like you to be part of the solution. It changed my attitude – you have to be on the inside as well as the outside,’’ Ms Smallwood said. Physiotherapist and medical student Danni Dries said it wasn’t until she tore her ACL and had 10 months of physio that she even knew what a physiotherapist does. “There are no health professionals in my family. It took me seven years to complete my physio degree. There were a lot of things happening during that time.” This included the death of her father, aged 58, of a heart attack and her uncle, aged 53, of a stroke. “I had a lot of people say that I wouldn’t go back, that I wouldn’t finish it.” Danni decided on studying medicine after “falling in love with the country” on rural and remote placements. “I want to work remote but there aren’t many physio positions out bush. So I thought maybe medicine but then there was the self-doubt. Our mob do not think we can achieve anything. But I had the support of the uni and now I finish in three months.” “We need more Aboriginal health professionals across the board and we need non-Indigenous health professionals that are culturally responsive and respectful.” September 2016 Volume 24, No. 3 5
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INDIGENOUS WELLBEING MEASURED BEST FROM GROUND UP Indigenous wellbeing is best measured by its own indicators, a report released last month shows. The Bankwest Curtin Economics Centre and Australian National University (ANU) research of the Western Australian Yawuru people of in and around Broome found connectedness and autonomy integral to wellbeing.
JIMMY EDGAR (A YAWURU AND KARAJARRI MAN) WITH HIS GRANDDAUGHTERS, MELECA JAMES AND OLA JAMES. PHOTO CREDIT: SANDRA HARRIS AND THE YAWURU CULTURAL MANAGEMENT PLAN.
“What is deemed a comfortable, healthy or happy life will differ from person to person depending on their cultural background and life circumstances.
Developing their own indicators of wellbeing is a better way to determine how they are faring according to their own benchmarks and standards, the research found.
“The findings from the Yawuru wellbeing survey show there are many factors that contribute to achieving and maintaining wellbeing for Yawuru, but particularly connectedness to culture, country and family and self-determination.”
ANU Centre for Aboriginal Economic Policy Research report author Mandy Yap said there was a tendency to enforce orthodox measures of wellbeing to represent diverse experiences across Indigenous cultures.
In the Community Wellbeing from the Ground Up: A Yawuru Example report, more than 93% considered their connection to family to be ‘strong’ or ‘very strong’. The strong connection was seen with frequent contact
WOUND CARE RN TAKES OUT HESTA AGED CARE AWARD
Yawuru women were twice as likely to report being very satisfied with their life (44%) overall than Yawuru men (23%). The Yawuru had devoted resources to revitalisation of language, reconnection of culture, management of waters and lands, improved housing, building capacity of youth and caring for senior people, Nyanmba Buru Yawuru CEO Peter Yu said. “The survey findings will help determine the success of Yawuru native title rights.”
The Wounds Resource Team includes RNs, ENs, personal care assistants, occupational therapists, dieticians, a clinical nurse manager, podiatrist and district nurses. Monthly team meetings focus on topics from skin tears to wound products. Results had shown improved practice, a reduction in the severity of wounds and better documentation. “Interestingly, at the start it appeared we had an increase in wounds,” Ms Koch said. “However we found an increase compliance in reporting – there was a push to report even the smallest wound which can turn into something big.”
Camille Koch (pictured) of the Macedon Ranges was recognised for researching and implementing changes to wound management practices in residential aged care.
“With organisational support, we set up the team to provide more holistic wound care. There are many facets to wound management, such as involving the occupational therapist for those at high risk of pressure ulcers: to get on to it early to decrease wounds. Some wounds cannot be healed – we want to improve the quality of
Autonomy was also important, with around 88% of Yawuru reporting having total control or quite a lot of control over their life.
study in wound care as I wanted to make a difference in my community. My aim is to improve wound management in aged care facilities, and hopefully reduce the chances of hospitalisation.”
A Victorian registered nurse improving wound care practice is the recipient of the individual distinction in HESTA’s national aged care awards announced last month.
A RN Nurse Supervisor at Gisborne Oaks Residential Aged Care facility, Ms Koch set up a multidisciplinary Wounds Resource Team.
with family and friends and available support.
life of all residents.” Ms Koch was recognised as a champion for change around policies, procedures and documentation. She started her career on an acute care surgical ward. “I cared for a number of patients with complex wounds coming in from aged care facilities. When I began working in aged care I decided to start post-graduate
Ms Koch said it was collaboration that had brought about change and improved practice. “The multidisciplinary team aims to prevent and manage wound practices holistically in the organisation, across residential aged care and community services. “At the end of the day it’s about evidence based practice, leading to improved quality of life. This award acknowledges the work done by the whole team at Macedon Ranges Health.”
September 2016 Volume 24, No. 3 7
HOW NURSING INFORMATICIANS CAN IMPACT PATIENT OUTCOMES A leading informatics nurse has encouraged others to take up the speciality, which facilitates the introduction of technology into the nursing environment, in order to streamline the work of nurses and consequently achieve better patient outcomes. Addressing the recent Health Informatics Society of Australia’s (HISA) HIC 2016 conference in July, Brittney Wilson pictured, widely known as the Nerdy Nurse, said informatic nurses were essentially “translators” that play the role of the middleman when new technologies are introduced into clinical settings. She said Australia should take special note of the US failure in not adequately consulting its nurses when broadly implementing Electronic Health Record (EHR) systems into hospitals. “You will have it fall flat and it will not be effective and you will have instances where hospitals will spend millions of dollars implementing EHR systems and the staff will revolt and it will be a huge failure.”
BID TO TACKLE BOOZE HARM The staggering extent of alcoholrelated harm in the NT was revealed ahead of the territory’s election last month in a last-ditch plea for political action. Alcohol is responsible for two deaths, 52 hospitalisations and 69 assaults every week in the NT. NT has the highest proportion of people in Australia who drink daily and the lowest proportion of non-drinkers. Drinking patterns were reflected in the high level of preventable alcohol-related illness, injury and death, People’s Alcohol Action Coalition (PAAC) spokesperson Dr John Boffa said. “Our drivers are 20 times more 8 September 2016 Volume 24, No. 3
“THEY’RE NOT HOSPITAL CEOS. IN MANY CASES THEY’RE NOT HUGE DECISION MAKERS. BUT THEY DO HAVE THE ABILITY TO MAKE AN IMPACT AND A DIFFERENCE.
Ms Wilson told the conference she became an informatics nurse in a bid to make a larger impact on the nursing workforce and patients. She said there are nurses currently on the frontline who probably feel the same but have never considered the effect nursing informatics can have. “They’re not hospital CEOs. In many cases they’re not huge decision makers. But they do have the ability to make an impact and a difference. If they decide that a button over here needs to be likely to return a breath test above the legal limit; alcohol’s a factor in at least 42% of road deaths. It’s a factor in 53% of all assaults, and in up to 65% of all family violence reported to police.” The PAAC and the Foundation for Alcohol Research and Education (FARE) called for action by politicians in nine priority areas at a public forum held in Alice Springs. This included reintroduction of the banned drinkers register and a minimum price for alcohol. The nine priority areas had a deliberate focus on supply reduction measures, Dr Boffa said. “We…demand that our political representatives acknowledge the scale of the problem and embrace those measures proven to be successful. “This is a problem that affects all Territorians. Aboriginal and Torres Strait Islander peoples suffer disproportionately but it touches all who live here.”
over there, or that 13 clicks is too much and it should be 9 clicks, they have the power to do that. They have the power to make one of the biggest impacts on patient care and healthcare technology by making sure that the needs of nurses are met and that they advocate for nurses at every conceivable opportunity.” Ms Wilson conceded informatics nurses make up just a small part of the profession and customarily have to fight uphill battles to justify their involvement in decision making. However, when given the opportunity, she said informatics nurses must first promote the idea of “technology empowerment”, before successfully engaging nurses prior to the implementation of EHR systems, and then spelling out how technology will improve the work and patient care they provide. “If you don’t assess the bare needs of the clinicians and the staff that you have in terms of the level of their technology understanding and education you’re going to fail.” FARE Chief Executive Michael Thorn said all sides of politics needed to support a comprehensive and long-term approach that prioritised community health and safety above commercial interests. “Governments need to do more than show concern about the damage caused by too much alcohol, while in the same breath approving more liquor outlets and relaxing regulation. “What’s needed is a comprehensive approach to ensure that workable solutions remain in place beyond the next election.”
Alcohol action areas include for: • Greater investment in treatment services • A reduction in the number of liquor outlets • Increased community involvement in liquor licence regulation • Geater investment in fetal alcohol spectrum disorder
NURTURING GRADUATE NURSES ENTERING MENTAL HEALTH An innovative education program supporting new graduate nurses as they transition into mental health settings is demonstrating how nurturing new nurses can enhance workplace culture and help retain staff within the sector. Addressing the 17th International Mental Health Conference on the Gold Coast last month, nurse leaders from the Northern Sydney Local Health District (NSLHD) revealed their approach in supporting new graduate nurses entering the service’s Mental Health Drug & Alcohol settings. New graduates are referred to as Transitional Registered Nurses (TRNs) by the health service, which devised the education program after recognising gaps in the
CHALLENGES FACE NURSES IN DIGITAL HEALTHCARE Australia’s nursing informatics community must build a stronger presence as it strives to drive the rising adoption of digital healthcare among both nurses and consumers, at Nursing Informatics Australia’s (NIA) annual conference, held in Melbourne in July has revealed. As part of a panel discussion Professor Patti Brennan, the Professor of Nursing and Engineering at the University of WisconsinMadison and the newly appointed Director of the US’s National Library of Medicine, said nursing informaticians needed to empower nurses with the confidence to use the digital tools available to provide better patient care. “There is technology moving faster than patient care and it is the responsibility of the nursing informatics community to make sure we’re on top of that.” As Electronic Medical Record (EMR)
transition from university to the clinical environment. Namely, shortcomings identified included entering mental health environments unprepared for the realities of the sector, and the transition potentially being harder due to the comparatively less theoretical and clinical exposure in mental health at an undergraduate level, culminating in a perceived lack of confidence and competence. “Despite a transition to tertiary education, literature research reveals that horizontal violence continues to exist and a significant proportion of new graduate nurses experience psychological abuse,” NSLHD Nurse Educator Jane Millar explained. The NSLHD’s program consists of nine face-to-face days of education run over the course of the graduate year. Key elements include clinical rotation through a diverse range of settings supported by a preceptor, a performance development review so that goals can be worked upon and extended with each new rotation, clear guidelines within both in-patient and community settings, e-learning modules, and credit points towards potential post graduate studies. The program also includes significant mentorship and support from clinical experts.
17TH INTERNATIONAL MENTAL HEALTH CONFERENCE
In 2015, 23 registered nurse graduates undertook the education program, with 83% of them later taking up permanent positions within the health service. Ms Millar said an evaluation of the program had revealed positive feedback regarding its objective, implementation, and the impact on young nurses finding their feet in challenging mental health settings. The NSLHD will also look at ways in which the education program could be applied to more senior mental health staff as they transition between roles in a bid to facilitate career development and foster a vibrant mental health workforce.
systems become increasingly implemented into hospitals, Australian College of Nursing CEO Kylie Ward warned that health literacy would be crucial. “I think that we’ll end up with a divide if we’re not careful of almost first world and third world type of understanding. That there’ll be those that are educated and articulate in Information and Communication Technology (ICT) and digital, and I think if we’re not careful we’ll leave behind a whole group of our workforce who doesn’t have the knowledge and the gap will get larger and larger.” The panel acknowledged that the nursing role in the new digital space was an evolving one and that collaboration and targeted strategy was now required as the profession adapts. CEO and owner of Trend Care Systems, Cherrie Lowe, said any new systems implemented, such as EMRs, should have a clear vision and be easy for nurses to use. Emerging nurse leaders and new graduates were put forward as the target audience of the future given their advantage of having grown up in the digital world. In the US, the implementation of EMR systems was widely considered a failure, with a 2014 report revealing 92% of nurses were dissatisfied with the new technology.
PANEL AT THE NURSING INFORMATICS AUSTRALIA CONFERENCE
Author and blogger Brittney Wilson, known as the Nerdy Nurse, said Australia had a unique opportunity to learn from the mistakes of the US. “The future is bright but we have to start today to make sure that the people who need to be using those resources are trained and efficient in those technologies because they need to be in order to be competent to provide the right provision of care,” Ms Wilson said.
September 2016 Volume 24, No. 3 9
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MATCH FUNDING FOR INDIGENOUS RESEARCH
LEFT TO RIGHT: EMMA GEE, EMMA GAFFY, STROKE FOUNDATION CEO SHARON MCGOWAN, TERRY KENNEDY, NATIONAL DISABILITY SERVICES CEO DR KEN BAKER AM, NICK RUSHWORTH, EXECUTIVE OFFICER BRAIN INJURY AUSTRALIA, ASSOCIATE PROFESSOR BRUCE CAMPBELL.
YOUNG STROKE ON THE RISE One in four strokes now occurs in young people, unpublished data released for Brain Injury Awareness Week shows. About 30% of stroke survivors, around 130,000 Australians are under 65 years, according to data by the Australian Stroke Clinical Registry. Awareness of stroke symptoms for fast action was the message during Brain Injury Awareness Week last month. Brain Injury Australia released a position paper to coincide with the launch held at the Melbourne Brain Centre. While rates of stroke had decreased in those aged over 65 years, there had been a 5% increase in those aged 45-65 years; and a 44% increase in those aged 25-44 years. Traditional risk factors such as obesity, high blood pressure and diabetes accounted for an increase in stroke in young people, Clinical Chair of the Stroke Foundation Associate Professor Bruce Campbell said. However about 25% of strokes had unidentified cause. “We have to do better at identifying the cause of these cases,” he said. National Disability Services CEO Dr Ken Baker described of his family’s “collision with stroke”. His wife had two strokes in her early 40’s and suffered aphasia. “The message which has been wellarticulated is that stroke can happen to anyone at any time.” Mr Baker described stroke on a young person as an “assault on their identity”. “It has a profound domino effect that extends well beyond the physical and
cognitive functionality.” Stroke survivor Terry Kennedy called for age-appropriate services for young people with stroke. “I was the youngest person there, by far [in rehabilitation]. While I know it’s important to know how to make a cup of tea, or fold clothes, all I wanted to do was walk and run again,” the marathon runner said. Occupational therapist Emma Gee, 24, used to help people with multiple sclerosis, muscular dystrophy and stroke. After a few ‘misdiagnosis’ following back pain and headaches, the fit and healthy long distance runner was diagnosed with a malformation on the brain. She suffered a stroke during high risk surgery. Her biggest message was for “awareness and education of the physical and emotional toll stroke has on your body”. Stroke Foundation CEO and nurse Sharon McGowan said more needed to be done to support the individual needs of young stroke survivors in the community. “Our health, welfare and community care systems are not well set up to support young stroke survivors, particularly those with high care needs.” These included health needs related to falls, pain, concentration and vision which limited their recovery. Allied health services were limited under Medicare, Ms McGowan said. Dr Baker said the NDIS was a ‘safety net’ for what people could not be expected to plan for. “There are intense costs for rehabilitation services and disability support; it’s crippling for most, if not all, people.” The NDIS negotiated between the Council of Australian Governments should not be bound by demarcation disputes with funding, he said. “I am hoping the doubling of funding for disability support across Australia will deliver continuity and support….for people to re-build and reconnect to community.”
Professor Tom Calma AO has called on the Australian Research Council (ARC) to match its proportion of funding provided by the National Health and Medical Research Council (NHMRC) for Aboriginal and Torres Strait Islander research projects. “The NHMRC now has a target of between 5-6% for funding to go towards Aboriginal and Torres Strait Islander projects. We’re calling on the ARC to match it.” The life expectancy gap between Indigenous and non-Indigenous Australians was now about 10 years compared with 17 years in 2005, Professor Calma said. “But there’s still a significant gap compared to our Indigenous brothers and sisters in New Zealand and Canada and the United States where they enjoy five to six years. All of our research projects are looking at ways we can influence the way we close that gap. If we can encourage more targeted initiatives, we’ll always get better outcomes.”
MENTAL HEALTH SUPPORT FOR VETERANS The federal government announced further mental health services for veterans and Australian Defence Force members including support to re-enter the civilian workforce last month. The announcement comes ahead of the government’s response to a Senate Inquiry into the mental health of ADF members and veterans due next February. An interim report is expected in December. A review of suicide and self-harm prevention services available to veterans was announced. As well as a suicide prevention trial site to be set up in north Queensland with a large veteran community. It will be one of 12 front-line trials, the government announced. “We will ensure ADF members and veterans who face mental health challenges, either during service or once they have left the ADF, can access the mental health services they require,” Federal Health Minister Sussan Ley said. September 2016 Volume 24, No. 3 11
EU nurses face uncertainty in UK Calls to secure the future of thousands of EU nurses working in the UK have followed Britain’s vote to leave the European Union.
More than 33,000 EU trained nurses are registered to work in the UK – more than the total number of nurses working in Wales. Figures from the Nursing and Midwifery Council (NMC) showed over 9,000 nurses joined the register in 2015-16 – a 21% increase on 2014-15. The Royal College of Nursing (RCN) estimated recruitment from the EU was at its highest level for 20 years. The figures came ahead of a House of Lords debate on the impact of the vote to leave the EU on safe staffing levels in the NHS. UNISON warned the NHS could not survive without the tens of thousands of EU health staff working in the UK. “Without these health professionals, the NHS would be facing even greater challenges and patients would be waiting much longer for treatment,” UNISON Head of Health Christina McAnea said. The union called on ministers to guarantee existing EU staff could continue living and working in the UK without restriction. The RCN also called on the government to safeguard the future of EU nurses working in the UK. “These are uncertain times for safe staffing in the health service and a lack of concrete assurances from the government over the future of EU nursing staff working in the UK is making the situation worse,” Regional Director of RCN North West Estephanie Dunn said.
Zika spread formidable challenge
Up to 1.65 million childbearing women in Central and South America could become infected with the Zika virus by the end of the first wave of the epidemic.
12 September 2016 Volume 24, No. 3
The research published in Nature Microbiology shows Brazil is expected to have the largest total number of infections – by more than three-fold – due to its size and ability for transmission. University of Southampton geographer Professor Andrew Tatem said Zika presented a formidable challenge to scientists. “It is difficult to accurately predict how many childbearing women may be at risk from Zika because a large proportion of cases show no symptoms.” An estimated 80% of Zika infections do not show symptoms and of those which do, some could be due to other viruses. The University of Southampton, University of Notre Dame and University of Oxford researchers modelled the possible scale of the projected spread of the Zika virus including places likely to be most affected. “These projections are an important early contribution to global efforts to understand the scale of the Zika epidemic, and provide information about its possible magnitude to help allow for better planning for surveillance and outbreak response, both internationally and locally,” Professor Tatem said. Scientists are still investigating the potential link between microencephaly in babies and Zika.
Inquiry into murdered Indigenous women
Canadian nurses are encouraged by the launch of a federal Inquiry into missing and murdered Indigenous women last month. While Indigenous women make up 4% of Canada’s female population, 16% of all women murdered in Canada between 1980 and 2012 were Indigenous. Amnesty International released a report on the violence and discrimination against Indigenous women in Canada in 2004. The Royal Canadian Mounted Police identified 1,181 missing and murdered Indigenous women and girls in 2014. “This is an important and long-awaited Inquiry to finally address the unacceptable
violence against Indigenous women,” Canadian Nurses Association (CNA) CEO Anne Sutherland Boal said. “Nurses contribute significantly to the care of Indigenous women. As nurses are often the first point of access for women who have been victimised, we have an important voice to lend to this Inquiry.” The first Indigenous woman judge in British Colombia province will lead a fivemember commission of lawyers, a professor and an activist in Indigenous rights. Reports and studies on violence towards Indigenous women in Canada have found socioeconomic factors including poverty and homelessness as well as racism, sexism and results of colonialism. “We are hopeful that this Inquiry will lead to concrete actions in reducing violence against Indigenous women across the country,” Ms Sutherland Boal said.
Invest in girls’ education
The International Council of Nurses has called for investment in girls’ education worldwide. “As the largest group of healthcare professionals in the world, and as a femaledominated profession, nurses know that by investing in women and girls, we invest in families, communities and health.” The theme of this year’s World Population Day is Investing in teenage girls. An estimated 31 million girls of primary school age and 32 million girls of lower secondary school age were out of school in 2013, according to UNICEF. “In many countries, the number of girls completing upper secondary school is so low that it is not possible to know how many are in or out of higher grades,” the World Bank reported. The ICN/FNIF Girl Child Education Fund (GCEF) supports primary and secondary schooling of girls under 18 years in developing countries whose nurse parent/s have died. The fund currently supports 103 girls in Kenya, Swaziland, Uganda and Zambia. www.gcef.chv anmf.org.au
ALL THINGS DIGITAL Recently I attend the Nursing Informatics Australia annual conference in Melbourne. The theme of the conference was the role of the nurse in digital health innovation for consumers, clinicians, connectivity and community. ANMF Federal Professional Officer Julie Reeves
This forum provided a platform to hear about the many nurse led innovative programs being implemented across the country, using digital health technology. We heard about using a data linkage to map and assess outcomes of telephone triage and advice services, and how effective wound imaging can support clinical assessment across great distances. I find the use of digital technology one of the most exciting developments for our professions. Potentially digital health innovation will have the greatest influence over the next decade, on improving health outcomes for the people for whom we provide care. The last session of the conference focused on the challenges nurses and midwives face in the digital healthcare environment. This discussion reinforced the importance of all nurses and midwives engaging more fully in the use of informatics.
WHAT IS CHANGING IS THE WAY WE ARE COLLECTING INFORMATION OR DATA, AND THE SPEED AT WHICH IT CAN BE AGGREGATED OR COMBINED AND ANALYSED.
Nursing informatics is defined as the practice of using nursing science and technology to enhance the pathway that data takes to become knowledge to improve patient care (McGonigle et al, 2014).
Reference McGonigle.D., Hunter.K.,Sipes. C. and Hebda.T. (2014) Why nurses need to understand nursing informatics. AORN, Vol 100, No. 3. p324-7
Informatics is not new to nurses and midwives. We have been using our scientific knowledge and information to enhance the care we provide since our professions first began. What is changing is the way we are collecting information or data, and the speed at which it can be aggregated or combined and analysed. In this rapidly evolving space, it is essential nurses and midwives recognise the importance of the role they play in collecting information and using information communications technology (ICT). The role of nurses and midwives may vary, such as a Chief Nurse Information Officer in a major tertiary hospital, a nurse or
be, developing and expanding. To help nurses and midwives further understand their role in informatics, the Australian Nursing and Midwifery Federation (ANMF), with funds provided by the then Australian Government Department of Health and Ageing, completed a project to develop National Informatics Standards for Nurses and Midwives.
PHOTO: ROHAN THOMSON
midwife using digital devices in the provision of direct care for people in a community setting or a nurse or midwife informatician in a healthcare service. Despite their varied roles, they all play an essential part in using digital technology to enhance nursing and midwifery practice. Nurses and midwives are collecting data in everyday practice and using tools such as an electronic health record or a triage and tracking system to collect and store data. These activities are essential to improving health outcomes. At all points along the care continuum, nurses and midwives input data into a variety of electronic systems, which should be connected and communicate with each other. This connection and exchange of data between systems is known as ‘interoperability’. The value of the appropriate management of data in improving care outcomes cannot be underestimated. It is imperative that all nurses and midwives understand the data they are collecting, understand why it is being collected and most importantly, how to effectively enter this data, for the safe delivery of quality care. I urge you to become engaged in ICT within your workplace, and for those who are inclined to take the next step, become a nurse or midwife informatician. Get involved in designing data systems, or analysing data, or participate in an ICT project, to educate and engage other nurses and midwives in informatics. It’s an exciting area and one where nursing and midwifery roles are, and should
The aim of the project was to develop standards that could facilitate ongoing development of a skilled, capable and informed nursing and midwifery workforce, capable of using the tools technology provides, in order to deliver safer, better integrated care. The standards were developed following a review of the literature and using data derived from focus groups of nurses and midwives, responses to an online survey and individual interviews. The ANMF standards project confirmed the importance of informatics in nursing and midwifery practice, with the standards providing three main domain areas of focus for nurses and midwives in developing their competence, namely: computer literacy, information literacy and information management. The ANMF standards should always be viewed in conjunction with the Nursing and Midwifery Board of Australia’s (NMBA) standards for practice for the registered nurse, enrolled nurse or midwife, which provide the regulatory framework for the professions. The NMBA standards for practice refer to informatics in a broader context of nursing and midwifery practice, whereas the ANMF informatics standards provide a more detailed resource and a valuable tool for nurses and midwives to assist them to build capability in informatics to enhance their practice and thereby improve health outcomes. The ANMF National Informatics Standards for Nurses and Midwives are available to download from the ANMF Federal Office website: http://anmf.org.au/pages/ national-informatics-standardsfor-nurses-and-midwives
September 2016 Volume 24, No. 3 13
ALL HANDS ON TECH HOW DIGITAL TECHNOLOGY IS REDEFINING HEALTHCARE Digital technology is on the cusp of transforming healthcare. The number of health apps at the fingertips of consumers has surpassed 165,000, giving people around the world more access to information than ever and the tools to take care of themselves. Similarly, the adoption of digital medical records across clinical settings is another catalyst shaping the new landscape. Robert Fedele explores the digital health movement amid its upward spiral. PHOTO: ROHAN THOMSON
14 September 2016 Volume 24, No. 3
FEATURE Leigh Dicker was in his early 40s when his first heart attack hit. He describes the episode as a “complete shock” when considering he exercised regularly, wasn’t overweight, and didn’t smoke or drink. “When I went into hospital most of the guys around me were in their 70s plus. It certainly felt very strange,” he recalls. “It happened at work. Just in the spur of the moment. I have a fairly stressful job. I just thought it was the usual stress coming on and in the end I realised things were fairly serious.” The heart attack triggered early onset diabetes and helped uncover unknown hereditary cholesterol problems. Feeling bulletproof, Leigh brushed off the heart attack as a minor glitch and had returned to work six weeks later as though nothing had changed. It would be his second heart attack, just two years later, that delivered the ‘wakeup call’ he needed. For Leigh, now 60, change meant fine-tuning his diet, reducing stress, and importantly, taking medications regularly. Over the years he endured a massive regime of trial and error in a bid to juggle his copious amount of medications before stumbling across health app MedAdvisor two years ago. MedAdvisor aims to improve the lives of people taking multiple medications by reminding them how much to take and when. It’s linked to participating pharmacies across Australia and once a patient signs up, the app keeps track of all medications dispensed, reminds patients when they need to take them, how long their supply will last, and also when it’s time to collect a refill or repeat script from their GP.
Health apps, in part, are viewed as an area which can help reduce the burden on the nation’s health system by enhancing self-care and keeping people out of hospitals. Adelaide’s Flinders University has just launched its Digital Health Research Centre, with the research and innovation hub being led by Australian digital health experts Professor Anthony Maeder and Professor Trish Williams. The centre will initially focus on developing smart and interactive technologies to monitor the health of the aged at home and target conditions like diabetes and cardiovascular disease. “We’re trying to set the centre up to see what contributions digital health can make to what you might call health smart living,” Professor Maeder says, explaining the priority will be on home-based self-care. Professor Maeder says technology exists to monitor health in various ways at home, such as being able to take one’s blood pressure or heart rate, but interoperability
“I THINK THERE’S A HUGE ROLE TO USE HEALTH APPS FOR PATIENT EDUCATION. IT ACTUALLY FACILITATES INFORMATION EXCHANGE AND CREATES MORE CONSISTENCY IN THE MESSAGE BEING DELIVERED.” Nurse Practitioner Chris Helms
The app, which has more than 120,000 active users, also links with GPs and allows them to track whether a patient is sticking to their medication program. Leigh, a busy architect who employs numerous people across multiple offices, uses the smartphone app to manage a cocktail of pills which he takes in different quantities and at different times of the day. “Its basically looking over my shoulder electronically and keeping it all in order,” he says. “It made it consistently easier. It means I’m taking my medications more regularly, which means better health outcomes.”
issues across systems is what’s affecting data integration.“For example, taking data from a home monitoring system, routing it back to the My Health Record, this is pretty much impossible at the moment.
Digital health research
Colleague Professor Trish Williams says. “We’ve got lots of things from the technology point of view, we can just monitor things, or we can collect it. But it’s actually making that data useful and delivering it in a way that is useful to the clinicians and the patients that is the key.”
In today’s new age of patient empowerment a person can use their smartphone to help them manage a myriad of conditions. There are apps which tackle obesity by motivating people to undertake exercise, apps that manage mental health by tracking mood and pinpointing the danger signs of depression and anxiety, or apps that prepare a patient before and after surgery and offer step-by-step rehab procedures. anmf.org.au
“The reason isn’t because it’s technically difficult. It’s just that all the standards and formats that people use vary and no real thought has been given up front to try and make everything compatible.”
Professor Maeder believes consumers are embracing new technologies available, such as health apps, because they’ve become
empowered from taking an active role in managing their own health. “Devices really range from smartphones that are just logging stuff on a little app through to dedicated Telecare stations. You can get Telecare devices with inbuilt spirometers that measure blood pressure and heart rate. “So the sophistication range varies widely. I think wearable devices are becoming more popular. You see that at the consumer end of the market with Fitbits and the like. I think those single measurement or range of measurement wearable devices is probably where the market will expand more rapidly in the future.” In response to misgivings regarding the accuracy of such devices, Professor Maeder argues their reliability is no more or no less risky than the likelihood of human error. He adds that the ripple effect of increased consumer engagement also provides untold benefits. “I think there’s an interesting social effect here which is the empowerment of patients. By giving them information, by giving them management duties or the gathering duties for that data, you’re getting buy in and you’re getting interest in their own health status and hopefully then some responsibility for managing their health status.”
Researchers from the University of Queensland (UQ) are among the swarm of app developers tackling health conditions through technology. Last year, researchers from the university’s Institute for Molecular Bioscience created PainPal, a smartphone app to help chronic pain sufferers. PainPal works by recording the level of chronic pain a person experiences day-to-day and personalising the data to generate graphs that illustrate an individual’s pain pattern. PainPal is still in development, with the team at UQ conducting an extensive survey of consumers in a bid to refine the app’s design and features before hitting the market. Researcher Prashanth Jutty Rajan says gauging the views of consumers should be an essential component of the developmental process .“Ultimately, they are the end users. They have to be able to decide what they would like because without the end users being in agreement with the kinds of ideas that we as app developers have it is almost futile going through this entire process.” Mr Jutty Rajan concedes the increasing use of health apps triggers valid concerns regarding the reliability of data, as well as newfound dangers in the shift to self-care, but he believes their use, once evidence and efficacy has been established, should be supported. September 2016 Volume 24, No. 3 15
“I THINK THERE’S AN INTERESTING SOCIAL EFFECT HERE WHICH IS THE EMPOWERMENT OF PATIENTS. BY GIVING THEM INFORMATION, BY GIVING THEM MANAGEMENT DUTIES OR THE GATHERING DUTIES FOR THAT DATA, YOU’RE GETTING BUY IN AND YOU’RE GETTING INTEREST IN THEIR OWN HEALTH STATUS AND HOPEFULLY THEN SOME RESPONSIBILITY FOR MANAGING THEIR HEALTH STATUS.”
“IT’S BASICALLY LOOKING OVER MY SHOULDER ELECTRONICALLY AND KEEPING IT ALL IN ORDER. IT’S MADE IT CONSISTENTLY EASIER. IT MEANS I’M TAKING MY MEDICATIONS MORE REGULARLY, WHICH MEANS BETTER HEALTH OUTCOMES.” Leigh Dicker
Professor Anthony Maeder
“NURSES ARE A SIGNIFICANT PART OF THE HEALTH WORKFORCE AND YET OUR VOICE IS NOT HEARD IN MANY CONVERSATIONS ABOUT EMRS AND ABOUT TECHNOLOGY GENERALLY IN HEALTH.” Alison Patrick
“It’s very important to remember that these are just tools to help patients communicate better with their doctors so it’s absolutely important to remember that doctors do play a really important role in any sort of therapeutic regime that a patient may have.”
Developed by Sense-T, a partnership between the University of Tasmania, CSIRO, and State government, AirRater was launched in October last year.
will also be provided with an individualised report showing how environmental conditions impact their symptoms and even providing them with danger alerts.
Asthma affects almost 12% of Tasmanians higher than the national average.
Fellow researcher Kathleen Yin echoes the attitude. “I think that digital health has a great future ahead of it. I personally believe that healthcare apps should be complimentary rather than antagonistic to the doctors. If anything, these apps should encourage people to engage more with their doctors, rather than less.”
The app is linked to a network of data sensors across Tasmania which capture information, including from the state’s Environmental Protection Authority and Bureau of Meteorology, as well as pollen stations deployed by the project team. The information is gathered in real-time and fed back to a central database which gives users vital information about current levels of pollution and potential triggers in their immediate area.
Project Manager Sharon Campbell says the app is the first of its kind to pool such data together to create a case history and pinpoint a person’s triggers. “If, for example, over winter, there’s a lot of wood smoke in certain parts of Tasmania as conditions are really cool and people use wood heaters, if that’s a trigger for people’s asthma, then we’re able to give them a little bit of warning that the wood smoke is quite high and then they can take their own steps towards managing that. That might be avoiding those areas, avoiding going outside, limiting the amount of physical activity they do or taking preventative medications.”
Over time, once users have entered their daily symptoms of asthma, allergies and hay fever into the AirRater smartphone app, they
Hobart resident Mike Cain is among the 1,000 Tasmanians who have already downloaded AirRater. The 33-year-old was
Another innovative health app making a difference is AirRater, an app that helps Tasmanians breathe easier by pinpointing the dangers of pollen and smoke that can affect sufferers of hay fever, allergies, asthma, and other lung diseases. 16 September 2016 Volume 24, No. 3
“TO BE HONEST, IT’S NOT LIFE-THREATENING. IT’S A COMFORT THING. I GET DIZZY AND CAN’T CONCENTRATE AND SOMETIMES GET A LITTLE BIT OF CHEST PAIN. IT’S NOTHING SERIOUS BUT I’D PREFER NOT TO HAVE THOSE SYMPTOMS.” Mike Cain
born with heart valve problems that affect his circulation and cause dizziness and chest pains when an immediate burst of energy or oxygen is required.
platform which delivers tailored information and advice for various conditions, as well as individualised care plans that can be emailed to the client.
AirRater has already made an impact, with Mr Cain cancelling a trip to Port Sorell earlier this year after a quick check of conditions revealed extra high smoke concentrations. On other occasions, during forestry burn-offs, he has monitored the situation before planning his day accordingly and limiting exposure and physical activity. “To be honest, it’s not life-threatening. It’s a comfort thing. I get dizzy and can’t concentrate and sometimes get a little bit of chest pain. It’s nothing serious but I’d prefer not to have those symptoms.”
For example, if a person suffers chronic lower back pain or osteoarthritis, the app can visually demonstrate the pathology of their condition and walk a patient through a basic physiotherapy exercise program based on their individual needs.
Nurses adopting digital tools
As consumers become increasingly empowered by technology, nurses and other health professionals have arguably been slower to adapt, depending on the individual or the organisation. Nurse Practitioner Chris Helms works in Canberra for National Health Co-op, a large group of general practices that operates across multiple sites. Chris works as a generalist, specialising in cardiology, and provides care for complex clients who might have chronic heart or other long-term conditions. He believes health apps can be useful in empowering clients as well as clinicians. As a nurse, he has embraced technology and regularly uses a variety of smartphone apps to streamline his delivery of care. One of them, Orca, boasts a suite of apps that provide graphics and videos related to numerous acute and chronic health issues affecting areas like the spine, eyes heart, and knee, in a bid to enhance patient understanding. The apps also provide a patient engagement anmf.org.au
“It can be used as a very good tool to help them understand not only the disease process, but how they can actually manage their condition themselves,” Chris suggests. “Some of these tools are excellent because they can actually help enhance motivation.” Chris feels comfortable using health apps in the workplace but admits there are some cohorts of nurses who might not due to pervading negative perceptions. “Looking at your smartphone during or after a consultation is very much looked down upon by employers. I think there’s an assumption you’re either playing on your phone or accessing text or email messages. But when you use them in front of a client and say this is what I’m doing, I’m using it to validate some of the risk factors you’ve identified, or I’m using it to create this care plan that can be emailed to you, I think consumers are actually quite happy to see you’re accessing up-to-date information and that your practice is evidence-based.” Chris believes a culture shift is emerging in healthcare when it comes to using new technologies and is confident nurses can lead the way. While concerns about accuracy of information and data security exist, Chris believes coming years will see greater emphasis on enforcing standards concerning health apps that will help alleviate doubts. “I think there’s a huge role to use health apps for patient education. It actually facilitates information exchange by
accommodating diverse learning styles, and creates more consistency in the message being delivered. I think there would be services reluctant to use apps, and those services might be ones that underestimate their role in advanced nursing practice.”
Digital medical records – a new frontier
The rise of increased consumer engagement in health is running parallel to the growing adoption of digital medical records across clinical settings. The government’s problematic system My Health Record is finally gaining momentum, with more than 4 million people, or 17% of all Australians now registered. My Health Record’s vision is to give both a patient and their healthcare professional online access to their complete medical history. The latest practice survey and whitepaper conducted by MedicalDirector revealed clinicians regard the use of technology in practice and patient management highly, with over 83% of practices stating they see the benefits of using technology to access or send patient records, and nearly half of survey respondents indicating they felt it would streamline their work and reduce administration time. Hospitals are too embracing the digital revolution through the inevitable implementation of Electronic Medical Record (EMR) systems. While just 6% of Australian hospitals have successfully put EMRs into place, rapid growth is expected. The Royal Children’s Hospital in Melbourne recently launched its EMR in April, becoming one of the first paediatric hospitals in Australia to replace paper-based medical records with an electronic system. The EMR stores a child’s clinical information September 2016 Volume 24, No. 3 17
A HEALTHY “APP”ETITE
A SNAPSHOT OF HEALTH APPS ON THE MARKET
beyondblue’s mental health app BeyondNow helps people suffering mental health issues by creating a safety plan for people contemplating suicide to get through tough times. The safety plan starts with things people can do by themselves, such as thinking about reasons to live, and distracting oneself with enjoyable activities. It then moves on to coping strategies and people you can contact for support.
Alzheimer’s Australia’s BrainyApp was developed in 2011 to raise awareness of the risk factors of Alzheimer’s disease and other types of dementia and to help keep the brain healthy. BrainyApp works by promoting physical activity, brain challenges, and an active social life.
HIGH-TECH REHAB FOR SURGERY PATIENTS SPORTSMED.SA has developed an interactive mobile phone app to help hip replacement patients prepare for surgery and manage their rehab. A ‘virtual physio’ provides users with a step-bystep animated program to guide them through pre and postsurgery processes. The app helps strengthen muscles, relieve pain, increase mobility, and ultimately restore normal levels of function.
IMPROVING BLADDER CONTROL PREVENTING HEART ATTACKS University of Sydney researchers have created a game-based app to prevent heart attacks among people who have previously had an episode. Prevention programs are a key part of cardiac rehabilitation, and the MyHeartMate uses interactive games, quizzes and challenges to help people make lifestyle changes in order to improve their heart health, such as increasing physical activity, changing their diet, quitting smoking, and reducing stress. It also helps people track their blood pressure and blood sugar levels.
The Continence Foundation of Australia’s Pelvic Floor First app allows people of all fitness levels and pelvic floor function to undertake pelvic floor safe workouts. It also teaches you how to exercise your pelvic floor muscles in order to maintain or improve bladder control.
REDUCING STRESS AND ANXIETY ReachOut Australia’s ReachOut Breathe app was created to help reduce the physical symptoms of stress and anxiety by slowing down your breathing and heart rate. The apps helps you control your breath and measures your heart-rate in real-time using the camera in your smartphone.
“I THINK DIGITAL HEALTH HAS A GREAT FUTURE AHEAD OF IT. I PERSONALLY BELIEVE THAT HEALTHCARE APPS SHOULD BE COMPLIMENTARY RATHER THAN ANTAGONISTIC TO THE DOCTORS. IF ANYTHING, APPS SHOULD ENCOURAGE PEOPLE TO ENGAGE MORE WITH THEIR DOCTORS, RATHER THAN LESS.” Researcher Kathleen Yin
in one place where it is readily accessible to all clinicians involved in care and also available to families via a secure online hub where parts of a patient’s medical record can be viewed via the internet. The EMR also has the capacity to offer prompts and warnings to clinicians as they make decisions about medication, and has the ability to link with GPs to share information. EMRs are becoming more common in Australia but resistance to change and drawbacks regarding usability issues are of genuine concern. A 2014 US report which surveyed more than 13,000 nurses to gauge their satisfaction with their organisation’s inpatient Electronic Health Record (EHR) system found 92% were dissatisfied with it, 94% did not believe communication between nurses and the rest of the care team had improved, and 85% said they struggled daily with flawed systems. Tellingly, 88% of surveyed nurses blamed their hospitals’ decision to choose low-performing systems based on price for the shortcomings, rather than quality of care delivery. A Nursing Informatics Conference, held in conjunction with the Health Informatics Conference (HIC) in Melbourne last July, featured several Australian health services, including Monash Health, and Mercy Public Hospitals, in the process of implementing EMRs. “The evidence suggests we need to advocate for user involvement at all stages of the development process,” said Associate anmf.org.au
Professor of Nursing Bernice Redley, who is working collaboratively on Monash Health’s project, set to come to fruition in 2018. “If we ever think we’re going to have an EMR that’s going to sit on our system and that’s going to be it, we’re wrong, because we want those systems which continually evolve and develop as our profession continually evolves and develops.” Likewise, Alison Patrick, the Executive Director of Nursing and Midwifery at Mercy Public Hospitals, revealed her health service’s ongoing plans to adopt an EMR and the critical considerations required. After discovering the health service’s paper based medical record systems were putting a strain on time, space, and money, Ms Patrick approached hierarchy with a new vision. An EMR Advisory Group was established, which Ms Patrick has led for the past 18 months, and implementation is expected to begin next year. Ms Patrick says it’s difficult to find an EMR that suits all of Mercy Health’s needs but stressed that defining what nurses are currently doing and involving them in discussions has been paramount to her inquiry. “Nurses are a significant part of the health workforce and yet our voice is not heard in many conversations about EMRs and about technology generally in health.”
So where to for digital health? One of the keynote presentations at HIC 2016, the annual conference bringing together health’s most forward thinking innovators, can perhaps offer a small window into the
shifting landscape. The presentation, was delivered by Ron Gutman, CEO of virtual healthcare provider HealthTap, a US innovation that involves a mobile health platform that connects consumers with doctors in real time at any given time of the day. HealthTap has accumulated a network of over 100,000 doctors and is already used by millions worldwide. It’s free to download and works via a subscription model where users pay to ask a specific doctor questions through a consultation. Gutman considers HealthTap a unique platform that delivers care from ‘query to cure’ and one focused on information, communication, and engagement by enabling people to take ownership in their health. HealthTap can be downloaded on your smartphone and consultations take place via text, video, or voice on any mobile device, or personal computer, from home or remote areas. Elsewhere, at HIC, a new Australian Digital Health Agency was launched. The advisory board is comprised of doctors, informatics specialists, digital experts, and customer service executives charged with ensuring the nation’s digital health plans flourish. Digital health is no longer a pipedream and it is clear technology is rapidly shaping the future of patient care and opening the door to consumers actively engaging in taking care of themselves. It’s merely a matter of how long it will take to iron out the kinks and get everyone up to speed. September 2016 Volume 24, No. 3 19
HAVE YOU HAD THE HPV VACCINE? YOU STILL NEED TO BE SCREENED FOR CERVICAL CANCER By Alexis Butler and Stella Heley Nearly all cervical cancer is caused by one or more oncogenic strain of Human Papilloma Virus (HPV) (Walboomers et al. 1999). There are about 40 anogenital HPV types and approximately 15 are associated with cancer of the cervix. Women are at risk of cervical cancer if they have an oncogenic type of HPV infection which is persistent. Nearly all transmission of the virus is by skin to skin contact- mainly sexual activity (International Agency for Research on Cancer, 2005). It is a very common infection and most people are exposed but clear it with no consequences (Wright et al. 2003). HPV types 16 and 18 cause approximately 70% of cervical cancers (International Collaboration of Epidemiological Studies of Cervical Cancer, 2004). The vaccine Gardasil, which is available through the National Immunisation Program for school children, provides immunity to these types. However there are about 13 other types of HPV that are potentially oncogenic and are not covered by the current vaccine (Wheeler et al. 2012). It is of major concern women aged 25 to 35 (our ‘vaccinated cohort’) are not presenting for screening as frequently as in the past (Victorian Cervical Cytology Registry Statistical Report, 2014). It is possible they may not realise that they are still at risk of cervical cancer. In May 2017 the new National Cervical Cancer Screening Program, Renewal will introduce a 20 September 2016 Volume 24, No. 3
test for oncogenic HPV types as the primary screening test for women aged 25-74. As the HPV test is much more sensitive and has a much greater positive predictive value for high-grade cervical intraepithelial neoplasia (CIN 2 & 3) than cytology (the Pap smear), the interval between negative tests will be extended to five years (Dillner et al. 2008). The new program, using HPV testing as the primary test, is expected to reduce the incidence of cervical cancer by 15-18% (Medical Service Advisory Committee, 2013). Currently HPV, as a screening test, is not covered by Medicare. However in the Compass Trial (a randomly controlled trial being conducted by Victorian Cytology Service Limited (VCS) and Cancer Council NSW) two thirds of women are randomised to no cost HPV testing as their primary cervical cancer screening test. The remaining one third will have no cost ThinPrep cytology. The Compass Trial is gathering invaluable information about cervical cancer screening in the Australian population and will inform the new National Program. Currently over 400 medical practices in Victoria are involvedthis number grows weekly. The trial has been very successful in recruiting women aged 37 to 74 years, but we now desperately need younger women (25-36 years), the group that represents the vaccinated cohort. If you are due for a Pap smear, aged 25 to 36 years, and reside in Victoria, please consider asking your GP about the Compass Trial. Having a more sensitive screening test will help to improve and inform the future of cervical cancer screening in Australia. To learn more about the trial, HPV testing and which practices are involved go to www.compasstrial.org.au/main Dr Alexis Butler is GP Liaison Physician Dr Stella Heley is Senior Liaison Physician both are at Victorian Cytology Service Ltd. This article is based on the views and research of the author(s) and has not been peer reviewed.
References: Dillner et al. 2008, Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening: joint European cohort Study, BMJ doi:10.1136/bmj. a1754 International Agency for Research on Cancer. IARC handbooks of cancer prevention: volume 10 - cervix cancer screening. Lyon: IARC Press; 2005 Available from: www.iarc.fr/en/ publications/pdfs online/ prev/handbook10/ HANDBOOK10.pdf. International Collaboration of Epidemiological Studies of Cervical Cancer. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies, 2007 Int J Cancer Feb 15;120(4):885-91 [Abstract available at www.ncbi.nlm.nih.gov/ pubmed/17131 Medical Service Advisory Committee. National Cervical Screening Program Renewal: Executive summary. Commonwealth of Australia; 2013 Nov. Report No.: MSAC application no. 1276. Available from: www. cancerscreening.gov. au/internet/screening/ publishing.nsf/ Content/75412791176 3F571CA257B8A001A DDC5/$File/ WebAccessiblility_ Combined_ Executive_summary__
Final_27Nov2013_ SentToDoHA.pdf. Victorian Cervical Cytology Registry Statistical Report 2014 p11-p13 Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999 Sep;189(1):12-9 [Abstract available at www.ncbi.nlm.nih.gov/ pubmed/10451482]. Wheeler CM, Castellsagué X, Garland SM, et al. Crossprotective efficacy of HPV-16/18 AS04adjuvanted vaccine against cervical infection and precancer caused by non-vaccine oncogenic HPV types: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012 Jan;13(1):e1]. The Lancet Oncology 2012;13:10010. Wright TC, Bosch FX, Franco EL, Cuzick J, Schiller JT, Garnett GP, et al. Chapter 30: HPV vaccines and screening in the prevention of cervical cancer; conclusions from a 2006 workshop of international experts. Vaccine 2006 Aug 31;24 Suppl 3:S3/251-61 [Abstract available at www.ncbi.nlm.nih.gov/ pubmed/16950014].
HOUSING HOMELESS SAVES HEALTH COSTS Providing stable public housing for homeless people could save the Western Australian health system more than $16 million a year. The University of Western Australia (UWA) research, released last month is the first study in Australia to link healthcare costs to national data on homeless programs and public housing. Reduction in the use of health services, particularly hospital stays and psychiatric care could save WA $4,846 per person per year for a total of $16.4 million per year. “After entering a public housing tenancy, the number of people presenting to hospital and the duration and frequency of health service use fell significantly,” UWA lead researcher Professor Paul Flatau said. “The reduction was most notable in emergency department admissions, duration of hospital stay and use of psychiatric services for those with severe mental health issues; all of which cost the health system an enormous amount each year.” The study undertaken for the Australian Housing and Urban Research Institute (AHURI) examined outcomes of the National Partnership Agreement on Homelessness (NPAH), a joint federal/ state and territory initiative. The findings provided compelling support for programs that provide stable permanent accommodation for the homeless and for continued funding of NPAH, Professor Flatau said. “We found that providing public housing for people who are homeless or at risk of homelessness could save nearly $5,000 per person each year in healthcare costs alone and when coupled with support from an NPAH program the annual saving was over $13,000 per person.” The report: ‘What are the health, social and economic benefits of providing public housing and support to formerly homeless people?’ is available at http://apo.org.au
COMMUNITY MEMBER KEVIN NEWTON (CENTRE) WITH UWA RESEARCHERS
DRUG RESIDUE IN DRINKING WATER New ways to remove drug residue from drinking water supplies are being investigated by Queensland researchers. James Cook University (JCU) researchers will use UV and natural sunlight to remove medicine ‘leftovers’ as well as natural minerals which act as absorbents. Current water treatment methods may not be enough with serious concerns of medicines residue accumulation in water supplies. “Recent studies from around the world have demonstrated that pharmaceuticals survive even the most advanced conventional water treatment processes. Hence, these compounds find their way into our drinking water supplies,” JCU Associate Professor Michael Oelgemoeller said. Latest therapeutic drugs which were designed to be more effective had a downside.
“RECENT STUDIES FROM AROUND THE WORLD HAVE DEMONSTRATED THAT PHARMACEUTICALS SURVIVE EVEN THE MOST ADVANCED CONAVENTIONAL WATER TREATMENT PROCESSES.”
“Newer compounds are better able to resist metabolism by the human body. But when these compounds are released into the waterways, they now persist longer and in more powerful concentrations,” Professor Oelgemoeller said. Scientists had only recently looked at the impact of pharmaceutical residue in water supplies. A recent environmental study showed a significant impact of drug residue on the feeding behaviour of fish. “The effects range from impacts on animal behaviour and populations to the enhancement of bacteria resistances,” Professor Oelgemoeller said.
PALEO DIET PROBED The Paleo diet causes more negative side effects than traditional diets, according to research from Edith Cowan University (ECU) published last month. The Australian-first study involved 39 healthy women. Half consumed a Paleo diet and the other half the Australian Guide to Healthy Eating (AGHE) diet over four weeks. Results showed more than one in five women who consumed the Paleo diet reported diarrhoea compared with none in the AGHE group. The Paleo group also reported higher rates of tiredness and difficulty sleeping. The side effects could be a result of the removal of dairy foods and grains in the Paleo diet, ECU Associate Professor Amanda Devine said. “We know that whole grains are a great source of dietary fibre, and a lack of fibre can impact the microbes in your gut, which could in turn cause problems like diarrhoea.” Dairy products contained the amino acid tryptophan which increased sleep-inducing compounds serotonin and melatonin which helped regulate sleeping patterns, Professor Devine said. “So removing dairy from your diet could adversely affect your sleep.” More than half of the Paleo group also reported that the diet increased their average cost of groceries, compared to only 6% of the AGHE group. The research followed another ECU study earlier this year that found the Paleo diet to be more effective for weight loss than the AGHE. Lead researcher Angela Genoni said work was currently underway on a new research project to examine the long-term impact of following the Paleo diet, particularly on gut health. “Removing entire food groups like dairy and grains from your diet is likely to impact overall health. This is why we are recruiting for a larger study involving participants that will look at the long-term effects of adhering to a Paleo diet.” Long-term Paleo followers interested in participating in the research can contact Ms Genoni at email@example.com ‘Compliance, palatability and feasibility of Paleolithic and AGHE diets in healthy women: a 4wk dietary intervention’ was published in Journal Nutrients.
September 2016 Volume 24, No. 3 21
DELIRIUM By Emily Tomlinson What is delirium? Delirium is a common but serious complication of hospitalisation. Delirium can occur in patients of all ages, but the highest incidence is in older patients (>65 years) (MacLullich et al. 2008).
References Australian Commission on Safety and Quality in Health Care (ACSQHC) (2014). A better way to care: safe and highquality care for pateints with cognitive impariment (dementia and delirium) in hospital. Sydney. Bellelli, G., A. Morandi, D. H. J. Davis, P. Mazzola, R. Turco, S. Gentile, T. Ryan, H. Cash, F. Guerini, T. Torpilliesi, F. Del Santo, M. Trabucchi, G. Annoni and A. M. J. MacLullich (2014). Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing. Boettger, S. and W. Breitbart (2011). Phenomenology of the subtypes of delirium: phenomenological differences between hyperactive and hypoactive delirium. Palliative & Supportive Care 9(2): 129-135. Cull, E. J., B. Kent, N. M. Phillips and R. Mistarz (2013). Risk factors for incident delirium in acute medical inpatients. A systematic review. JBI Database of Systematic Reviews and Implementation Reports 11(5): 62 - 111. de Lange, E., P. F. M. Verhaak and K. van der Meer (2013). Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review. International Journal of Geriatric Psychiatry 28(2): 127-134. Demeure, M. J. and M. J. Fain (2006). The elderly surgical patient and postoperative delirium. J Am Coll Surg 203(5): 752-757. Ely, E. W., A. Shintani, B. Truman, T. Speroff, S. M. Gordon, F. E. Harrell, Jr., S. K. Inouye, G. R. Bernard and R. S. Dittus (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Jama 291(14): 1753-1762.
22â€ƒâ€ƒSeptember 2016 Volume 24, No. 3
CLINICAL UPDATE The term delirium derives from the Latin word ‘delirare’ which means “deviates from a straight track” and was documented in the writings of Hippocrates around 2,500 years ago (Lipowski, 1990). The American Psychiatric Association denotes five key elements of delirium: (1) disturbance in attention and awareness; (2) develops over a short period of time and tends to fluctuate during the day; (3) additional disturbance in memory deficit, disorientation, language, or perception; (4) one and three are not better explained by another pre-existing neurocognitive disorder, and (5) the disturbance is a direct physiological consequence of another medical condition (American Psychiatric Association, 2013). Delirium can be classified as either hyperactive, hypoactive, or a mixture of both (Boettger and Breitbart, 2011). The following table describes the main characteristics of each type of delirium.
Incidence of delirium
At any one time there will be at least one patient with delirium in a general medical, surgical or orthopaedic ward (Schofield, 2008). Incidence of delirium can range between 3 – 29% in the medical setting (Siddiqi et al. 2006), up to 80% in the ICU setting
(Ely et al. 2004) and around 9% - 87% in general surgical settings depending on both the patient population and the degree of operative stress (Demeure and Fain, 2006). Incidence of delirium can be as high as 70% in residential aged care settings (de Lange et al. 2013).
Cause of delirium
Delirium is a complex syndrome and may be caused by a number of physiological factors (Inouye et al. 2014). To effectively manage delirium it is important to be able to identify the cause so that it can be treated promptly. The DELIRIUMS acronym can be used to aid in the detection of the possible cause of delirium. Some medications are also known to have a high risk with the development of delirium including benzodiazepines and dopamine agonists. Other medications such as acetylcholinesterase inhibitors, antidepressants, digoxin, narcotics, and NSAIDs have been found to have a moderate to low risk with delirium development (Flaherty et al. 2003).
Outcomes of patients with delirium
Patients experience a range of poor outcomes as a result of developing delirium. Some of these include: functional decline, complications of longer hospital stays (McCusker et al. 2003), increased risk of admission to a long-term care facility (Voyer et al. 2006), increased falls (Lakatos et al.
2009), higher mortality and morbidity (Witlox et al. 2010) and increased risk of developing long term cognitive impairment (MacLullich et al. 2009). These outcomes are devastating for any patient that may have been functionally independent and living in their own home prior to developing the delirium.
A better way to care
The Australian Commission on Safety and Quality in Health Care (ACSQHC) have prepared documents which outline ‘A better way to care’ for patients with cognitive impairment (dementia and delirium) in hospital (ACSQHC, 2014). The strategies in these documents can be linked to the NSQHC standards and have been prepared ready for the release of the Delirium Clinical Care Standard which was under public consultation in July 2015. Some strategies outlined in the following sections are recommended in the Better Way to Care publication.
Risk factors for delirium
Even if the patient is exposed to potential causes listed in the DELIRIUM acronym, development of delirium may not always occur. Often, delirium develops in patients that also have a high level of vulnerability. The factors that can make a patient vulnerable to delirium are called predisposing and precipitating risk factors. Predisposing risk factors are already present on a patient’s admission to hospital, the most common being dementia (Inouye,
Table 1. Delirium subtypes Hyperactive
psychomotor hyperactivity restless easily distracted hallucinations agitation confusion
reduced alertness lethargic and quiet withdrawn sluggish confusion decreased motivation
features of both increased and decreased psychomotor activity
(BOETTGER AND BREITBART, 2011)
Table 2. Causes of delirium according to DELIRIUMS acronym Delirium causes D
drugs eg. alcohol, opiates, anticonvulsants, recreational, post-general anaesthetic
electrolyte imbalance eg. hypoglycaemia, hypo/hypernatraemia
lacking medication/drugs eg. alcohol withdrawal OR low oxygen sauration
infections eg. encephalitis, meningitis
reduced sensory input eg. lack of sleep
intracranial eg. trauma, strokes
(FLAHERTY ET AL. 2003)
Note: There may also be other potential causes of delirium not listed anmf.org.au
Flaherty, J. H. (2011). The evaluation and management of delirium among older persons. Med Clin North Am 95(3): 555-577, xi. Flaherty, J. H. and M. O. Little (2011). Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium. Journal of the American Geriatrics Society 59: S295-S300. Flaherty, J. H., S. H. Tariq, S. Raghavan, S. Bakshi, A. Moinuddin and J. E. Morley (2003). A model for managing delirious older inpatients. Journal of the American Geriatrics Society 51(7): 1031-1035. Inouye, S. (2006). Delirium in Older Persons. The New England Journal of Medicine 354(11): 11571165. Inouye, S., C. H. van Dyck, C. A. Alessi, S. Balkin, A. P. Siegal and R. I. Horwitz (1990). Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine 113(12): 941-948. Inouye, S. K., R. G. J. Westendorp and J. S. Saczynski (2014). Delirium in elderly people. The Lancet 383(9920): 911-922. Lakatos, B., V. Capasso, M. Mitchell, S. Kilroy, M. Lussier-Cushing, L. Sumner, J. Repper-Delisi, E. Kelleher, L. Delisle, C. Cruz and T. Stern (2009). Falls in the General Hospital: Association With Delirium, Advanced Age, and Specific Surgical Procedures. Psychosomatics 50(3): 218-226. Lipowski, Z. J. (1990). Delirium: Acute Confusional States. New York, Oxford University Press.
September 2016 Volume 24, No. 3 23
CLINICAL UPDATE Table 3. Precipitating and predisposing risk factors for delirium Predisposing factors
age > 65years
dementia / cognitive impairment
history of delirium
treatment with multiple drugs
history of falls
use of physical restraints
use of bladder catheter
sensory impairment (visual and hearing)
fracture or trauma
treatment with multiple psychoactive drugs
(INOUYE 2006, CULL ET AL. 2013)
2006). Precipitating factors are those that occur during hospitalisation and can be more easily controlled by health professionals. Precipitating factors should be avoided if possible. Environmental risk factors can also impact on the development of delirium and include: multiple room changes, use of medical/ physical restraints and the lack of a clock, watch and/or reading glasses (McCusker et al. 2001). Table 3 outlines the most common precipitating and predisposing risk factors for delirium. The ACSQHC recommends that health professionals should “be alert to delirium and the risk of harm for patients with cognitive impairment.” (2014). This includes evaluating the risk of older people developing delirium by having a good understanding of risk factors for delirium.
An important step in improving the care for older people in hospital is to “recognise and respond to patients with cognitive impairment” (ACSQHC, 2014). Cognitive assessments should be performed routinely for patients during admission to healthcare settings. This can provide clinicians with a baseline measurement of a patient’s cognition and thereby assist in the prediction of patients’ level of risk for delirium. A baseline cognitive assessment can also be used as a marker for improvements or declines in the patient’s cognitive function. Some recommended tools to perform cognitive assessments include: 24 September 2016 Volume 24, No. 3
Mini Mental State Exam (MMSE), Abbreviated Mental Test (AMT), Mini-Cog, and Rowland Universal Dementia Assessment Scale (RUDAS). The Kimberly Indigenous Cognitive Assessment (KICA) is a specialised tool that has been developed to test cognition in Indigenous Australians living in rural and remote areas (LoGiudice et al. 2006). Family members are also a valuable resource when performing cognitive assessments and should be able to provide information about the patient’s usual level of cognitive function. Cognitive assessment will need to be repeated if there is a sudden change in the patient’s level of cognition, the patient experiences deterioration in their condition overall, or there is a decline in their ability to perform ADL’s (ACSQHC, 2014). A decline in the patient’s cognition may indicate the presence of delirium and further tests should be conducted in order to diagnose delirium.
Recognition and diagnosis of delirium
The clinical detection of delirium can be challenging (Wong et al. 2010) and research has suggested that approximately 50 - 80% of people with delirium remain unrecognised (Young and Inouye, 2007). There are a number of signs that patients with delirium may exhibit including, difficulty focusing attention, memory impairment, disturbance of sleepwake cycle, rambling speech, disorientation to place and time, agitation, sluggishness, and auditory or visual hallucinations (Inouye et al. 2014). Furthermore, if a patient develops delirium they may have
difficulty maintaining or following conversation and may also become easily distracted. One way to test a patient’s level of attention is by asking them to state the days of the week or the months of the year backward (Meagher et al. 2015). If the patient is unable to sustain attention during this task, this may indicate a delirium and a formal assessment and diagnosis of delirium then may be required. The 4AT, is a recently developed tool which has been validated for use in international populations and can provide a rapid assessment for the presence of delirium and cognitive impairment (Bellelli et al. 2014). The tool was designed to be used by any health professional at first contact with the patient, and at other times when delirium is suspected. However, there are limitations with the 4AT as it has not been extensively tested in culturally and linguistically diverse backgrounds (CALD) populations. While not yet tested in the Australian population, the 4AT appears to be a tool that could assist in the recognition of patients with delirium. If possible delirium is indicated using the 4AT, additional diagnostic assessment is required. The Confusion Assessment Method (CAM) was developed by Inouye et al. (1990) and is the gold standard for delirium diagnosis. The CAM was developed to allow non-psychiatric physicians to quickly and accurately diagnose delirium (Wei et al. 2008). The diagnostic algorithm of the CAM is based on four features, acute onset and fluctuating course, inattention, disorganised thinking, and altered level of consciousness (Inouye et al. 1990). Formal training to use the CAM accurately is highly recommended.
LoGiudice, D., K. Smith, J. Thomas, N. Lautenschlager, O. Almeida, D. Atkinson and L. Flicker (2006). Kimberley Indigenous Cognitive Assessment tool (KICA): development of a cognitive assessment tool for older indigenous Australians. International Psychogeriatrics 18(02): 269-280. MacLullich, A. M., A. Beaglehole, R. J. Hall and D. J. Meagher (2009). Delirium and long-term cognitive impairment. Int Rev Psychiatry 21(1): 30-42. MacLullich, A. M. J., K. J. Ferguson, T. Miller, S. E. J. A. de Rooij and C. Cunningham (2008). Unravelling the pathophysiology of delirium: A focus on the role of aberrant stress responses. Journal of Psychosomatic Research 65(3): 229-238. McCusker, J., M. Cole, M. Abrahamowicz, L. Han, J. E. Podoba and L. Ramman-Haddad (2001). Environmental risk factors for delirium in hospitalized older people. Journal of the American Geriatrics Society 49(10): 13271334. McCusker, J., M. G. Cole, N. Dendukuri and E. Belzile (2003). Does Delirium Increase Hospital Stay? American Geriatrics Society 51(11). Meagher, J., M. Leonard, L. Donoghue, N. O’Regan, S. Timmons, C. Exton, W. Cullen, C. Dunne, D. Adamis, A. J. Maclullich and D. Meagher (2015). Months backward test: A review of its use in clinical studies. World Journal of Psychiatry 5(3): 305-314.
CLINICAL UPDATE Table 4. Delirium prevention strategies Delirium prevention interventions • ensure appropriate lighting • provide a clock and a calendar • promote cognitive stimulation • ensure that pain relief is adequate • avoid room changes (may increase disorientation) • avoid use of indwelling catheters • avoid use of mechanical restraints • encourage family or carer and friends to visit and be involved in patient care • avoid psychoactive drugs • optimise communication (for example, use interpreters and liaison staff) • ensure that patients who usually wear hearing and visual aids are assisted to use them • promote relaxation and sufficient sleep and discourage daytime napping • encourage and assist the patient with eating and drinking (INOUYE, 2014)
Delirium or dementia?
Delirium can often be missed or misdiagnosed due to the presence of dementia. Often it is difficult to differentiate between delirium and dementia. If you ask the patient orientation questions, pay particular attention to how the patient answers the question. The delirious patient will often give disorganised answers which may be rambling or incoherent. Patients with delirium will also have difficulty focusing attention during a conversation.
Delirium can be prevented in up to one third of patients in hospital settings. Prevention of delirium using non-pharmacological multicomponent intervention is most appropriate (Inouye, 2014). Identification of patients at high risk for delirium and other potential precipitants is important to be able to target specific preventative strategies. Once potential risk factors have been identified, patients classified as moderate or high risk should have a number of preventative strategies implemented into their care. The following table outlines some of these strategies (Table 4).
Once delirium has developed the application of standard procedures of behavioural and educational intervention is necessary to reduce the many consequences of delirium. Firstly, it is important to actively seek and treat the cause of the delirium (Burns et al. 2004). These may be as simple as eliminating all the precipitating factors eg. treatment of infections (Kamholz, 2010). The management of delirium should also be directed at the relief of symptoms and providing supportive care to the patient until recovery. Therefore, it is necessary to develop and implement an individualised management plan in partnership with the patient, carer and family. Care strategies can include, providing individualised care, prevent/minimise harm, manage medical issues and modifying the environment (Table 5). One of the biggest issues nurses face, is responding to the behavioural issues that a patient with delirium can exhibit. The management of patients with difficult behaviours during an episode of delirium should have the philosophy of providing a restraint free environment with mainly nonpharmacological interventions
(Flaherty, 2011) The TADA approach can be useful in the management of patients with delirium. TADA stands for Tolerate, Anticipate and Don’t Agitate (Flaherty and Little, 2011). Tolerating behaviours can seem dangerous, but under close supervision, can allow patients to respond naturally to their situation (Flaherty, 2011). For example, a patient trying to get out of bed may indicate a desire to go to the toilet. Anticipating behaviours involves being prepared for what the patient might do. Some common behaviours that can be anticipated include pulling on things that are not usually there, such as IV lines. Techniques to avoid this include hiding the IV line and having a decoy IV line. Don’t Agitate is one of the most important factors of delirium management. Don’t agitate is a rule that comes from the recognition that there are many agitating events and objects in a hospital. Even reorienting can sometimes make a patient mad. So if it doesn’t seem to help it is best to stop doing it. Distracting or humouring the patient may be more helpful (Flaherty and Little, 2011). Dr Emily Tomlinson is a Lecturer of Nursing at Deakin University, Melbourne
Table 5. Delirium management interventions Management interventions • • • • • • •
regular orientation continuity of care from nursing staff patient is approached and handled gently encouragement of family involvement good fluid and diet intake encourage regular sleeping pattern things to avoid: ward transfers, physical restraints, catheters, routinely sedating, arguing with patient.
(POTTER AND GEORGE, 2006)
Potter, J. and J. George (2006). The prevention, diagnosis and management of delirium in older people: concise guidelines. Clinical Medicine 6(3): 303 - 308. Schofield, I. (2008). Delirium: challenges for clinical governance. Journal of Nursing Management 16(2): 127-133. Siddiqi, N., A. O. House and J. D. Holmes (2006). Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age and Ageing 35(4): 350-364. Voyer, P., M. G. Cole, J. McCusker and E. Belzile (2006). Prevalence and Symptoms of Delirium Superimposed on Dementia. Clinical Nursing Research 15(46): 46 - 65. Wei, L. A., M. A. Fearing, E. J. Sternberg and S. K. Inouye (2008). The Confusion Assessment Method: A Systematic Review of current usage. Journal of the American Geriatrics Society 56(5): 823-830. Witlox, J., L. Eurelings, J. de Jonghe, K. Kalisvaart, P. Eikelenboom and W. van Gool (2010). Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia. JAMA: The Journal of the American Medical Association 304(4): 443-451. Wong, C. L., J. HolroydLeduc, D. L. Simel and S. E. Straus (2010). Does this Patient have Delirium? Value of bedside Instruments JAMA: The Journal of the American Medical Association 304(7): 779-786. Young, J. and S. K. Inouye (2007). Delirium in older people. BMJ 334(7598): 842-846.
September 2016 Volume 24, No. 3 25
NURSES – ARE WE EVER OFF DUTY? By Karen Thompson Halfway home from a family holiday to Fiji I had just put down my book and closed my eyes, when my husband nudged me and pointed out a man in the opposite row calling for help. Without thinking I jumped up and assessed the situation.
The man’s wife, Sophie* was lying awkwardly across the seats and floor in the clonic phase of a seizure. I noted her advanced state of pregnancy and immediately suspected eclampsia, an obstetric emergency. A quick primary survey told me she was in imminent danger from surrounding fixed structures and at risk of positional asphyxia, so her husband assisted me to re-position her as the call went out for a “doctor on board”. Two men promptly arrived and identified themselves as Sam*, an obstetrician and Peter*, a urologist. I was working in a small multi-purpose centre on the west coast of Tasmania at the time and had recently completed my Graduate Certificate in remote nursing. I identified myself to the doctors present as a remote area nurse (RAN) and proceeded to hand over the patient. Sophie was no longer actively seizing but her unresponsive post-ictal state was causing me further concern over the patency of her airway. After the brief handover I enlisted the help of the two doctors and the cabin manager to carry Sophie to the galley, where we would have room to further assess and more effectively manage her. Deciding Sophie was in good hands I turned to resume my seat, but Sam asked me to stay; primarily because I had last cannulated less than two weeks previously and neither he nor Peter had done so in over ten years. While conducting Sophie’s secondary survey, we discovered that she had many risk factors; she had been treated for pre-eclampsia in her previous pregnancy and hypertension during this pregnancy. A revision of the primary survey assured us Sophie was protecting her own airway for the present, with no signs of aspiration. She was breathing spontaneously, her respiratory rate was regular, with bilateral 26 September 2016 Volume 24, No. 3
equal chest movement and no audible adventitious sounds. Our attention turned to the first aid kit supplied by the cabin manager and I found a sphygmomanometer, stethoscope and thermometer. I attended a set of vital signs, finding that apart from hypertension they were within range, then Peter began auscultating her chest. Before we had completed a proper assessment however, Sophie began to rouse, becoming confused and combative, 5mg IV midazolam was ordered, but Sophie became more agitated as I was setting up to obtain IV access. I asked Sam if he was happy for me to administer the dose IM instead and administered it to Sophie’s left gluteus muscle as the others held her steady and secure.
MOST EMERGENCY NURSES WILL FIND THEMSELVES, AT SOME POINT, PRACTICING IN CHALLENGING AND/OR REMOTE SITUATIONS. HOWEVER, I CONFESS BEING 30,000 FEET ABOVE THE PACIFIC OCEAN WITH A SEVERELY HYPERTENSIVE POST-ICTAL WOMAN AND LIMITED MEDICAL SUPPLIES WAS THE MOST ISOLATED AND CHALLENGING SITUATION OF MY CAREER. Most emergency nurses will find themselves, at some point, practicing in challenging and/ or remote situations. However, I confess being 30,000 feet above the Pacific Ocean with a severely hypertensive post-ictal woman and limited medical supplies was the most isolated and challenging situation of my career.
We were advised by the cabin manager that the flight was being diverted to Brisbane, the closest major centre. Sophie settled with the IM sedation and we were able to site a cannula in her left cubital fossa. Upon further investigation of the first aid kit, we discovered that despite a comprehensive range of equipment, we had no hydralazine, the one drug Sam wanted to administer to resolve the hypertension. We settled for incremental doses of IV morphine which resulted in a drop from a systolic blood pressure of 210mmHg to 170mmHg – not ideal but an improvement. Sophie’s conscious state had also improved to a drowsy but rouseable state, and she was only mildly disoriented rather than severely confused. We were still concerned about her airway, given her fluctuating level of consciousness and the morphine she had been given, so I was deputised to manage her airway as we came in to land. Sitting on the galley floor with Sophie as the aircraft descended gave me time to reflect on this highly challenging situation. I thought back to how I had automatically commenced a DRABC primary survey, and it reminded me of how resourceful one becomes when working in challenging situations. Finally, I remembered other situations – first on scene at a roll-over, a woman collapsing in front of me at a supermarket checkout and dealing with a distressed vomiting teenager at a music festival to name a few – where I was required to respond quickly and utilise the resources at hand. It reminded me yet again, that nursing is more than just a job. We can debrief, reflect and leave the problems at work when the shift is finally over, but we never leave the caring shut up in our locker, and regardless of the situation will always answer the call. *Not real names anmf.org.au
INAPPROPRIATE ACCESS TO MEDICAL RECORDS – A CASE OF PROFESSIONAL MISCONDUCT Linda Starr
Health Professionals’ code of ethics and conduct emphasise a duty of confidentiality owed to the patient by their treating health practitioner. While these codes are not laws they are often used in disciplinary tribunal matters in consideration of what is proper professional conduct. Gaining a patient’s trust is critical in developing a therapeutic relationship between the health practitioner and the patient. Part of this trust relationship is the confidence the patient has in the health practitioner’s obligation to observe their privacy and confidentiality. Electronic access to patient’s medical records has made it possible for those authorised to use the system to access patient records despite not having a role in their care. Snooping into interesting, high profile and novel cases out of a sense of entitlement, curiosity, interest or concern for the welfare of the patient or risk to staff can lead to disciplinary action as the following case demonstrates.
Reference The Medical Board of Australia v Shah  QCAT 158 (22 March 2016)
An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia anmf.org.au
Dr Shah was married to SLC, it was a volatile marriage and SLC was frightened of her husband. SLC had been diagnosed with cancer and was undergoing treatment at the Nambour General Hospital, where her husband Dr Shah worked. Prior to their marriage breakdown in mid-August 2012, when SLC moved to Brisbane, she had expressed concerns about her husband accessing her medical records without her permission. In response to her complaint Shah told her that ‘I am your husband……I can check anything I want’ and claimed that the Privacy Act was ‘westernised ….rubbish’ (p165). There was no doubt that SLC did not want Shah involved in her treatment on any level. On 22 September SLC, without informing her husband, transferred her care to the Royal Brisbane Women’s Hospital (RBWH) under Dr Burge. On 25 September while undergoing chemotherapy at RBWH, Shah unexpectedly arrived at the hospital with flowers for SLC. The staff could see that SLC was distressed following this visit and assisted her to
make contact with police leading to domestic violence proceedings being taken out against Shah. Thus it ought to have been clear to Shah that his estranged wife did not want him to be ‘ethically involved’ in her care nor was he ‘entitled to monitor or be informed of her progress’ in any way. Nonetheless, Shah continued in his attempts to gain information from her treating practitioners and further accessed her records on 26 and 27 September. There is no doubt that Shah’s conduct falls below the standard expected of medical
GAINING A PATIENT’S TRUST IS CRITICAL IN DEVELOPING A THERAPEUTIC RELATIONSHIP BETWEEN THE HEALTH PRACTITIONER AND THE PATIENT. PART OF THIS TRUST RELATIONSHIP IS THE CONFIDENCE THE PATIENT HAS IN THE HEALTH PRACTITIONER’S OBLIGATION TO OBSERVE THEIR PRIVACY AND CONFIDENTIALITY.
practitioners and calls into question whether he is a fit and proper person to hold registration as a medical practitioner. In proceedings before a tribunal such as this case protection of the public is the paramount consideration when considering what disciplinary action should be imposed on the practitioner. Orders could be made that would prevent unfit practitioners from practising or that would ensure the maintenance of proper professional standards in the future through conditions, a reprimand or a fine. In submissions to the tribunal, Shah argued that his deceptive conduct
should not result in any period of suspension as in his view, his conduct did not involve any significant risk of harm to the public. He also claimed that as a result of the Inquiry he had already suffered ‘stress, embarrassment, and humiliation’ (p 171) and a period of suspension would prevent him from providing for his new wife and baby. In Shah’s opinion a reprimand and/or fine would serve as a sufficient deterrent for the purpose of disciplinary action. The tribunal considered Shah’s conduct to amount to professional misconduct. Penalty in these cases is determined to some degree by the extent the conduct of concern departs from what is considered to be proper professional standards. In this case, SLC was a vulnerable patient, she was also his estranged wife. Shah had breached his position of trust and confidence as a doctor as he had no right to be involved in her treatment nor to follow her case through accessing her medical records. Furthermore, Shah knew what he had done was wrong, but despite being given the opportunity he failed to make a full admission and instead attempted to justify and minimise the seriousness of his conduct during the Inquiry. In the tribunal’s view Shah’s conduct would likely attract the disapproval of his medical colleagues and was a breach of both the professional code of conduct and code of ethics. Furthermore, the tribunal noted that the medical profession requires ‘scrupulous candour’ at all times and considered Shah’s failure to be frank and honest with the Board as evidence of a flaw in his character suggesting he would not be honest with his dealings with patients and colleagues. Shah’s license to practice was suspended for six months. He was also required to undertake a course in ethical decision making and confidentiality. It is important that the public is assured that appropriate standards are maintained within the various health professions and that appropriate disciplinary actions are taken when these are not upheld. The patient’s right to privacy and confidentiality is both a legal and ethical obligation of health practitioners that may be enforced through disciplinary proceedings such as these where necessary. September 2016 Volume 24, No. 3 27
ELDER ABUSE Federal Education Officer Jodie Davis The following excerpt is from our Elder Abuse tutorial on the ANMF’s Aged Care Training Room (ACTR). Subtopics covered include defining elder abuse, legalities, contributing factors, indicators of elder abuse, organisational issues, characteristics of the abused resident/client and their abuser, worker characteristics, prevention and compulsory reporting to name but a few.
Elder abuse is the intentional or unintentional hurting either physical or emotional of a person who is aged 60 or over. It is neglect or harm to an elderly person resulting in physical, emotional, sexual, social, psychological or material (financial) injury caused by the behaviour of a person with whom the older person shares a relationship implying trust. Elder abuse can include mistreatment and neglect. Characteristics of individual older people, characteristics of families, organisational issues and culture in residential care settings, loss of social connection, and access to community amenities and ageism all contribute to elder abuse. Elder abuse is not bound by socioeconomic status, ethnicity or gender. Abuse occurs in the older person’s home, in residential care facilities and to a lesser degree in ‘public’ settings. The perpetrators of the abuse may be paid carers or aged care workers, other professionals, unpaid carers or family members. ‘Strangers’ or opportunistic abuse is far less commonly perpetrated against older people. The risk for abuse for older people is strongly correlated with: • Their age. The ‘oldest’ old are most at risk. • Imbalance of power in a relationship – this may be between the older person and a family member, a paid 28 September 2016 Volume 24, No. 3
carer or other professional or service provider. • The level of need (of the older person) and the individual burden (as experienced by the perpetrator) of providing physical or mental health care…, personal care or financial management or support to the older person. • Trust in the perpetrator/s of abuse. Elder abuse most commonly occurs in the context of the older person believing and expecting that they are in a safe and protective environment. • The expectation of being treated with dignity and respect is cornerstone of trust. • Alcohol or other drug dependency and or mental health illness that compromises the perpetrators ability to behave in a respectful way towards the older person. • The continuum of domestic violence into later life. • The inability to stop the abuse from happening because of cognitive or mental impairment. • Ageism is another factor that makes older people more vulnerable. Disrespect for the older person’s rights to make decisions, to be independent and to be safe both devalue and disempower the older members of our society. The figures for elder abuse suggest a prevalence of around 5% amongst older people aged 65 years or older, both
nationally and internationally. The most common forms of abuse are psychological and financial abuse. Data on elder abuse for people receiving aged care services is not clear due to the inconsistency in defining, recognising and reporting abuse or suspected abuse. The introduction of compulsory reporting for providers of residential aged care services may shed some light on prevalence and the profile of abuse in these settings. The principles of “do no harm” and conscientious enforcement of the rights of aged care residents and community aged care clients should form the basis for responding to abuse in aged care service provision. All complaints of elder abuse must be taken seriously from all residents or clients. Physical abuse is physical force that results in injury or distress; it includes threat of physical force. Indicators of physical abuse may include fearfulness especially with particular people, bruising, skin tears, scratches, increase in aggressive actions (residents/ clients with dementia may act aggressively to defend themselves), refusing to be cared for by particular staff, staff/carer reports of increase in falls, inconsistency between injuries and history of cause. Lag between injury and seeking help. Emotional or psychological abuse is abuse that causes the victim to feel fearful, anmf.org.au
EDUCATION intimidated, powerless, guilty, worthless, isolated, shameful or disrespected. Indicators of this type of abuse can include showing signs of fear with certain people, not wanting to be with people, changes in the way the older person usually interacts with people, increase in health complaints, saying negative things about themselves, not saying what they are thinking, not complaining, not asking for help and depression. Sexual abuse is sexual contact or threat of sexual contact with an older person without that person’s consent. It includes the use of power or threat in a professional or trusting relationship to gain consent and taking advantage of the older person’s inability to consent due to cognitive impairment. Complaints of pain or itching in the genital area, showing signs of fear with certain people, refusing to be cared for by certain staff, lacerations, bruising, bleeding in the genital region, bruising on upper arms, evidence of sexually transmitted infections, blood stained underwear/pads, increased anxiety with personal care including showering and toileting, signs of emotional abuse or physical abuse. Neglect is not providing care that is seen as necessary for the person’s physical health, mental health, welfare and safety. Pressure sores, malnutrition, dehydration, poor personal care, dental problems, poor continence care, constipation and
abandonment are some of the indicators of neglect of the older person. Financial abuse is the use of the older person’s money or assets illegally or in a way that is not proper for the older person. Unexplained disappearance of jewellery or personal belongings may be an indicator financial abuse is occurring. Wanting to change power of attorney/will beneficiaries, fearfulness, agitation especially with particular people, requesting money for no particular reason, financial hardship that is inconsistent with income and that was previously not an issue, may be strong indicators of financial abuse. Social abuse includes isolation of the older person from family and or social networks. Loss of contact with family and friends, being critical of family and friends (that is not usual), making excuses for not wanting to go out or have people come to the victim’s home.
READING THIS ARTICLE WILL GIVE YOU 15 MINUTES OF CPD, WHILE THE COMPLETE COURSE IS ALLOCATED TWO HOURS OF CPD TOWARDS ONGOING REGISTRATION REQUIREMENTS.
The information presented here is just a snippet of the information provided in this comprehensive tutorial. To learn more about, or just refresh your knowledge on Elder Abuse, go to: http://anmf.org.au/pages/ online-education-programs For further information, contact the education team on 02 6232 6533 or firstname.lastname@example.org
WHAT HAPPENS NEXT IS UP TO YOU MedicAlert® can mean the difference between life and death. Don’t forget to check for a MedicAlert medical ID during patient assessment.
around your patients’ wrists or neck for the genuine MedicAlert emblem. If conscious, ask your patient if they are a MedicAlert member.
the medical and personal information engraved on the reverse of the patient’s MedicAlert medical ID.
the 24/7 emergency hotline number engraved on the medical ID (08 8272 8822) to receive further medical and personal information.
on handover that your patient is wearing a MedicAlert medical ID.
REFUGEES IN NAURU A report alleging appalling abuse and neglect of refugees and asylum seekers living in detention on Nauru has recently been released based on Amnesty International and Human Rights Watch’s investigations. The report detailed inhumane conditions, abuse and assault of detainees including neglect by locals and healthcare providers. The Department of Immigration has lashed out strongly refuting many of the claims in the report. Registered Nurse and citizen of Nauru Sue Barker also says the treatment of refugees and asylum seekers is very different to the one painted by the media. Sue has written to the ANMJ asking to give her account about the humane support refugees and asylum seekers are given by the locals on Nauru.
By Sue Barker I ask readers to take their minds back to the Tampa crisis where Australia rejected these desperate people but the people of Nauru took them. Yes, there was a deal done between governments but that is not what this article is about. Upon arrival on Nauru, asylum seekers were disembarked at the harbour and welcomed with songs and frangipani leis by the people of Nauru. Every asylum seeker who stepped onto their shores that day was personally welcomed by the Nauruan community with genuine warmth. This of course is forgotten as the Australian people and the media damn the Nauruans at every turn. The Nauruans have been accused of rape, beatings, and much more however these allegations have turned out to be untrue. Many of the refugees are desperate. They did not choose to be on Nauru. In July 2013 there was a riot and a fire in one of the camps on Nauru, which potentially threatened to paralyse the island if the fire had extended to the fuel farm where all essential 30 September 2016 Volume 24, No. 3
services such as electricity, power and transport would have been crippled. I was appointed the Disaster Management Coordinator at the hospital that evening and was proud to be part of that health community. It was a true example of interprofessional collaboration as everyone worked together to ensure the hospital continued to provide adequate services for their own community as well as services for the refugees. Many of the refugees were severely traumatised and were treated by all the staff at the hospital with tremendous dignity and compassion. There was no mistaking the goodwill and kindness which was demonstrated through touch and gentle words that night. The hospital was already at capacity but the Nauruans put themselves second. Many of the Nauruan patients were put on mattresses on the floor. The beds vacated by the Nauruan patients
THE REFUGEES LIVE OPENLY IN THE COMMUNITIES AND WORK ALONGSIDE THE NAURUANS. THEY HAVE SMALL BUSINESSES WHICH ARE PATRONISED BY ALL PEOPLE ON NAURU. FRIENDSHIPS HAVE DEVELOPED ALONG WITH RELATIONSHIPS.
were then allocated to the refugees who were admitted. But these stories never reached Australia because the Nauruan people are modest people and they did what they had to do that night. The health of the Nauruan population is on a parallel with Australia’s Aboriginal and Torres Strait Islander people with the exception of lower life expectancy. Despite this it has been about seven years since Nauru has had a maternal death – a statistic that stands out from the rest of the Pacific region, including Australia and New Zealand. For the critics in Australia who claim Nauru is an unsafe place for the refugees to give birth, how do you explain that they are the only country in the region not to have maternal deaths? Yes, the facilities are old but the standard of care is excellent, the midwives exceptional.
SUPPLIED ASYLUM SEEKER RESOURCE CENTRE
It saddens me every time I read or hear criticism of the Nauruans, not of their government but of the people to which the Nauruans feel anger and bewilderment. They do not understand why they receive such criticism. They are the most generous, hospitable people who would give you anything and do anything for you. They have welcomed the refugees and have opened up their communities to them. Their children school alongside the refugee children, all being taught in English, which is contrary to the reports in the media. The refugees live openly in the communities and work alongside the Nauruans. They have small businesses which are patronised by all people on Nauru. Friendships have developed along with relationships. The Nauruans have ensured that the refugees have been provided with sacred prayer spaces in safe places. Others have been welcomed into their church communities. Additionally, the living conditions of the refugees are in many cases superior to that of the Nauruan people. From afar It is easy to find fault and criticise the people of Nauru rather than policies. Australians, please understand that neo-colonialism is alive and well. If there is corruption in any of these tiny Pacific nations please understand that they have learnt well from their colonial masters and continue to do so. So rather than denigrate the people of Nauru, their lifestyle, their island, their health and education systems, please congratulate them for having been so generous with their 22sq. kms of land and their hospitality to not only the refugees but the Australians who have also experienced their generosity and warmth while working there.
Dr Suzan Barker is a Registered Nurse who lives in Nauru and Victoria. She runs a nongovernment organisation, Equatorial Opportunities on the island, which she founded 10 years ago. This article is based on the views and research of the author(s) and has not been peer reviewed. anmf.org.au
Part 1 EDUCATION
HEALTH HISTORY TAKING WITH VOLUNTEER PATIENTS By James Bonnamy and Lorraine Walker Monash University aims to produce dynamic graduate nurses and midwives recognised for their excellent, innovative practice and positive impact on people’s lives. To achieve this goal Monash Nursing and Midwifery is committed to quality teaching and learning underpinned by relevant teaching and learning pedagogies and assessments. Students are required to demonstrate theoretical knowledge and clinical skill competence as well as the professional behaviours expected of a professional registered nurse or midwife. Health assessment forms the foundation of all nursing and midwifery care. It is an ongoing cyclical process that evaluates the person as a physical, psychosocial and functional whole, whatever their age or health status. Taking an accurate and complete health history is a fundamental component of a comprehensive health assessment. The health history can provide information on a patient’s social, emotional, physical, cultural, developmental and spiritual identities which facilitates the planning of person-centred care that underpins nursing and midwifery practice. First year nursing and midwifery students enrolled in a foundational nursing unit have recently had the anmf.org.au
HEALTH ASSESSMENT FORMS THE FOUNDATION OF ALL NURSING AND MIDWIFERY CARE. IT IS AN ONGOING CYCLICAL PROCESS THAT EVALUATES THE PERSON AS A PHYSICAL, PSYCHOSOCIAL AND FUNCTIONAL WHOLE, WHATEVER THEIR AGE OR HEALTH STATUS opportunity to prepare, undertake and document a health history assessment on volunteer patients. Students worked in small groups to develop a structured health history-taking template which they subsequently used for the interview of a volunteer patient. During the actual interview the students employed this template to determine why their patient was seeking care, and explore relevant past health and medical history. The volunteer patients had been briefed with a case scenario appropriate to their age and gender and were
encouraged to adlib as necessary. At the completion of the simulation the volunteer patients provided feedback about their subjective experience of the health history assessment. Feedback centred on the students approach to the interview, specifically their verbal and nonverbal communication and how this fostered trust and open disclosure from the patient. Students then met with an academic to debrief and discuss the challenges associated with taking a health history. Both the volunteer patients and students described this simulation as a valuable experience. The volunteer patients, some of whom were retired nurses and midwives, have relished the opportunity to support development of the next generation of nurses and midwives. The students reported that it provided them with a realistic hospital experience in a safe environment that enabled them to further develop the skill of health history taking. Students also commented that it fostered confidence when communicating with patients and challenged them to ‘think on their feet’. The success of this session has prompted planning for involvement of volunteer patients for the first year vital signs clinical skills examination scheduled later in the semester. The use of volunteer patients will provide a more realistic examination experience. If you are interested in being involved in future activities involving volunteer patients please contact either of the authors.
MONASH STUDENT WITH SIMULATED PATIENT
James Bonnamy is Lecturer and Lorraine Walker is Senior Lecturer. Both are in the School of Nursing and Midwifery at Monash University in Victoria.
September 2016 Volume 24, No. 3 31
EDUCATION Part 1
COUNCIL OF DEANS FOR NURSING AND MIDWIFERY By Amanda Rowe Established in 1993, the Council of Deans for Nursing and Midwifery (Australia & New Zealand) (CDNM) is the peak organisation that represents the Deans, Leaders and Heads of Higher Education providers offering courses for nursing and midwifery throughout Australia and New Zealand. The Council is the voice of higher education for nurses and midwives, and provides leadership on health policy, education standards and research as applied to health, nurses and midwives. Members are experts in the field of healthcare and educating future and current health professionals. Many members also undertake research in their areas of expertise that benefits patients, nurses and the healthcare system as a whole. Professor Wendy Cross is the current chair of the Council, with 37 years of experience as a mental health nurse and more recently as Associate Dean, Nursing and Allied Health for Monash University. With this wealth of experience, we put some questions to Wendy on the challenges facing the education of nurses and midwives both now, and in the future.
What is the role of the CDNM? CDNM members are experts in nursing and midwifery as well as broad healthcare issues. They are also experts in education and research. As such, the Council is the peak body of higher education for nurses and midwives. Our role is to bring these nursing leaders together to develop, contribute to and disseminate information on health policy, education standards and research as it applies to nurses and midwives. Our role is also to connect with other groups that have an interest in nursing and midwifery such as governments, professional and industrial bodies in order to ensure that legislation, policies and other decisions affecting nursing and midwifery education and research has our input.
What difference has the CDNM made with regards to the education of nurses and midwives?
Since its establishment, the Council has strived to standardise the best in healthcare education for nurses and midwives across Australia and New Zealand. By representing the leaders in nursing and midwifery higher education, the Council is in a unique position to encourage the sharing of education practices between the industry’s thought leaders to benefit the education of all nurses and midwives in Australia and 32 September 2016 Volume 24, No. 3
How do you see that education changing and involving?
Australia and New Zealand are experiencing radical changes in healthcare as immigration, increasing cultural and ethnic diversity, and an ageing population change how nursing and midwifery services need to be delivered at the point of care. Access to technology also means that service users are increasingly better informed about the healthcare options available to them, and are keener to be involved in the decisions regarding their care. Importantly though, this access to information is often not heterogeneous with different levels within the ethnic and cultural groups highlighted above. As such, the education of nurses and midwives will become increasingly complex as it must include a range of new society and cultural-based skills beyond the traditional biomedical model.
What are the CDNM’s thoughts on attracting and keeping people in the field of nursing and midwifery?
Nursing and midwifery is still seen as a vocation by many, but the CDNM is keen to ensure that nurses and midwives require appropriate education and ongoing professional development to enable them to provide evidence-based care. Care and compassion are core in nursing and midwifery but they are not the sole requisites. Sound knowledge, critical thinking and curiosity are essential for nurses and midwives to operate in to the future. It is known that when people are able to work to their scope and have job enrichment they experience greater satisfaction and remain in the work force longer. It is the Council’s remit to respond to these needs by offering courses that are based on contemporary evidence and that challenge nurses and midwives to constantly grow and develop.
What are the CDNM’s aims for the next 12 months?
“Over the next 12 months, the Council will continue to influence health and higher education policies that impact on the development of our expert healthcare professional workforce across Australia and New
Zealand and respond effectively to changes in higher education and the health sector. We will undertake a range of projects aimed at creating standard practices in learning and teaching as well as in assessment for nurses and midwives. Importantly, we will continue to promote the public image of nursing and midwifery”.
What do you as chair want to achieve with the CDNM?
“In my second term as chair, I will continue to involve members in a stronger political conversation in order to bring to governments’ attention the needs and interests of higher education providers when delivering courses for nurses and midwives. We are the ultimate body for nursing and midwifery education and must take a strong stance regarding issues of importance that affect our ability to operate. Legislative and policy decisions that influence our work must be given serious attention and response. I am also keen to broaden the scope and reach of the Council influencing positive outcomes for both students and health system users as a result of enhanced education for nurses and midwives”.
What projects are the CDNM involved in?
“The Council is represented on a number of significant nursing and midwifery forums. These include the Coalition of National Nursing Organisations, the Chief Nursing and Midwifery Officer’s Nursing and Midwifery Strategic Reference Group, the National Nursing and Midwifery Education Advisory Committee, Universities Australia Health Professional Standing Group. Each of these groups provide national strategic leadership in nursing and midwifery, including education and workforce development. The CDNM provides input regarding matters pertaining to education and ongoing professional development of nurses and midwives. Two specific projects that the Council will undertake this year are the Scoping Review and Peer Review of Assessment. These are funded national projects that Council supports to enable standardised practices and benchmarking to occur to achieve consistent and best outcomes in nursing and midwifery education”.
Amanda Rowe is Communications and PR Advisor for the Council of Deans of Nursing and Midwifery (ANZ) anmf.org.au
Part 1 EDUCATION
LOCATIONS OF CLINICAL PLACEMENTS CRUCIAL FOR LEARNING AND WORK READINESS By Demi Freer and Joy Penman The value of clinical placements in the Bachelor of Nursing program cannot be over emphasised. Students undertake a variety of clinical experiences during the threeyear program in order to develop and hone an effective range of competencies for a beginning Registered Nurse. In order to achieve these competencies, the clinical placements must be challenging, varied and of high quality. The locations of clinical placements (rural, metropolitan and international clinical placements) are crucial for learning and work readiness. Geographic location does affect the health of community members. On average, the health of people living in rural areas is poorer than that of people living in major cities. There is also limited diversity and number of healthcare professionals in rural and regional areas, more so in remote areas.
the learning that transpired from experiencing regional, metropolitan and international clinical placements. Both authors agreed that majority of clinical placements whether rural, metropolitan or international, expanded theoretical knowledge and practical skills, with some more than others. There were more advanced skills practice occurring in Australian metropolitan health services, less in rural locations, but much less in an international placement. The later involved more community health maintenance and promotion activities from this student’s experience. Different types of skill were used and honed, such as team work, communication, interpersonal, and cultural awareness and sensitivity rather than advanced nursing skills.
The health profile of community members in places overseas is dependent on environmental and socio economic factors that impact on health, including geographic location. These determinants will influence the clinical experiences of nursing students.
The varied roles of nurses were clarified in all placements. The generalist and specialist roles of nurses were clearly delineated in rural and urban health services. In the international placement, however, nurses played a very different role by comparison to their Australian counterparts. It appeared that the nurses’ prime focus was administering medications and coordinating care with the doctor. The first author reported, “Care is relegated to the family that is responsible for all activities of daily living … The doctors were in-charge of all assessments and the nurses followed their orders.”
The first author recently graduated from the School of Nursing and Midwifery, University of South Australia, Whyalla Campus. She has experienced a wide variety of clinical placements provided by the university, while the second author is an experienced academic, who was responsible for organising clinical placements and supervising students on placement in past years. Together, they draw on their personal experiences to examine
On reflection, the opportunity to work closely with health professionals was true for all placements, however, the extent to which inter-professional collaboration happened varied. One could argue that there would be less health professionals in rural areas, much less in developing countries. However, the first author formed a different conclusion, “I found I was able to work much closer with health professionals in regional and in the international placements. They were
much easier to get along with and more willing to take on students.” The placements succeeded in providing an understanding of the healthcare delivery. There were opportunities to compare and contrast the methods of healthcare delivery. In all placements, inculcating the graduate qualities (body of knowledge, effective communication, independent worker/team player and so forth) was achieved, however, gaining international perspective in graduates was achieved thoroughly with an international placement. The graduate qualities, the traits employers look for in their recruits, were developed and these enhanced work readiness and increased employment prospects. Sending students to developing countries for academic experience is “invaluable as you never would you encounter this reality in Australia. It is an eye-opener, enriching and transforming my way of thinking and behaving.” New insights and perspective are gained from international clinical placements. The first author explained, “I gained an understanding of the nurse education in the country and became familiar with the host culture and health determinants, learnt about tropical diseases like dengue fever and infection control measures.” The second author added, “Transcultural nursing allowed the broadening of cultural understanding, increasing cultural sensitivity, accepting of similarities and differences, and being encouraged to provide holistic and individualised care.” Diverse placements extended theoretical knowledge and practical skills, clarified the roles of nurses, provided opportunities to work closely with health professionals, provided a better understanding of the healthcare delivery, learnt about transcultural nursing, and inculcated graduate qualities.
Demi Freer completed her Bachelor of Nursing degree from the University of South Australia, Whyalla Campus. Her degree was conferred in April 2016. Dr Joy Penman was Lecturer at the Whyalla Campus at the University of South Australia at the time of writing. She is now Senior Lecturer at Monash University.
September 2016 Volume 24, No. 3 33
EDUCATION Part 1
CREATING SIMULATION ACTIVITIES FOR UNDERGRADUATE NURSING CURRICULA By Shirley McGough and Karen Heslop Simulation is considered a valuable educational strategy to prepare nursing students for clinical practice and bridge the gap between theory and clinical experience (Unsworth et al. 2012) with Milkins et al. (2014) advocating for the use of simulation in student education to support the National Safety and Quality Health Service Standards (NSQHSS) (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2012). This paper outlines the experience of developing authentic and genuine simulation scenarios in mental health for nursing curricula.
PARTICIPANTS REPORTED ENJOYMENT IN THE EXPERIENCE AND FELT POSITIVE ABOUT THEIR CONTRIBUTIONS TO THE DEVELOPMENT OF AN EDUCATIONAL RESOURCE FOR STUDENTS
Method: The strategic priority of this project was to design teaching and learning strategies which aligned with field work preparation and skills that support employability and graduate attributes. The aim was to develop simulation scenarios reflecting the NSQHSS (Clinical handover and Patient identification and procedure matching; Partnering with consumers; Recognising and responding to clinical deterioration in acute health care; and Medication safety).
presenting another insight into the standard ‘Partnering with consumers’.
Scenarios were developed based on ‘real’ clinical situations. Then six experienced mental health clinicians were invited to review the scripts and to participate in the recording of the scenarios on action cameras in the School’s simulation suite. Clinicians took on roles of nurses, patients and or relatives, using their own experiences to enhance credibility and believability of the scripts. The clinicians formed mutual bonds, while sharing clinical experiences and effectively demonstrating collegial practices in the scenarios. This culminated in an impromptu scenario
Following recording, the scenarios were reviewed by all as part of the debriefing process. Gaffs and inconsistencies were identified, with the team referring back to the educational objectives of the simulations. Participants reported enjoyment in the experience and felt positive about their contributions to the development of an educational resource for students. In the formal evaluation, participants confirmed the realism and genuineness of the scenarios and considered them ‘readily accessible by new and experience clinical staff’.
34 September 2016 Volume 24, No. 3
Clinicians stated they were also able to reflect on their own practice and application of the NSQHSS to their clinical settings: “The collapsed patient scenario following the good/ poor handover was particularly wellcrafted and I think demonstrates the importance of the standards succinctly”. Implications for nursing practice: The development of authentic simulation activities grounded in clinical practice and clinical standards will enhance and personalise the learners’ experience and assist students in developing critical thinking relevant to the healthcare environment. Conclusion: Collaboration with clinicians in developing simulation activities for educational curricula was seen as essential for authentication and in presenting genuine clinical scenarios to students. This activity highlighted the importance in partnerships in educational design and bridging the academiaclinician gap. Acknowledgement: This project is funded by a Curtin University, Teaching Excellence Development Fund (2016).
References Australian Commission on Safety and Quality in Health Care (ACSQHC) 2012. National Safety and Quality and Health Service Standards. Sydney, Australia: Australian Commission on Safety and Quality in Health Care. Milkins, L., Moore, C., & Spiteri, J. 2014. Simulation based education: Professional entry student education and training. In: Health Education and Training Institute (ed.). Sydney, New South Wales: Health Education and Training Institute. Unsworth, McKeever & Kelleher, 2012. Recognition of physical deterioration in patients with mental health problems: the role of simulation in knowledge and skill development. Journal of Psychiatric and Mental Health Nursing. 19(6):536-545.
Shirley McGough (RN PhD) and Karen Heslop (RN PhD). Both are at Curtin University anmf.org.au
Part 1 EDUCATION
ACTIVE LEARNING: WHAT DO WE KNOW ABOUT IT? By Katie Piper It’s critical for nurse educators to have a solid understanding of the principles underpinning active learning, to mediate some of the pitfalls which include: inadequate student preparedness for active learning, poorly designed learning activities and an unprepared or unsafe learning environment (White et al. 2014). Active learning has been defined as ‘involving students in doing things and in reflective thinking about the things they are doing.’ (Matveev & Milter, 2010). Active learning is more than passive listening. Terms frequently used to define active learning include analysis, synthesis, reflection and evaluation (The University of Sydney, 2012). Active learning involves a process of inquiry, targets the development of skills and provides students with the opportunity to explore attitudes and values (Huber et al. 2016). Active learning is creating ‘learning experiences to stimulate reflection, problem solving, knowledge building, inquiry and critical thinking.’ (Rosciano, 2015 p. 93). Publication of the revised registered nurse standards for practice (Nursing and Midwifery Board of Australia [NMBA], 2016) has reminded us of the need for nursing graduates to analyse, apply critical thinking skills and to self-reflect. There has been a shift away from teacher centric approaches to learning towards using student centred methods of learning (Waltz et al. 2014). At a systemic level this requires educators to move away from traditional pedagogic behaviourist approaches, to cognitive approaches to teaching and learning (Mackintosh-Franklin, 2016). Cognitive approaches stimulate curiosity and increase the capacity for lifelong learning (Boctor, 2013; Mackintosh-Franklin, 2016) these are essential qualities for a Registered Nurse. A student centred environment is a vital component of nursing education. It’s important to recognise increasing international globalisation and a rapid growth of international students undertaking nursing studies within Australia (Salamonson et al. 2012). It’s also essential to acknowledge the generational diversity of students (Boctor, 2013) who are used to a technological and fast-paced world (Baid and Lambert, 2010). Student centred learning is essential for the development of autonomous nursing graduates. The core components of Active Learning could be summarised as: • student centred; • more than passive listening; anmf.org.au
ACTIVE LEARNING HAS BEEN DEFINED AS ‘INVOLVING STUDENTS IN DOING THINGS AND IN REFLECTIVE THINKING ABOUT THE THINGS THEY ARE DOING.’ (MATVEEV & MILTER, 2010).
• students are engaged in: analysis, synthesis,
reflection and evaluation;
• stimulates curiosity, lifelong learning and
Some examples of active learning approaches include: • collaborative learning, case studies, peer learning, enquiry based learning, problem based learning, project based learning ( The University of Sydney, 2012); • mind mapping (Rosciano, 2015); • educational games ( Boctor, 2013); • find the error, what’s my line, student generated tests, notable quote, reverse bingo, comic strip connection, posting a pyramid, making a mnemonic ( Bowles, 2006); • Online discussion (Huber et al. 2016). There are significant opportunities for research into active learning. Students report improved learning through active methods, however the impact of active learning on academic achievement is still unknown (Waltz et al. 2014). Active learning doesn’t work for all students. Some students may elect to adopt active non-participation as a coping strategy (Hockings, 2009). Research is needed into student preparedness for active learning and environmental, social, political and cultural factors which may affect the successful implementation of active learning strategies. Katie Piper is a Lecturer at Monash University in Victoria
References Baid, H. and Lambert, N. 2010. Enjoyable learning: The role of humour, games, and fun activities in nursing and midwifery education. Nurse Education Today. 30: 548-552. Boctor, L. 2013. Activelearning Strategies: The use of a game to reinforce learning in nursing education. A case study. Nurse Education in Practice. 13: 96-100. Bowles, D.J. 2006. Active learning strategies...Not for the birds! International Journal of Nursing Education Scholarship. (3)1:1-11. Hockings, C. 2009. Reaching the students that student centred learning cannot reach. British Educational Research Journal. 35 (1): 83-98. Huber, D.M., Joseph, M.L., Halbmaier, K.A., Carlson, M., Grill, S., Krieger, K., Matthys, N. and Mundisev, A. 2016. Leadership for transitions of care: An active learning innovation. The Journal of Continuing Education in Nursing. 47(2): 82-88. Mackintosh-Franklin, C. 2016. Pedagogical principles underpinning undergraduate nurse education in the UK: A review. Nurse Education Today. 40: 118-122. Matveev, A.V and Milter, R.G. 2010. An implementation of active learning: assessing the effectiveness of the team infomercial assignment. Innovations in Education and Teaching International. 47(2): 201-213.
Nursing and Midwifery Board of Australia. 2016. Registered nurse standards for practice. www. nursingmidwiferyboard. gov.au/News/2016-0201-revised-standards. aspx Accessed June 2016. Rosciano, A. 2015. The effectiveness of mid mapping as an active learning strategy among associate degree nursing students. Teaching and Learning in Nursing. 10:93-99. Salamonson, Y., Ramjan, L., Lombardo, L., Lanser, L. H., Fernandez, R. & Griffiths, R. 2012. Diversity and demographic heterogeneity of Australian nursing students: a closer look. International Nursing Review. 59 (1): 59-65 The University of Sydney. 2012. Active learning. http://sydney. edu.au/staff/fye/ during_semester/active_ learning.shtml Accessed June 2016. Waltz, C.F., Jenkins, L.S and Han, N. 2014. The use and effectiveness of active learning methods in nursing and health professions education: A literature review. Nursing Education Perspectives. (35)6:392400. White, C., Bradley, E., Martindale, J., Roy, P., Patel, K., Yoon, M. and Worden, M.K. 2014. Why are medical students “checking out” of active learning in a new curriculum? Medical Education. 48: 315-324.
September 2016 Volume 24, No. 3 35
EDUCATION Part 1
DIVERSITY: RESEARCHERS AND NURSE EDUCATORS COLLABORATE By Sally McMillan Inter-professional collaboration between the RDNS Education and Learning Centre and RDNS Institute has resulted in the design and development of a diversity training workshop for community aged care staff. This unique workshop is designed to help staff develop the skills to identify diversity characteristics in clients that may impact their ability to access appropriate healthcare and how to seek solutions through a strengthsbased approach. In this training, frontline staff work with managers to consider how their own practice and organisational policies and procedures may be unintentionally excluding clients (eg. an assessment form with only an option for male or female gender excludes clients that
EXAMINING THE RICHNESS OF A CLIENT’S DIVERSITY PROFILE CREATED IN THE WORKSHOP AND HOW THIS IMPACTS THEIR ACCESS TO APPROPRIATE HEALTHCARE. DR CLAUDIA MEYER PHD, SALLY MCMILLAN RN AND ELIZABETH NUNAN RN PICTURE: JERRY GALEA
identify as non-binary).
have either a positive or negative impact on accessing healthcare. By the end of the workshop, participants generate an action plan to create change in the workplace and this is evaluated three months after the session by the research team. As a group, participants share resources that may assist to overcome negative impacts, such as social isolation, and focus on what strengths the client can also draw on as a resource.
Participants are encouraged to develop an awareness of their own perceptions, biases and assumptions, and how these can unintentionally impact their practice. Woven into the training is time to practice the use of inclusive language, gently reminding each other of negative language that may cause distress. There is a focus on equity over equality, acceptance over tolerance. The facilitators aim to assist the participants to understand that diversity characteristics are, simply, what make us unique, and that characteristics do not exist in isolation.
After workshop completion, participants will be given access to a Libguide, an online resource designed to facilitate information sharing with other organisations. Evaluation is critical to see whether there has been a transfer of knowledge to practice.The RDNS institute will publish the results on the RDNS website by mid-2017. The project is funded by the Department of Social Services.
Working in groups, the participants build a client with rich characteristics, with encouragement to think of diversity beyond cultural identity. We identify that these characteristics can
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Part 1 EDUCATION
PEER REVIEWED BASED ASSESSMENT IN POST GRADUATE EDUCATION By Lori Delaney Students have a propensity to focus their learning aligned to the assessment items established within the units of study, rather than acknowledging the broader need to learn and apply the content taught. This approach to education stifles students’ learning and their ability to apply knowledge, and as a result, essential content can be poorly retained. In order for students to develop a more rounded approach to education within the post graduate curriculum, peer based assessment has been implemented within the post graduate critical care curriculum at the University of Canberra. As future clinical specialists these students have important roles in the professional domain in providing education, supervision and clinical leadership. Providing feedback to colleagues and self-evaluation of performance can be confronting, but anmf.org.au
are necessary processes within the clinical setting. The implementation of peer based assessment within the post graduate critical care curriculum was undertaken in order to develop students’ metacognitive skills, the ability to articulate constructive feedback and to promote insight and reflection into individual performance (Boud, 2007). This augmenting of student learning was undertaken to meet professional attributes rather than students focusing solely on outcomes of their own work, and was viewed as a pediological opportunity to deepen students understanding of content (Thomas et al. 2011).
PROVIDING FEEDBACK TO COLLEAGUES AND SELF-EVALUATION OF PERFORMANCE CAN BE CONFRONTING, BUT ARE NECESSARY PROCESSES WITHIN THE CLINICAL SETTING
The implementation of the peer reviewed process required students to reflect on colleagues’ evaluation of a clinical case, decision making processes and clinical recommendations. Engaging in this process of evaluation and self-reflection has the potential to challenge students’ positions, identify alternative approaches to clinical issues, and alter their
future interpretation of events and approaches to remedy clinical challenges. While peer based assessments are challenging to students due to the vulnerability associated with being judged, they pose challenges to educators in their ability to relinquish control and to trust the reliability of results provided by students to each other. However, through the development of rigorous assessment rubrics that provide clear direction and assessment aims, the process can be utilised to develop graduate attributes associated with leadership and professional responsibility, and the ability to self-evaluate own practice. Saddler and Good (2006) reported that ensuring students understood the quality requirements of assessment resulted in a high level of agreement between grades awarded by students and teachers. The ability to provide constructive feedback that does not disparage colleagues, also permits students to self-identify own errors and understand academic requirements within the teaching process. This promotes students ability to utilise feedback from colleagues rather than be grade focused, and develops their ability to utilise assessment rubrics to enhance the quality of future academic submissions. The employment of peer based assessment items within post graduate curriculum provides an opportunity to extends students learning beyond that of the content explicitly taught, and contribute to the development of graduate attributes required within the professional environment in which students are employed.
References Boud, D. 2007. Reframing assessment as if learning were important. In D. Boud & N. Falchikov (Eds.), Rethinking assessment in higher education: Learning for the longer term (pp. 14-25). London: Routledge. Saddler, P.M. & Good, E. 2006. The impact of self-and peer-grading on student learning. Educational Assessment. 11(1). 1-31. Thomas, G.l., Martin, D. & Pleasants, K. 2011. Using self- and peerassessment to enhance students’ future-learning in higher education. Journal of University Teaching & Learning Practice 8(1),
Lori J Delaney is Assistant Professor in Clinical Nursing at the University of Canberra and PhD Scholar at College of Medicine, Biology and Environment at Australian National University
September 2016 Volume 24, No. 3 37
EDUCATION Part 1
INDUSTRY SPECIFIC EDUCATION By Wendi Bradshaw All nurses registered with AHPRA are aware of the requirements to maintain regulation standards, including continuing professional development (CPD). So too are numerous healthcare organisations and peak bodies, all offering a range of conferences, clinical courses and workshops along with many other practical and theoretical opportunities for learning. Yet the challenge amongst these competing groups is to offer CPD that is innovative, affordable, up-to-date and relevant to the nurse’s clinical practice. The Renal Society of Australasia (RSA) is the peak body representing nephrology nurses and allied health professionals who care for people with kidney disease. The RSA offers educational services that cover extensive geographical areas and time zones, and over the past 18 months have extended their capacity to deliver these via the internet using hi-fidelity e-learning and other contemporary resources. The incorporation of e-learning facilities includes the use of webinars, which are on-line learning events
exclusive to members, offering interactive information sessions through live attendance – from the comfort of the most convenient internet access, either at work or from home. The recordings of these sessions are also made available after the event, for secondary viewing or for those unable to join in live. Additionally, through partnering with Kidney Health Australia and Home Dialysis First, a suite of peer-reviewed, nephrology specific on-line learning is offered through the Online Nephrology Education (ONE) portal. This ONE stop, ONE password, ONE learning e-place, is accessible through the RSA website, and contains a variety of e-learning modules including introductions to haemodialysis, peritoneal dialysis, reviews of renal physiology and related medical conditions, as well as showcasing specific cannulation techniques through the use of virtual ultrasound and cannulation applications. These modules are displayed brilliantly and informatively in cartoon format, and successful completion of each results in a printable CPD certificate. The Renal Society of Australasia Journal is the RSA’s official, peerreviewed publication which receives contributions from local and international sources, is accessible on-line and available to members in hard-copy format. It provides a forum for the sharing of evidence-based research and exchange of ideas for nephrology care personnel and is published quarterly.
The one highly anticipated event show-casing most aspects of nephrology education and research is the RSA Annual Conference, held in a different state or territory every year. The event incorporates master classes and intensive workshops for enhancing clinical skills; holds poster displays of attending delegates; streamlines plenary and concurrent seminar sessions from local and international experts; and offers a wide selection of informative and upto-date renal specific knowledge from all renal modalities. Through maintaining a focus on the individual’s variable and timeprecious learning needs, RSA offer a wide range of learning opportunities that not only aim to fulfil CPD requirements, but more importantly, stimulate the clinician to engage in world-class, contemporary knowledge bases that serve to progress their professional learning theoretically and practically. For further information please contact http://www.renalsociety.org/
Additionally beneficial in sharing local information is the quarterly electronic magazine, Communiqué, and the
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Part 1 EDUCATION
USEFUL TIPS FOR TEACHING INTERNATIONAL NURSING STUDENTS
SARAS HENDERSON (SECOND LEFT) WITH STUDENTS IN DISCUSSION
By Saras Henderson International students studying nursing in Australia has increased (Glew, 2013). For most of these students, English may not be their first language. The style of teaching and learning international students had previously experienced differ vastly from the Western style of teaching. This can create challenges such as language issues, cultural differences, communication difficulties, the relevance of plagiarism, and negotiating academic processes for international students (Crawford & Candlin, 2013). For example, students can rote learn from the book and write verbatim in their essay, not realising this is plagiarism. The English language has its own nuances that may not be translated into another language. International students often experience difficulties with understanding accent, pace, terminology, and colloquialisms (Shakya & Horsfall, 2000). Therefore, they are reluctant to interact with teachers and other students and can
come across as not being interested. Cultural differences can be perceived as threatening (Vardaman & MastelSmith, 2016). Risks to cultural safety exist when different cultures meet. For example, international students can appear to agree to the teacher’s question even if they do not agree with it, as in some cultures, the teacher is looked upon as someone who is knowledgeable and has power and one who cannot be questioned (Hofestede, 2005). International students clearly need support from academics to overcome challenges. Some useful tips include:
• Build a trusting relationship by
getting to know students’ names and ask students how the name is pronounced. Invite students to ask questions instead of waiting for them to initiate the question. Speak at a slower pace so students can understand and follow what is being stated. Ask students to repeat back what the
teacher had explained to ensure understanding. Use relevant and culturally appropriate examples in teaching sessions so as not to offend cultural values. For example, use neutral examples rather than, for example a gender bias exemplar, Articulate expectations at the outset of the teaching session making sure the student understands what is required of them, Foster application of content by using case scenarios to prevent rote learning and promote problem solving skills, Avoid stereotyping certain behaviours with particular cultures, Direct international students to available support services.
Associate Professor Dr Saras Henderson is Program Director, Health Professional Education in the Menzies Health Institute QLD, School of Nursing and Midwifery at Griffith University
Crawford ,T. & Candlin, S. 2013. Investigating the language needs of culturally and linguistically diverse nursing students to assist their completion of the bachelor of nursing programme to become safe and effective practitioners. Nurse Education Today, Vol. 33, pp. 796-801. Glew P.J. 2013. Embedding international benchmarks of proficiency in English in undergraduate nursing programmes: Challenges and strategies in equipping culturally and linguistically diverse students with English as an additional language for nursing in Australia. Collegian, Vol. 20, pp. 101 – 108. Hofestede, G. 2005. Cultures and organizations: Software of the mind (2nd ed.). New York: McGraw-Hill. Shakya, A. & Horsfall, J. M. 2000. ESL undergraduate nursing students in Australia: Some experiences. Nursing and Health Sciences, Vol 2. pp. 163-171. Vardaman, S. A. & Mastel- Smith, B. (2016). The transitions of international nursing students. Teaching and Learning in Nursing, Vol. 11, pp. 43-43.
EDUCATION Part 1
Managing COPD A course for professionals to improve their understanding and knowledge of current treatments and management of COPD. 6 – 7 October 2016 20 – 21 April 2017 Influencing Behaviour Change in Chronic Illness A day program of Tips and skills for creating safety to change, incorporating Mindfulness, Neuroscience and Psychological Understanding 17 October 2016 Spirometry Principles & Practice This extensive course aims to develop an individual’s knowledge & skills to enable them to perform spirometry to internationally recognised best practice. 24 – 25 October 2016 16 – 17 February & 27 – 28 April 2017 COPD Update This day program will give health professionals the opportunity to improve their skills and knowledge in caring for the person with lung disease. 7 November 2016 Asthma Educator’s Course A three day program covering the latest advances in asthma care management and delivery, enabling professionals to work effectively to improve health outcomes. 16 – 18 November 2016 1 – 3 March 2017 Smoking Cessation Course This evidence based program equips participants with the knowledge and skills to treat and manage nicotine dependency to help people addicted to smoking to quit. 24 – 25 November 2016 9 – 10 March 2017 Victorian Respiratory Professional Development Day (VRPDD) A day program delivered in partnership with the National Asthma Council Australia, covering a wide variety of respiratory health and management topics. 28 November 2016 Allergy Day Seminar Immunology, Allergy and Respiratory medicine - insights and advances in assessment and management are discussed by a panel of many of Australia’s leading experts in their field. 28 February 2017 Respiratory Course A four day program, split into two modules during a week, for individuals wanting to update and develop their skills and knowledge of respiratory care and the holistic management of respiratory illness. 1 – 2 May (Module A) 3 – 4 May (Module B) 2017
Lung Health Promotion Centre at The Alfred P: (03) 9076 2382 E: email@example.com W: www.lunghealth.org.au
UNDERGRADUATE NURSING EDUCATION RELATED TO EUTHANASIA By Lyn Croxon and Judith Anderson Euthanasia is a subject that has been debated in health ethics courses for many years. With the increase in quality palliative care and emphasis on ‘dying well’, in response to the increased number of people living with life limiting conditions (Swerissen & Duckett, 2014), it has not been so prevalent in public forum discussions of late. However, with the increasing older population and a doubling of the number of people dying each year over the next 25 years (Swerissen & Duckett, 2014), is this about to change? Nurses need a sound theoretical knowledge of ethical principles to be able to form opinions on issues such as euthanasia. Johnstone (2011) identifies the risk of leaving moral decisions such as those related to euthanasia to public opinion and the possible manipulation of media which plays a large part in developing public opinion. Even in Bulgaria where voluntary euthanasia was legalised in 2002 Gielen et al. (2011) found opinions about it amongst nurses was still divergent and religiosity played a significant part in predicting opposition. As nurses have a substantial role to play in caring for people at the end of their life, what education they have been given on the topic is considered to be pertinent. A brief literature review of EBSCOHOST, CINAHL, Primosearch and GoogleScholar using the search terms undergraduate nurse education and euthanasia (limited to 2010-2016) found very few results.
NURSES NEED A SOUND THEORETICAL KNOWLEDGE OF ETHICAL PRINCIPLES TO BE ABLE TO FORM OPINIONS ON ISSUES SUCH AS EUTHANASIA. Adesina et al. (2014) in their qualitative interviews about end of life care with Australian students did not specifically ask about euthanasia, but identified it as a key issue for their students. They specifically describe student concerns about legal and moral conflicts between law and ethics concerning euthanasia. However, despite most students in this study viewing it as an ethical issue rather than a legal one, they were quite polarised in their opinions about it either providing comfort and peace or being an act of murder (Adesina et al. 2014). In a Turkish study (Ozcelik et al. 2014) of 600 nursing students, nearly a third (32.4%) were against euthanasia. Interestingly the majority (78.9%) indicated that they had not received any education on the topic and less than half (42.5%) felt that this would be useful. In a Czech study Bužgová and Sikorová (2013) found that more than half of the nursing students surveyed (662) agreed with euthanasia and this was particularly the case with students who were already working in the industry. The most common reason cited by the students was in order to preserve the patient’s autonomy. Similarly, in their Polish study (Mickiewicz et al. 2012) found that nearly half of the nursing students (49.6%) were opposed to active euthanasia, but favoured legalisation of euthanasia. Although not much has been written in academic literature recently about the need to educate nursing students specifically about euthanasia, some authors (Iglesias et al. 2011; Leuter et al. 2013) advocate for significant theoretical and practical training in ethics and ethical decision making. Lyn Croxon is a Lecturer in the School of Nursing, Midwifery and Indigenous Health at Charles Sturt University Dr Judith Anderson is the Course Director in the Faculty of Science at Charles Sturt University
References Adesina, O., DeBellis, A., & Zannettino, L. 2014. Third-year Australian nursing students’ attitudes, experiences, knowledge, and education concerning end-of-life care. International Journal of Palliative Nursing, 20(8), 395-401 397p. Bužgová, R., & Sikorová, L. 2013. Moral judgment competence of nursing students in the Czech Republic. Nurse Education Today, 33(10), 1201-1206. doi: http:// dx.doi.org/10.1016/j. nedt.2012.06.016 Gielen, J., Branden, S. V. D., Iersel, T. V., & Broeckaert, B. 2011. The diverse influence of religion and world view on the palliative-care nurses’ attitudes towards euthanasia. Journal of Empirical Theology, 24(1), 36-56. doi: 10.1163/157092511X 571169 Iglesias, M. E. L., Vallejo, R. B. D. B., Ceña, D. P., & Fuentes, P. S. 2011. Knowledge and positions on bioethical dilemmas in a sample of Spanish nursing students: A questionnaire study. Contemporary Nurse: A Journal for the Australian Nursing Profession, 38(1/2), 1823 16p. doi: 10.5172/ conu.2011.38.1-2.18 Johnstone, M.J. 2011. Public Opinion and Ethics. Australian Nursing Journal, 19(1), 25. Leuter, C., Petrucci, C., Mattei, A., Tabassi, G., & Lancia, L. 2013. Ethical difficulties in nursing, educational needs and attitudes about using ethics resources. Nursing Ethics, 20(3), 348-358 311p. doi: 10.1177/096973301245 5565 Mickiewicz, I., Krajewska-Kułak, E., Kułak, W., & Lewko, J. 2012. Attitudes towards euthanasia among health workers, students and family members of patients in hospice in north-eastern Poland. Progress in Health Sciences, 2(1), 81-88. Ozcelik, H., Tekir, O., Samancioglu, S., Fadiloglu, C., & Ozkara, E. 2014. Nursing students’ approaches toward euthanasia. Omega: Journal of Death & Dying, 69(1), 93-103. doi: 10.2190/ OM.69.1.f
Part 1 EDUCATION
FACILITATION OF NURSING EDUCATION By Rebekkah Middleton The role of the educator is a pivotal one in nursing both in clinical and tertiary settings. How to engage in the role of educator is viewed through different lenses at times. My key learning of this role, over 15 years of education in both a hospital and tertiary setting, is that the educator should be more facilitative than seen as an expert imparter of knowledge. Why is this method of education more effective? When facilitation of learning occurs, the environment is conducive to meaningful engagement which is person-centred and learning focused
CADAVERBASED ANATOMY FOR NURSES: A REAL LEARNING EXPERIENCE By Matthew J Barton, Amy Johnston and Michael Todorovic Anatomy is a cornerstone science for nurses and regardless of speciality, it underpins effective clinical practice. Considering the importance anatomy has in nursing, undergraduate nursing programs have seen a reduction in hands on teaching time often replaced by technological learning resources. So, we asked the question: ‘Do cadaver-based teaching methods still hold validity?’....We think so! Within nursing, anatomy education typically employs a passive pedagogical approach; commonly an educator presents text-dense images/ anmf.org.au
(Johnson-Farmer & Frenn, 2009; Horsfall et al. 2012). This establishes trust, which builds towards effective teamwork as the learner feels empowered to be part of the learning process, rather than at the end of it (Lerret & Frenn, 2012). Education becomes inclusive and participatory rather than directive. For educators/facilitators to work in a facilitative manner and have positive influence in the learning setting, they need to enable a space that contextualises and connects theory to practice. They need to be able to establish agreed and shared ways of working together with the learners, to identify individual and group values, to clearly communicate activities, to be transparent in critical discussions and to use multiple intelligences to engage all learners in the process. This can require creativity, discernment and flexibility. To build skills in facilitation, it is wise for the educator/facilitator to figures using a didactic teaching method. Students may be provided access to learning resources such as plastic models and computer animations, or occasionally be treated to dissection of an unlucky rodent or frog. But, rarely do nursing students have exposure to human cadaver-based anatomy (CBA), even at universities who have such facilities. For centuries, anatomy students – including nursing students - have relied on CBA learning for their anatomy education, which makes perfect sense, as nurses require intimate anatomical knowledge to routinely probe, palpate, auscultate and assess patients or provide therapeutics to hidden anatomical structures. With the reduction in allocated anatomy teaching time, and corresponding budget constraints for learning resources, it is essential educators consider what content and methods should be implemented to be congruent with clinical practice. Herein we report the learning experiences of nursing students with access to CBA as a teaching resource. In anatomy and physiology courses (BN; Griffith University), students described their experience with CBA as highly effective (4.4/5 Likert scale) and with qualitative comments like “cadaver labs were brilliant, I learnt a lot more than a typical tutorial”. Theoretically, CBA used as a learning resource integrated into a broader bioscience course, will transition surface learning (rote memorisation) into a much deeper constructivism knowledge base.
References Greene, J., Grant, A. 2003. Solution-focused coaching. Harlow, UK: Pearson Education. Horsfall, J., Cleary, M., Hunt, G. 2012. Developing a pedagogy for nursing teachinglearning. Nurse Education Today. 32(8):930-933.
ENGAGING WITH THE LEARNER
find a mentor or critical companion who can provide the opportunity for the facilitator to explore and reflect on their own practice in a safe environment. Critical conversations help to ensure consistent approaches, to understand what is working and to encourage more of that, along with improving performance (Greene & Grant, 2003). Rebekkah Middleton is a Lecturer in the School of Nursing at the University of Wollongong and a PhD Candidate
Johnson-Farmer, B., Frenn, M. 2009. Teaching excellence: what great teachers teach us. Journal of Professional Nursing. 25(5):267–272. Lerret, S., Frenn, M. 2011. Challenge with care: reflections on teaching excellence. Journal of Professional Nursing. 27(8):378-384.
Our results continue to demonstrate that a significant motivator for anatomy learning in nurses is for students to interact with hands-on, ‘real’ material (Johnston, 2010). Moreover, using CBA for nurse education has many additional advantages: it introduces students to the reality of death and nursing management of human bodies, highlights pathological alterations caused by disease, contextualises medical terminology, and highlights biological variation (Older, 2004). As patient acuity and comorbidities continue to increase, even graduate nurses are required to use complex clinical reasoning to support their day-to-day nursing care. Often, tertiary educators are under increasing pressure to provide nursing students with the knowledge and understanding required to meet these demands. CBA can be an indispensable part of the educator’s (biosciences) toolkit, thus ensuring high quality graduates and providing ongoing educational support for the continual professional development of nurses. Dr Matthew J Barton and Dr Michael Todorovic are Lecturers, Biosciences, School of Nursing & Midwifery at Griffith University in QLD Dr Amy Johnston, Emergency Care Gold Coast Hospital & Health Service, Menzies Health Institute, QLD, Griffith University
References Johnston, A. N. 2010. Anatomy for nurses: providing students with the best learning experience. Nurse Educ Pract 10 (4):2226. doi: 10.1016/j. nepr.2009.11.009. Older, J. 2004. Anatomy: A must for teaching the next generation. Surgeon 2 (2):79-90.
September 2016 Volume 24, No. 3 41
EDUCATION Part 1
ENHANCING FERTILITY LITERACY FOR NURSES AND MIDWIVES IN PRIMARY CARE By Kerry Hampton Prevention in healthcare through improved health literacy is at the very heart of change in Australia’s health system to improve overall population health, ensure health equity, and make Australia’s health system sustainable into the future (Australian government Department of Health and Ageing, 2010). Critical to the success of this change is the development of new roles for nurses and midwives to fill gaps in areas of identified need (Australian government Department of Health and Ageing, 2010). In Australia, one in six couples has trouble conceiving (Loxton and Lucke 2009). Of infertile women who attend in vitro fertilisation (IVF) clinics, only 13% understand the fertile window of the menstrual cycle for correctly timed intercourse (Hampton et al. 2013). In addition, one in three men and women of reproductive age has a lifestyle risk factor – including cigarette smoking, alcohol consumption, unhealthy weight and poor diet – that not only reduce the chance of natural conception and success with ART treatment, but also impact the long-term health of children (Anderson et al. 2010). Few nurses and midwives in Australia are trained in fertility awareness and reproductive wellness to assist natural conception (Hampton et al. 2016). Yet, a recent Australian study shows that women want this type of educational support from their primary care practitioners to help them conceive naturally and avoid costly and invasive IVF procedures (Hampton et al. 2013). In another Australian study, primary care nurses and midwives were identified as being best placed to deliver this type of care for women and couples (Hampton et al. 2016). Endorsed by the Australian Primary Health Care Nurses Association 42 September 2016 Volume 24, No. 3
FEW NURSES AND MIDWIVES IN AUSTRALIA ARE TRAINED IN FERTILITY AWARENESS AND REPRODUCTIVE WELLNESS TO ASSIST NATURAL CONCEPTION (HAMPTON ET AL. 2016). YET, A RECENT AUSTRALIAN STUDY SHOWS THAT WOMEN WANT THIS TYPE OF EDUCATIONAL SUPPORT FROM THEIR PRIMARY CARE PRACTITIONERS TO HELP THEM CONCEIVE NATURALLY AND AVOID COSTLY AND INVASIVE IVF PROCEDURES (HAMPTON ET AL. 2013).
(APNA), the following professional development events will equip nurses and midwives with the necessary knowledge and skills to assist natural conception and reproductive wellness through men’s and women’s enhanced fertility literacy. Comprehensive Course in Natural Fertility Education© In this course, participants will learn how to structure natural fertility education to assist women to achieve and avoid pregnancy over reproductive life through a better understanding of when in the menstrual cycle pregnancy is a possibility. On satisfactory completion, registered practitioners can advertise themselves as a Trained Teacher in Natural Fertility Education. Advanced Practice in Natural Fertility Education© In this interactive workshop, participants will learn how to structure lifestyle consultations for reproductive wellness based on the principles of motivational interviewing. These events will take place in October and be facilitated by Dr Kerry Hampton, RN, RM, PhD, a highly qualified and experienced practitioner in the field of natural fertility. For more information or to register for these events, please contact Dr Kerry Hampton on 0419 830 530 or go to www.wisewomanbusiness.com Dr Kerry Hampton is in the Department of General Practice at Monash University in Victoria
ONBOARDING AT MIDLAND By Jeffrey Williams and Leonie Cross DR KERRY HAMPTON
The onboarding of 1,200 people for the opening of the 307-bed St John of God Midland Public Hospital (Midland) was a massive undertaking. From the onset we wanted to ensure that the onboarding effectively provided cultural alignment, technical expertise and a safe opening. Planning phase analysis identified all aspects of change management needed to be addressed, with onboarding playing a key component. This included factoring in the complexity of opening a new hospital as well as transitioning services from Swan District Hospital (SDH), the facility Midland was replacing.
References Anderson, K., Nisenblat, V. and Norman, R. 2010. Lifestyle factors in people seeking infertility treatment: A review. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 50:8-20. Australian government Department of Health and Ageing. 2010. Building a 21st century primary care system, Australia’s first national primary health care system. Commonwealth of Australia. Hampton, K. D., Mazza, D. and Newton, J. M. 2013. Fertility-awareness knowledge, attitudes and practices of women seeking fertility assistance. Journal of Advanced Nursing 69 (5):1076-1084. doi: 10.1111/j.13652648.2012.06095.x. Hampton, K.D., Newton, J. M., Parker, R. and Mazza, D. 2016. A qualitative study of the barriers and enablers to fertility-awareness education in general practice. Journal of Advanced Nursing Mar 9. doi: 10.1111/jan.12931. [Epub ahead of print]. Loxton, D., and Lucke, J. 2009. Reproductive Health: Findings from the Australian longitudinal study on women’s health. Australian government Department of Health and Ageing.
In addition, about 40% of the workforce transitioned from SDH. The remainder came from public and private sector hospitals. As Midland is a public hospital run by St John of God Health Care, it was important that the workforce aligned with the organisation’s culture. Our values of Hospitality, Compassion, Respect, Justice and Excellence guide the way we deliver our services and interact with people. With a high proportion of Aboriginal people living in the catchment area, great focus was placed on Aboriginal culture awareness. A structured onboarding program was developed with units tailored for different roles. The program was implemented 12 weeks prior to opening, with multiple sessions held daily. Thanks to the dedicated Learning and Development (L&D) Team we achieved our goal of training 94% of the workforce prior to opening. This feat was made even more remarkable given some people could not undertake training until just prior to opening, due to commitments with their current employer. Onboarding was provided to medical practitioners on Saturdays to assist with their schedules. A hospital resource guide was created to provide staff with a single source of truth from opening day. A group, known as ‘Super Users’, were identified from across the workforce. anmf.org.au
Part 1 EDUCATION They were allocated to wards and departments in the first two weeks of operations and were available 24/7 to provide high level support on systems and processes. This strategy proved very effective and feedback from staff showed they felt supported. L&D team members were available 24/7 for the first six weeks of the hospital’s operations to provide critical educational support. Feedback showed high levels of cultural awareness and a strong sense of belonging by staff from the beginning. This strong foundation has enabled us to ensure our workforce provides great patient care in accordance with our values.
WITH A HIGH PROPORTION OF ABORIGINAL PEOPLE LIVING IN THE CATCHMENT AREA, GREAT FOCUS WAS PLACED ON ABORIGINAL CULTURE AWARENESS
In the first six months of operations, more than 70,550 people were treated at Midland. We have received excellent feedback about our care and have been quickly embraced by the local community. Our recommendation to others undertaking large-scale inductions is to start the process as early as possible, ensure all policies, procedures and documentations are finalised prior to onboarding and allow plenty of time to undertake the training sessions. It is also important to allow enough time for managers to be effectively inducted and that they have sufficient buy-in into the onboarding process. St John of God Public Midland Hospital is part of the Bigger Picture Health $7 billion hospital building and refurbishment program. It is jointly funded by state and Commonwealth governments and operated by St John of God Health Care under a public private partnership. The facility includes a 60-bed private hospital. Both hospitals opened 24 November 2015.
Jeffrey Williams is Director of Nursing at St John of God Midland Public and Private Hospitals Leonie Cross is Manager Learning and Development Perth Northern Hospitals, St John of God Health Care anmf.org.au
COLLABORATIVE CLUSTERS EDUCATION MODEL – AN EVOLUTION OF THE DEDICATED EDUCATION UNIT By Debby Morris, Lyn Armit and Laurie Grealish Clinical experience is critical for the development of practice knowledge that can support patients and their families. How opportunities for students to learn from experience, particularly workplace experiences, are structured is an important aspect of curriculum design in nursing. From a sociocultural viewpoint of learning, the learner should be totally engaged in the culture of the workplace (Billet, 2014). However, recognising the opportunity to shape, inspire and grow capacity in the future nursing workforce continues to elude some clinicians (Newton and Darbyshire, 2016). One health service in Queensland is addressing the preparation of nursing students and newly qualified nurses in the workplace through an innovative model, known as the Collaborative Clusters Education Model (CCEM). Like the Dedicated Education Unit (DEU) model of clinical education, the focus is on learning in a community of practice (Grealish and Ranse, 2009). Unlike the DEU, the CCEM does not rely on university curriculum design to release students for two days per week. Instead, students undertake block placements as usual. The key element in the CCEM is facilitation. The hospital-appointed Entry to Practice (E2P) Facilitator has a key role in: (1) sequencing work activities and responsibilities to support development over three years (Bachelor of Nursing) and into the new graduate year; (2) supporting nurse clinicians on how to engage students in their work, to hold students to account for their learning and to provide ‘on the spot’ feedback related to performance and goals; and (3) directly providing activities that promote deep learning such as ask Socratic questions, shape problems and develop possible solutions, and scenario or case analysis. The E2P Facilitator is on site mornings and evenings, works collaboratively within facilitation teams (one team per cluster), and monitors students’ performance in order to produce summative assessments. The E2P Facilitators work closely with academic course conveners from
partner universities to support student learning. The CCEM was introduced in 2015, and has been underway for 18 months. Early findings from the initial feasibility study indicate that the model is feasible. Changing from a 1:8 model of supervision to the CCEM has required a significant education and development program for the E2P Facilitators. The change of focus from small groups of students across four to six different wards to groups of 25 to 30 students across the same wards (one cluster), covering am and pm shifts, has required changes to E2P practice. Some changes include developing a communication book, a re-focus from student to ward teams and a deeper understanding of the value and practice of feedback. In the CCEM, the practice of facilitation is critical and provides an area for further development and research in order to refine the role, and develop an induction program for new E2P Facilitators. Debby Morris is Nurse Educator, Mental Health and Specialist Services at Gold Coast Health/Gold Coast University Hospital Lyn Armit is Director of Nursing, Nursing/Midwifery Education and Research Unit, Clinical Governance, Education & Research and Adjunct Professor School of Nursing and Midwifery at Griffith University, Gold Coast Health/Gold Coast University Hospital Dr Laurie Grealish is Associate Professor of Subacute and Aged Nursing, School of Nursing & Midwifery at Griffith University and Gold Coast Hospital & Health Services and Adjunct Associate Professor, The Education for Practice Institute, Charles Sturt University
References Billett, S. 2014. Integrating learning experiences across tertiary education and practice settings: A socio-personal account. Educational Research Review, 12, 1-13. Grealish, L. and Ranse, K. 2009. An exploratory study of first year nursing students’ learning in the clinical workplace. Contemporary Nurse, 33(1): 0-92. Newton, J. and Darbyshire, P. 2016. ‘Why don’t nurses like students?’ Nurse Education Today, 38, p.1.
September 2016 Volume 24, No. 3 43
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SEPTEMBER 5th Rural and Remote Health Scientific Symposium Excellence in rural and remote health research 6-7 September, Old Parliament House, Canberra. http://ruralhealth.org.au/ symposium2016/ 8th National Paediatric Bioethics Conference 7-9 September, Ella Latham Auditorium, Royal Children’s Hospital, Melbourne, VIC. http://www.rch.org.au/ bioethics Enrolled Nurse Professional Association Conference I can and I will. Watch me! 8-9 September, Novatel North Beach Hotel, Wollongong NSW. www. enpansw.org/ ANMF Vic Branch - Australian Nurses and Midwives Conference 8-9 September, Melbourne Convention and Exhibition Centre. www.anmfvic. asn.au/events-and-conferences Acute Care: Seriously Ill Patients 8-9 September, The Lakes Resort Hotel, Adelaide. www.ausmed.com.au/ Australasian Neuroscience Nurses Association Conference The jewel in the crown: keeping it safe in our hands 9-11 September, The Novotel, Brisbane. www.anna.asn.au Palliative Care Nurses Australia 6th Biennial Conference 11-12 September, Canberra ACT. www.pcna.org.au/conference XIX International Congress for Tropical Medicine and Malaria 18–22 September, Brisbane Convention & Exhibition Centre. http://tropicalmedicine2016.com/ Australasia-Pacific Post-Polio Conference Polio: Life stage matters 20–22 September. Four Seasons Hotel, Sydney. This conference will facilitate better care and build international connections by bringing together health care providers, researchers, polio survivors, their caregivers and patient organisation representatives. www.postpolioconference.org.au
NETWORK Royal Women’s Hospital, ‘theatre staff’, 1980-1990 reunion Interested? Contact Leesa Samarin. E: firstname.lastname@example.org Ballarat University, Diploma of Applied Science 1986-1988, 30-year reunion 18 September, George Hotel, 27 Lydiard Street, North Ballarat from 2pm onwards. Contact Paul Smith M: 0410 561 421 E: email@example.com Woden Valley Hospital, L Group, 35-year reunion 1-3 October. Contact Murray Harper M: 0448 211 059 E: dodgerlily21@ bigpond.com or search Facebook page Woden Valley Hospital L Group
IARMM General Assembly jointly with 5th World Congress of Clinical Safety 21-23 September, Harvard University Medical School, Boston, Massachusetts, USA. www.iarmm.org Australian College of Neonatal Nurses Conference 22-24 September, Rydges on Swanston, Melbourne. www.acnn.org. au/news-and-events/acnn-nationalconference/ Improving Patient Flow in Emergency Departments Innovative patient-centred models to improve outcomes 28–30 September, Crowne Plaza, Melbourne. https://akolade.com.au/ events/patient-flow-in-emergency/
OCTOBER Australasian Implementation Conference Driving effective implementation 5–6 October, Melbourne Convention Exhibition Centre. www. ausimplementationconference.net.au/ Lung Health Promotion Centre at The Alfred 6-7 October – Managing COPD 24-25 October – Spirometry rinciples & Practice P: (03) 9076 2382 E: firstname.lastname@example.org World Mental Health Day 10 October. Australasian Rehabilitation Nurses’ Association 26th Annual Conference Hands, hearts and minds: Capturing the essence of rehabilitation 10-11 October, Betty Cuthbert Room, MCG, Melbourne. www.arna.com.au/ Short term memory loss & considering behavioural expression Sydney Workshop 11 October, Y-Hotel - Hyde Park, Sydney. http://internationalfaculty.cmhe. org/events/shorttermmemorylosscon sideringbehaviouralexpression/ CRANAplus 34th Annual Conference Going to extremes 12-14 October, Grand Chancellor, Hobart. https://crana.org.au/ conference/2016-conference
Princess Alexandra Hospital, Group 59C 30-year reunion 7-8 October. Contact Jenny Whittle (nee Dredge) E: jennydredge@hotmail. com or search Facebook page 59C Princess Alexandra Hospital Group Royal Melbourne Hospital, October 1976, 40-year reunion 8 October, Naughtons Parkville Hotel. Contact email@example.com or Kris Alderson (nee McGuigan) E: pjka@ ozemail.com.au or Jane Beetham (nee Collyer) E: firstname.lastname@example.org Australian Women’s Health Nurse Association 30-year anniversary inservice and reunion dinner 17-18 November, Carrington Hotel Katoomba (17 and 18 November inservice/18 November reunion dinner). E: Jenny.Bath@hnehealth.nsw.gov.au
Childbirth and Parenting Educators of Australia National Conference Nurture the primal instinct 12-14 October 2016, ‘the Sanctuary’ Adelaide Zoo. Registration Open. www.ivvy.com/event/capea Anti-Poverty Week 16-22 October. http://www.antipovertyweek.org.au/ about/about-anti-poverty-week World Federation for Mental Health International Conference 17-19 October, Cairns Convention Centre, Qld. www.wfmh2016.com Innovations in Hospital Management Forum Driving organisational efficiency and reducing operating costs 18–20 October, Sydney. https://akolade.com.au/events/ innovations-hospital-management-forum/ 21st International Congress on Palliative Care 18-21 October, Montreal, Canada. www.mcgill.ca/palliativecare/congress Transplant Nurses Association Conference 19-21 October, Adelaide Convention Centre. www.tnaconference.com.au Birth and Beyond Conference 19-22 October, Ontario Canada. www.birthandbeyondconference.ca/ Australian Disease Management Association 12th Annual National Conference Person centred healthcare: Achievements & challenges 20-21 October, Melbourne Convention Centre (MCEC). www.adma.org.au/ E: email@example.com T: (03) 9076 4125 Assessment: Neurological Nursing 24-25 October, Comfort Inn Haven Marina, Glenelg North. www.ausmed.com.au 42nd International Mental Health Nursing Conference Nurses striving to tackle disparity in healthcare 25-27 October, Adelaide Convention Centre, South Australia. www.acmhn2016.com/
Prince Henry’s Hospital 25-year reunion 22 October, 3-9pm, Bells Hotel, 157 Moray Street, South Melbourne. Cost $38 per head (includes finger food and a complimentary drink, security and venue hire). Drinks at bar prices. Bookings essential. Dress is smart casual. To book go to http:// www.trybooking.com/JVEX Prince Henry’s Memorial Page reunion. This reunion is in honour of the hospital’s closure and demolition in 1991 (25 years ago). Go to Prince Henry’s memorial page: https://www.facebook. com/Princehenryshospital/ to share memories and old photos.
The National Nursing Forum The power of now 26-28 October, Melbourne Park Function Centre, VIC. https://www.acn.edu.au/nnf2016 Australian College of Children & Young People’s Nurses Conference Honouring the past, treasuring the present, shaping the future 26-28 October, Stamford Grand, Glenelg, SA. www.accypn.org.au/ conference-2016 34th Audiometry Nurses Association of Australia Annual Conference & AGM 26-28 October, Noahs on the Beach, Newcastle NSW. http://anaa.asn.au/ conference-2015/ 21st Nursing Network Violence against Women International Conference Strengthening healthcare systems to promote safety and health of women and families 26-28 October, Melbourne. www.latrobe.edu.au/jlc/news-events/ NNVAWI-Conference-2016 18th South Pacific Nurses Forum Through nursing excellence for universal health 31 October-4 November, Honiara, Solomon Islands. Contact Edward Iuhanisuna E: firstname.lastname@example.org or www.facebook.com/spnf.org.au or www.spnf.org.au
NOVEMBER 25th National Conference on Incontinence 9–12 November, Adelaide Convention Centre. South Australia. www.continence.org.au/nationalconference.php Lung Health Promotion Centre at The Alfred 16-18 November – Asthma Educator’s Course 24-25 November - Smoking Cessation Facilitator’s Course P: (03) 9076 2382 E: email@example.com National Primary Health Care Conference 23-25 November, Pullman Albert Park Melbourne. www.phaa.net.au/events/ event/NPHCC-2016
RAH, group 772, 40-year reunion February 2017. Interested? Contact Bronwyn Glitheroe (nee Deed), AnneMarie McBride (nee Rogers), Helen Kirby (nee Osborn) or Rhona Edwards (nee McGarrigle) E: rah772reunion@ gmail.com or search Facebook page Rah772
Email firstname.lastname@example.org if you would like to place a reunion notice September 2016 Volume 24, No. 3 45
CLIMATE CHANGE IMPACT
REWARDING CAREER IN PRIMARY CARE
I write in response to the ANMJ feature, Ground Zero written by Robert Fedele (July, 2016). Violence, drugs and alcohol abuse are related to thousands of presentations into EDs daily. My studies have highlighted we may be missing an important piece of the puzzle – our changing environment and its effects on human behaviour.
It was wonderful to see primary care nursing featured in the ANMJ August 2016. A couple of years after graduating as an EN, I decided to become an RN specifically to help me move into the primary care sector. I was lucky to be given my first preference for a grad year with RDNS, and have worked in various primary care roles since then.
The ecology of the world is changing, and when we look at escalating violence and substance abuse in the context of violence against healthcare workers, we need to look at underlying causes. How will global warming affect health risks and health outcomes? Is the increasing abuse of alcohol and illicit drugs as discussed in the ‘Ground zero’ feature a symptom of the emerging social, demographic and economic disruptions (Anderson, 2001) of global warming?
I have found community nursing, district nursing and practice nursing to be interesting, fulfilling and rewarding. I see myself as a ‘specialist generalist’, with knowledge in many areas from childhood immunisation to care coordination for the elderly. I also enjoy the element of not knowing who’s going to walk into my treatment room with an emergency, but feeling confident enough in my skills to be able to cope with whatever may arise.
Whether you subscribe to the global warming phenomenon, a comment once made by a climatologist holds true. The earth has been experiencing ‘climate change’ since time began. We need to understand that human induced global warming is impacting on health. Increasing substance abuse and escalating violent behaviour within our community may just be a side effect. Anecdotally as an ED nurse of 20 years, I have found in particular aggression is more prevalent during extreme cycles in our weather, intense heat waves for example. Is this due to increased alcohol consumption which leads to alcohol fuelled violence? Or that hot temperatures increase aggression by directly increasing feelings of hostility and indirectly increasing aggressive thoughts (McMichael et al. 2006).
Most nursing students I have preceptored have started their primary care placements feeling uninterested and expecting to be bored. Without exception, all of these students left either inspired to work in the area or at least with an admiration of the amazing work that primary care nurses do. The same is true with medical students. If we want more junior nurses choosing to work in this area, I think the key is to open the eyes of students who may feel that ward-based nursing is the only type of ‘real nursing’, and help them see what a great career primary care can hold for them. I can’t see myself making the move back to ward-nursing, which after working as a primary care nurse feels stifling and repetitive.
We are facing a crucial point in time about societal behaviour and expectations, and we need to understand all the factors. As an ED nurse I think it’s important we keep talking about violence in healthcare. Raise the bar high and care for the caregivers. Vanessa Gorman RN, CCRN, VIC
It may not have the prestige of an ICU, an ED or theatre nurse, but I wouldn’t want to work in any other field.
Elisabeth Hall RN, VIC
Anderson, C. 2001. Heat and Violence. Current Directions in Psychological Science. 10(1):33-38 McMichael, A, Woodruff, R, Hales, S. 2006. Climate change and human health: present and future risks. Lancet. 364(9513):859-869.
OPPOSING VOLUNTARY EUTHANASIA I am writing to express an opinion in the Voluntary Euthanasia (VE) debate, an opinion opposed to VE. I think human life is sacred and that we should not take it into our hands to end it.
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Wales, euthanasia. and The of podcasts (Willmot practice? of voluntary an illega tabled in New Families play out in your professional reports Denton will raise the issue ber and con for your SA ACD form,is critical. might tary currently pro Andrew uced a num ss you be prepared to discuss VE with n in the new ss volun conc and Commonwealth governments that erns – both Tasmania issue them discu optio tell te I Would discu to this prod an l to this, 2013) deba on need have government, I In addition ia g able toess individua athe Australia has put this in their Advance et al. 2016).bein VE is truly(Willmot who it may Act. (South of the VE anas nurse feel the a person Your voices who professionals F’s Not aspects rstand whether and if so, how be prepared to to addr Centre me as the topic says that carer TheiaWheeler healthcare voluntary euth The ANM andanas Directive? Would you Andrew Dentoneuth specifically ic and frustrates is us. Care ort on all ssing as VE to VE should it forndVE do of podcasts – to unde ralian publ re, 2016). so with a request a number erns arou in discu respond to ins an t this issue supp in the act of administering have produced abou Aust cannot to ed and conc Cent conit rema pro train us the assist – both for the debate act.ld be able wish legal? From a nursing point of view, Wheeler t gives s amade d by aan illegal because boun I am cons truly aspects ion of the VE currently shou be feel posit extent an option expresse statemen occur (The VEt is am ld be whether e has a – to understand to shouare thel pros and cons of this nurse I position ere a person , nurseswhat any grea if as practice ing a ral Offic and voluntary dying yet so,ahow it may orts for ssional Not being public discuss the lega so “Wh F Fede rpinn able todo l act, practice? the Australianillega ss your h supp discufor to selfs and profe tenets unde concerns 2016). The ANM t on VE whic tance with individual Centre, ethic ared to this request as on’s rightoccur (The Wheeler very for assis allyasprep euthanasia to address I of code of Families statemenrespect a pers tion of quality orts the me a nurse. person meters to the voice on this issue is critical. educationical parathe about this issue frustrates Your which supp position nurse to ation, identificafor those who has ofaVE. discussing nstopic available ledgcarers inmed eable who feel the need to discuss Federal Office ANMF am constrained I choice and The feel ifery and ion rmin optio the r a pass Midw dete it remains anof know F, 2015).around voluntary euthanasia because as othe on VE which supports and com n Nursing and statement well to any great extent concerns assistance (ANM t by a g of life, do?to selfthe bound right with us. The ANMF’s to ortin ntly a person’s nurse tralia seekI am yet as a or statemen ssionals” to respect act, Supp nurse illegal should be able to do so is curre So what of quality suffer (Ausn, 2015). The ted dying practice Nurses us the support to hcare profe professional ed by identification of ethics and healt determination, codep’s position statement gives of the SA The grou Federatio dges that assis berwho are oblig withi those n for expresses a wish en p. mem the very tenets underpinning st and compassion nurses of life,ate supports writt which do so “Where a person g grou I am a and be oper acknowle act and that s on reque Midwifery in Dyin s tosuffer Nursing and I have the MSc l with dying, nurses should of VE. Reference general (Australian choice the in for assistance RN, al code ever, Choices Susie Byrne legal an illega and VE , 2011; its The statement ley is an educationally professionof the law. How prepared to discuss the Care group s that2015). Federation, convenordying is currently law and ra L Brad Advance also 2008, 2010 also state public that assisted daries of this request as about the t Sand has es do? parameters ley, and p to boun men what medical acknowledges So and articl der ershi (Brad byF lead state , PhD those are Jobliged to the person nurses ANM to and that ) as well position in the broa Research Consultant ANM ionact an illegal well as other options available for the to operate tt, 2013 ist, ANMF “participate Nurses Supporting and knowledgeable organisat professional codes 2013). The within SA ctive ct (LeveI am to member of theDire seeksthe assistance of or view ifery voice Byrne, However, opriate law and ngaethic the d nursi role is ). law.on this subje not (ANMF, 2015). d on the group. The group’s as an appr ng and midw in Dying gnise those boundaries of the writtenalso states is base or(s) healthcare and has professionals” itsJohnChoices stone (2014 nursi lewritten debate ral, I have ralia’s recothatne and artic auth ). that the Susie Byrne This ANMF position statement convenor the s, in gene as Austbroader an-Ja of ensure (ANMF, 2015 public general Meg in nurse gh . VE and arch in the wed throu ralian articles about the group rese is tote“participate role Professor ess, Aust References on request is heard” deba 2011; 2010,revie organisation to issue. 2008,peer 27 in this as an appropriate 1 this debate tives Neverthel for the ANMJ (Bradley,been also e 24, No. e as a nurse quiet on voice andinmidwifery RN, MSc care directhat it is The ANMF leadership has Volum ity the nursingrema Sandra L Bradley is an Byrne, t VE,2013). advance ensure I participat July 2016 commun (ANMF, Care (Levett, 2013) as well rch on 2015). ing is feel abou h heard” written on this subject Research, PhD and Advance my resea 2015), by hold the new Sout r way you nursing ethicist, Australia’s recognised Whicheve Directive Consultant nars on Directive Form (Bradley, debate through as Johnstone (2014). and semi Care I participate as a nurse in this Professor Megan-Jane forums Advance care directives nurses, in general, 4:26 pm views and based 2016 on the my research on advance Nevertheless, Australian This article is22/06/ Australianform). community and has not (Bradley, 2015), by holding remain quiet on this issue. research of the author(s) (SA ACD the new South forums and seminars on been peer reviewed. Form is it VE, Directive about Australian Advance Care Whichever way you feel u anmf.org.a 27 (SA ACD form). Volume 24, No. 1
I consider extraordinary measures to prolong life unnecessary. People should be allowed to die with good palliative care and pain control; but not active measures to end life.
46 September 2016 Volume 24, No. 3
A SIA EUTHANATE THE VOLUNTARY DEB EUTHANA SIA DEBATE
D I FEEL I AM CONSTRAINE IN DISCUSSING THE TOPIC TO ANY GREAT EXTENT BECAUSE IT REMAINS AN ILLEGAL ACT, YET AS A NURSE I AM BOUND BY AND ETHICS OF A CODE PROFESSIONAL PRACTICE VERY WHICH SUPPORTS THE THE TENETS UNDERPINNING CHOICE OF VE.
22/06/2016 4:26 pm July16_Clinical Update_Issues.indd
heighten one’s dignity.
Nursing care is to protect life and to allow a terminal person to die with care and with as little suffering as possible. To die with dignity is a vague statement and very subjective. To be killed does not
Nurses are caring people, and it is unfair and cruel to expect them to kill another person, which VE would require. Language
can be deceptive. To talk about killing people sounds harsh. Voluntary euthanasia sounds nicer, but in reality is the same. The article by Sandra Bradley in the July issue of the ANMJ states the code of ethics and professional practice supports the very tenets underpinning the choice of VE. Sandra did not provide any evidence or commentary to support such a statement. My reading of those statements and codes did not find evidence for her statement. Pain and suffering are hard. Dying can be hard. Good palliative care helps deal with most cases, but not all. However, I do not consider VE the solution. I could kill my dog when it is dying, but human life is more valuable and precious than that of an animal. It needs care and support in its difficulties, not killing. Chris Georg RN, SA
GETTING TO THE CRUX OF THE PROBLEM
THE MORAL SIGNIFICA OF ANTI- NCE MICROBIAL RESISTANCE THE MORA L SIGNIF On 14 April ICANC 2016, ABC News and The 7.30 Report bothOF AN E reported the TIcase of a 46M year old man who died from ICRO hepatitis B BIAL believed to RE have SIS been contra TANCE cted from anothe patient while on dialysis On 14r Apr at a Melbo
Megan-J Johnsto ane ne
Battin, M.P, Francis, L.P, Jacobson, J.A. & Smith, C.B. 2009. The patient as victim and vector: Ethics infectious disease. and Oxford University Press, New York. Fukuda, K. 2014. Foreword. Antimicrob ial resistance: global report on surveillanc e. Geneva, p.ix. WHO,
urne hospit and The il 2016, ABC al (http:/ www.abc.net / 7.30 Rep News .au/7.30/ reporte ort bot d in this case, withhsometh content/2015 ing as small year old the as cas an infected /s4443575.ht e of a foot is not just man 46 blister) are likely become hepm). who died all too commo These media to problem a clinical or technical atitis B has reports focused n. As the . Notably among warned: ‘Afrom believe bee on the Victoria primaril post-antibiotic WHO the difficult them are n con d to hav y trac n Health Departm which commo questions that investigation ted n infectio e ns and era - in poses in regard ent’s AMR into the case patient injuriesfrom minor to: first, how can kill ano B is a notifiab (hepatit - far to promote thefrom Me is whileapocaly on dial best le r being and ptic ysis ‘ruled out’ that disease), which lbourne hos fantasy, wellbeing and protect people’s at a is instead a an ww the real pita man possibil w.a welfare interest very could havebc.n contracted l (httityp:// for the 21st the face of the disease s in et.a (Fukuda century’ con the Referenc u/7.30/ from , 2014 p.ix). source anyten other human health growing threat to and that t/2015/ es the This prospec undersc in this t is Battin dialysis unit and life posed ored s44 the likely , M.P, in was 43575.h a recent UKasreportcase, withapocalyptic superbu Francis, source L.P, Jacob by Tackling of transmiThes an infec e med son, J.A. drug-retm) Departm ssion. gs; second, & Smith sistant ething tosom . infectio ent respond ted foot also reporte on the The ia repo , C.B. how globally beco justly as
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There posed the mor to assist s as are by al chal constitut several reas was redr AMR. It is es an ons why time this lenges ethical AMR ethiessed and that subs silence issue andAMR by nurs cs guideline tantive 22-23 ing orga 21/07/2016 s are4:01 _ANM pm the worl deve J Augus nisation t16_W d. s arou loped orking nd Life_E thics.i Johnstone, M-J. 2016. Editorial: moral significancThe e of antimicrobial resistance and the rise of ‘apocalyptic superbugs’. Journal of Clinical Nursing. Epub of print: doi: ahead 10.1111/ jocn.13350
I write in regard to the article, The moral significance of mail antimicrobial resistance by Professor Johnstone (ANMJ August 2016). Although the case of the 46 year old man who died from Hepatitis B while on dialysis is tragic, we are looking at the problem in reverse. ndd 23
e 24, No.
Surely one should ask why did the patient not respond to the ‘powerful’ antibiotics in the first place. Obviously his antibiotic resistance was already compromised because of the antibiotics that are in the food chain. Until we address the problems in animal husbandry without the use of antibiotics, this problem will not go away. Maria Liew RN, RM, VIC
EUTHANASIA DEBATE My personal ethic is that I have a conscientious objection to any therapy that is harmful either to physical or mental health unless there is evidence allowing a person to conclude that the therapy is the less harmful option. This applies to euthanasia as much as to any other therapy. In South Australia there is no legal barrier to suicide provided that nobody, apart from the person contemplating this, is involved. Changing the law to allow assisted suicide would probably lead to less physical and emotional distress for the one wanting to end their life, but what are the implications for those providing legal assistance? We don’t know because the law has not been changed or tested. Family and friends could continue to be guided by their own conscience or ethical belief, but evidence suggests that any personal ethical beliefs of a nurse will be trumped by any law in place. Only where the law impinges on professional ethical standards would a nurse be entitled to challenge the law and argue entitlement to remain in his or her profession. The general consensus within the literature is that nurses have no right to attempt to impose their personal ethics on patients, but that in some specific cases they do have the right to ‘opt out’ of participating in therapy. However, opting out would not include refusing to refer on. A critical element to consider in the legalisation of voluntary euthanasia is whether the rights of the patient in this regard are so critical to the good functioning of society that the rights of health professionals to act in good faith need to be subordinate to this. My belief is that in some cases, voluntary euthanasia would be the least harmful therapy, but without the acceptance of service providers neither the existing law nor any amendment to the law will be effective or fair on the ultimate person affected. Mick Hawkins Mental Health Nurse, SA anmf.org.au
JOBS FOR AUSTRALIAN NURSES Thank you RN, VIC for having the courage to bring to attention the very real impact foreign nurses are having on the availability of nursing jobs for Australian nurses, particularly in the hospital setting and aged care sector. The number of unemployed, or under employed RNs, both senior and junior is increasing. So why are the number of foreign nurses not decreasing? How many foreign nurses apply for permanent residency status, and remain in their position of employment?
The impact of foreign nurses on Australian nurses and jobs needs to be fully investigated by the ANMF and Australian government before any more valuable Australian nurses leave the profession for good. RN, SA
LETTER OF THE MONTH
ANMJ QUALITY I wish to congratulate you for the quality of our ANMJ. I have been a nurse for 50 years now and a member of the union for as long as I can remember. The journal has improved so much. I particularly enjoyed Volume 24. Articles about Advanced Practice Nursing and the primary/community healthcare in Focus and the various roles performed by nurses made me feel so proud of nursing. I have always loved my profession and will continue to work in the clinical area in acute cardiac nursing for as long as I can. I have reduced my hours and have the luxury of being able to expand my professional reading and study requirements in the extra time I have in a week. This means I enjoy my work even more. Thank you for broadening my knowledge of the work my colleagues do nationally. Margot Maule RN, VIC
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 email@example.com Letters may be edited for clarity and space. September 2016 Volume 24, No. 3 47
Annie Butler, Assistant Federal Secretary
MORAL DUTY TO STAND UP FOR WHAT MATTERS For the first half of this year, the Australian Nursing and Midwifery Federation’s (ANMF) key focus was, necessarily, the Federal Election and our national election campaign, If you don’t care, we can’t care, which endeavoured to position the most important issues for nurses and midwives as the most important issues for politicians and voters. To that end, in my last column (June 2016) I urged nurses and midwives to get involved in the campaign. I argued that with the size of our national membership, ANMF members could make a real difference, and we could bring the community with us. That we needed to ask the community to show they cared and help us make politicians care about the issues of most importance for nurses and midwives and, therefore, for a decent Australian society. I
BUT A TRULY HEALTHY SOCIETY IS THE PRODUCT OF MORE THAN JUST THE ACTIONS OF NURSES AND MIDWIVES, AND OTHER HEALTH CARE PROVIDERS, WITHIN HEALTH SETTINGS. IT IS THE PRODUCT OF INCOME, EDUCATION, EMPLOYMENT, HOUSING, THE WIDER ENVIRONMENT AND SOCIAL SUPPORTS. TO BE TRULY HEALTHY WE NEED TO BUILD CAPACITY IN ALL THE AREAS THAT MAKE US HUMAN. I think it’s fair to say the ANMF’s campaign did that with some success. More than 11,000 people joined our online campaign and over 16,500 joined the ACTU’s on the ground campaign. In concert with campaigns from other unions and grass roots organisations such as GetUp, health for all Australians and the protection of Medicare ultimately became the most important issues for the Federal Election. 48 September 2016 Volume 24, No. 3
The strong community support for the ANMF’s and many other groups’ election campaigns once again confirmed the commitment of the Australian people to Medicare and their confidence in its ability to give all Australians access to adequate, affordable healthcare, irrespective of their personal circumstances.
of asylum seekers detained on Nauru.
But with the Federal Election now finally decided, all MPs and Senators formally declared, and the opening of the 45th Australian Parliament done and dusted, and as the ANMF returns to its ‘everyday’ work to defend, protect and further the interests of nurses and midwives, I find myself reflecting on the extent of our campaign’s contribution to a decent Australian society.
In the last two issues of the ANMJ, my fellow back page co-columnists, Sally-Anne Jones and Maree Burgess, ANMF President and Vice-President, and ANMF member Dr Sandra Bradley, Advance Care Directive Consultant, urged nurses and midwives to participate more broadly in society’s ethical debates and act to address the human suffering occurring beyond the confines of hospital walls.
Of course, the health of a society is vital to its development and success. As outlined by the World Health Organization, better health is central to human happiness and well being… and makes an important contribution to economic progress. It is therefore entirely appropriate, perhaps even a core professional requirement, for nurses and midwives to focus on healthcare and to advocate for better health services for their citizens, as many did in our election campaign. But a truly healthy society is the product of more than just the actions of nurses and midwives, and other healthcare providers, within health settings. It is the product of income, education, employment, housing, the wider environment and social supports. To be truly healthy we need to build capacity in all the areas that make us human. What are the responsibilities of nurses and midwives in this regard? This is the question I have been pondering, what should the extent of nurses’ and midwives’ contribution to developing a truly healthy society be? While the positive contribution of nurses and midwives to their patients’ lives and improving the health of the community is undeniable, if building a truly healthy society requires us to contribute to the development of all areas that make us human, I think we still have much work to do. Since the election we have witnessed a series of deeply disturbing events both internationally and domestically. From the brutal and barbaric attack on innocent people celebrating their national day in Nice, France to the heartless assault on an elderly nursing home resident in South Australia, the disgraceful treatment of juvenile detainees in NT, and the horrific abuse
Nurses and midwives have rightly condemned these events. But as professionally licensed nurses and midwives is it sufficient to stand by as witnesses to these events and express our outrage or do we have a moral duty to act?
I could not agree with them more. In fact, as health professionals we have a moral duty to do so. The mechanisms that grant us registration explicitly require this of us. When we renew our registration each year, or gain it for the first time, we agree to uphold the codes determined by the Nursing and Midwifery Board of Australia (NMBA) and thus the values of our professions. The NMBA’s codes of ethics state that nurses and midwives: …contribute to and support strategies preventing or minimising the harmful effects of economic, social and ecological factors such as crime, poverty, poor housing, inadequate infrastructure and services, and environmental pollution and degradation… (NMBA, 2013, Code of Ethics for Midwives) And that, …acting through [our] professional and industrial organisations and other appropriate authorities, [we] participate in developing and improving the safety and quality of healthcare services for all people. This includes actively promoting the provision of equitable, just and culturally and socially responsive healthcare services for all people living, or seeking residence or asylum, in Australia… (NMBA, 2013, Code of Ethics for Nurses) Our duty is clear. And through the collective strength that is the membership of the ANMF we can continue to work on fulfilling our entire professional responsibilities by acting to alleviate suffering wherever it occurs. Reference NMBA, 2013, Code of Ethics for Midwives, available online at: www.nursingmidwiferyboard.gov.au
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September issue of the Australian Nursing & Midwifery Journal