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Australian Nursing & Midwifery Journal Volume 21, No. 9. April 2014

Flying under the radar: The health of refugees and asylum seekers in Australia www.anmf.org.au

Australian Nursing & Midwifery Journal - www.anmf.org.au

Editorial Lee Thomas, AnMf Federal Secretary While last month we fondly farewelled Assistant Federal Secretary Yvonne Chaperon, this month we warmly welcome Annie Butler to the role. Annie has a wealth of industrial and professional experience after working at the NSWNMA for 11 years. She has also worked in the university sector and has a vast amount of clinical experience under her belt. Annie’s expertise and determination will make her a great asset to the Federal Office, the ANMF and to the members. I, along with the rest of the office, am pleased to be working with Annie and look forward to a great working partnership with her now and into the future. As I write this editorial the terms of reference for the Royal Commission into union corruption has been released. While there are five trade unions named to be investigated, the terms of reference are broad and wide-ranging and will therefore include the examination of all unions’ affairs and the businesses associated with them. It’s fairly evident from these terms that the inquiry will be little more than a witch hunt set to destabilise and weaken the public’s trust in the union movement. Tony Abbot’s emotive language such as ‘good unions have nothing to fear’ is just another ploy to weaken and fragmatise the collective, all at a time when the government is set to attack workers’ rights and potentially dismantle the social safety net, including Medicare.

On 25 April many of you will be at dawn services around the country remembering our service men and women for ANZAC day. Each year at this time the ANMF places a wreath at the Australian Service Nurse Memorial, Canberra, in memory of the Australian nurses who bravely looked after the sick and injured during both World Wars, all conflicts and peace keeping missions since. It is also at this time we particularly remember our South East Asian Treaty Organisation (SEATO) nurses who volunteered to serve in Vietnam at the time of the war. Like Vietnam veterans many of them experienced the traumas of conflict and have consequently been affected by the same physical and mental conditions as their counterparts. However, unlike those who served in the military, our SEATO nurses do not have access to veteran’s entitlements because they are viewed by our government as civilians. The SEATO nurses with the support of the ANMF have been campaigning for some time to have them recognised under the Veterans’ Entitlements Act. Recently the nurses gained the support of the RSL, which is a massive step forward in gaining the entitlements they so rightly deserve. A full report about SEATO nurses and other nurses that served during the wars can be read on page 21. Lest we forget.

As you are all well aware the ANMF, as with most unions, is here to protect the rights of its members. We will continue to fight for our nurses and midwives no matter the political climate or agenda. The inquiry report is due with the government by 31 December. I urge you as union members to stay informed on the matter and we will report to you any developments as they occur.

PAGE 1 April 2014 Volume 21, No. 9.

ANMF Directory Australian Nursing & Midwifery Federation National Office www.anmf.org.au Canberra

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

Melbourne & ANMJ

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

Federal Secretary Lee Thomas

Assitant Federal Secretary Annie Butler


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


The Media Company, Jana Gungor Phone (02) 9909 5800 Fax (02) 9909 5810 Email jana.gungor@themediaco.com.au

Australian Capital Territory

Branch Secretary Jenny Miragaya Office address Unit 3, 36 Botany Street, Phillip ACT 2606 Postal address PO Box 1995, Woden ACT 2606 Ph: (02) 6282 9455 Fax: (02) 6282 8447 E: anmfact@anmfact.org.au

Northern Territory

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

South Australia

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


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

Design and production Design: Origin of Image (Ooi) Pty Ltd Printing: AIW Printing Distribution: D&D Mailing Services

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

New South Wales

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



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


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

Western Australia

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

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


Source: BCA verified audit, September 2013

Contents Volume 21, No. 9. News 5 World 17 Industrial 18 Lee 19 Ethics 20


Page 5

Anzac Day

Page 21





Issues 28

New Assistant Federal Secretary welcomed

Reflections 29 Research 30 Wellbeing 31 Clinical Update


Focus 36 Clinical View


Page 29

Mentoring in nursing: an invaluable exchange


Page 36

Primary & Community Health Care

Feature: Flying under the radar


Calendar 52 Mail 53 Sally 56

Page 22

The health of refugees and asylum seekers in Australia

PAGE 3 April 2014 Volume 21, No. 9.


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News New Assistant Federal Secretary welcomed

Graduate nurse jobs could be hit by 457 visa review There are concerns the federal government’s review of the 457 visa program could make it harder for Australian graduate nurses to find jobs. The Australian Nursing & Midwifery Federation (ANMF) campaigned strongly in support of new 457 visa laws requiring employers to prove they have seriously attempted to recruit local nurses before hiring nurses from overseas. The laws came into effect in November last year but the federal government has now announced a review of the program. ANMF Federal Secretary Lee Thomas said it was concerning. “We had a situation where large numbers of nurses were coming to Australia on 457 visas, yet graduate nurses were struggling to find work. The new laws addressed that issue so to have the government now reviewing these important changes to the 457 visa program is concerning.”

Assistant Federal Secretary Annie Butler and Federal Secretary Lee Thomas

The ANMF Federal Office has a new Assistant Federal Secretary, Annie Butler.

in research projects and then in undergraduate nursing programs as a sessional lecturer and then as a program facilitator.

Ms Butler comes to the position with a broad range of experience from the clinical, professional and industrial arenas.

Ms Butler said she was thrilled to be appointed to the position and looked forward to working with ANMF Federal Secretary Lee Thomas and the rest of the office on a number of key industrial and professional matters. “I look forward to working with Lee on a range of issues on a national scale that will help better the professions.”

For the past 11 years Ms Butler worked at the New South Wales Nurses and Midwives’ Association (NSWNMA) as a Professional Officer until 2011 and then as an Organiser and Lead Organiser until her appointment to her new position at the Federal Office. Ms Butler spent the first decade of her career working as a registered nurse in the acute public hospital sector, community health sector and on health education projects. Following this, and prior to joining the NSWNMA, Ms Butler spent several years in the university system participating

ANMF Federal Secretary Lee Thomas said she was pleased that Ms Butler had been appointed to the position and welcomed her to the Federal office family. “I am delighted Ms Butler has been appointed to the position. Her skills and experience make her an asset to the organisation.”

Ms Thomas said the federal government needed to guarantee the review would not affect the employment of graduate nurses. “The ANMF supports a strong permanent migration program and recognises the importance of temporary migration programs to meet genuine short term market needs, but the employment of graduate nurses cannot be compromised in the process.” Ms Thomas said the ANMF would fight any move to scrap the requirement for employers to recruit locally before looking overseas. The review of the 457 visa program is expected to be finished by mid-2014.

Ms Butler commenced her new role on 31 March 2014. PAGE 5 April 2014 Volume 21, No. 9.

News Action needed against antibiotic resistance

No one is flu-proof

Australian Public Hospitals are reporting high rates of Staphylococcus aureaus, (golden staph) bloodstream infections, acquired through the health care system, according to a report released by the National Health Performance Authority last month.

It is estimated that about a quarter of the Australian population could face an increased risk of severe complications from influenza this season. The Influenza Specialist Group (ISG) warns many of the people at risk because of an underlying medical condition, are in younger age groups and consider themselves flu-proof, with ISG data showing only 30-40% of people in this high risk category are being immunised.

The report, which showed a big difference in the rate of infections contracted in public hospitals, indicated that there were 1,724 cases of the potentially deadly Staphylococcus aureus bloodstream infection acquired through public hospitals during 2012-13.

The annual influenza vaccination program got underway across Australia last month with free vaccinations for groups at an increased risk of influenza complications.

While most cases are treated with antibiotics, there are more serious antibioticresistant strains. Estimates suggest 20 to 35% of people who experience health care-associated S. aureus bloodstream infections die from this or a related cause. “It is important to remember that every case of health care-associated S. aureus bloodstream infection is preventable,“ Performance Authority CEO Dr Diane Watson said. NPS MedicineWise CEO Dr Lynn Weekes said the data highlighted the importance of both professionals and other individuals taking responsibility to stop the spread of antibiotic-resistant bacteria. “We know that without sustainability changing our behaviour and attitudes when it comes to using antibiotics wisely, we are potentially facing a future in which we return to the pre-antibiotic era where the simple infections cannot be treated with antibiotics. “Health professionals and individuals alike have a responsibility to preserve the miracle of antibiotics – and we must step up and act now or risk losing these miracle drugs forever.” Meanwhile the Griffith Health Institute has been commissioned to create a detailed framework for Australia’s future national system for the surveillance and reporting of antimicrobial resistance (AMR) and antibiotic use. Research lead for the framework Professor Ramon Shaban said the main concern was that antibiotics used to treat infections individuals acquired following increasingly routine surgical procedures, such as hip/ joint replacements were rapidly running PAGE 6

out. “This problem has two main facets, the growth and adaptation of microbes becoming resistant to antibiotics and the lack of new or pipeline antibiotics.” Professor Shaban said modern medicine and health care had mastered techniques to treat complex conditions to now only be thwarted by infections that were unable to be treated. “Individuals who acquire a multi-drug resistant, health care-associated infection face a bleak future – we no longer have antibiotics to treat them.” Professor Shaban said the first step was to establish systems of data gathering and reporting on patterns of AMR and antibiotic use coordinated through a single national coordinating centre.

Those at greater risk include people with heart conditions, asthma and respiratory conditions, type 1 or 2 diabetes, kidney disease, impaired immunity and neuromuscular disorders, or those who smoke, are obese, pregnant, aged over 65, or of Aboriginal or Torres Strait Islander background. This season’s dominant flu strain in the United States was the H1N1 virus, the same one that struck in 2009, with high rates of hospitalisation and death among young adults and the middle aged. About 60% of those who died from influenza in the US this season were 24 to 64 years old, compared with 18% last season. ISG chairman Dr Alan Hampson said that while influenza was often most severe in the elderly and very young, the ages most affected varied depending on the circulating viruses. “The H1N1 pandemic virus has consistently had its greatest impact in the younger adult group, which is a concern because a recent ISG survey has again shown that people under 65 years, with various underlying medical conditions, are still not being vaccinated and are not aware of the risks they face.” Influenza causes more than 18,000 hospitalisations and 1,500 deaths in Australia each year and costs the health care system $85 million dollars.

News Strength in numbers midwife, personal care assistant and student for creating the union we are today. There is strength in unity and in numbers and that strength is needed now, more than ever.” Ms Thomas said the federal government had set a clear agenda to attack unions and workers’ entitlements such as penalty rates. The attack on unions was also signalling a return to WorkChoices through the Productivity Commission’s review of the Fair Work Act, Ms Thomas said. “Far from being dead, buried and cremated, as Tony Abbott said, it seems WorkChoices is being resurrected under the cover of the Productivity Commission.”

Federal Executive celebrate ANMF membership milestone

The Australian Nursing & Midwifery Federation (ANMF) has grown to almost 233,000 members, cementing its place as one of the largest and most influential unions in the country.

The milestone was marked with a cake when state and territory secretaries met in Melbourne last month. ANMF Federal Secretary Lee Thomas said almost 9,000 new members joined the union last year. “I commend every nurse,

Don’t wait until it’s too late Hospital funding in Victoria will be linked to the implementation of a new state government strategy to promote advance care planning.

“Many avoid the discussion and often it’s left too late because a loved one becomes too ill to share their wishes about the level of health care and quality of life they want,” said Mr Davis.

As a condition of funding, patients will be encouraged to create advance care plans detailing the type of medical care they would want during a serious illness, such as cancer or dementia.

The new strategy is designed to help health workers work with patients and families to discuss the issue and ensure the patient’s wishes are honoured.

“Talking about end-of-life care and treatment that loved ones want during a serious illness can be a challenging and highly sensitive topic,” said Victorian Health Minister David Davis.

Ms Thomas said the view by the federal government that penalty rates were bad for business was a slap in the face for Australia’s nursing and midwifery workforce. “Australia is already experiencing a nursing crisis, with a shortage of 109,000 nurses by 2025. How can we expect to retain and recruit new nurses and midwives if the government now wants to take away their penalty rates and shift loadings?” Ultimately the health care delivered to everyday Australians will suffer as a consequence of a dwindling nursing and midwifery workforce, said Ms Thomas. “Penalty rates and other allowances are critical issues for our members and together, we will fight to save them.”

The new strategy, Advance care planning: have the conversation: A strategy for Victorian health services 2014-2018, will see advance care plans take into account future conditions and allows patients to appoint a substitute decision-maker. Implementation has been tied to hospital funding to ensure such plans are embedded in clinical practice.

“By supporting our health services and health workforce to implement advance care planning we can better support patients and their families at an incredibly difficult time,” Mr Davis said. PAGE 7 April 2014 Volume 21, No. 9.

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News Doing what we can to improve environmental sustainability By Elizabeth Reale, Federal Professional Research Officer and Elizabeth Foley, Federal Professional Officer The ANMF Victorian Branch held its second annual Health and Environmental Sustainability Conference at the Melbourne Convention Centre last month. ACTU President Ged Kearney opened the conference with a story from Nobel Peace prize winner Wangari Maathai about a hummingbird. In the face of a massive bush fire, all the forest animals stand by helplessly as the fire devours their home. All except one. A tiny hummingbird flies backwards and forwards from a stream, taking beakfuls of water to drop on the fire. The larger animals watch and chide her: ‘What are you doing? This fire is big and you are too tiny to put it out - your efforts are futile’. The hummingbird replies, ‘I’m doing what I can.’ This story about ‘doing what I can’ sets the tone for the rest of the conference. Keynote speaker, University of San Francisco’s Professor Barbara Sattler spoke about human health being inextricably linked to the quality of the environment. So close is the tie, the World Health Organization (WHO) acknowledges quality of the environment as a key determinant of health.

ICU nurse Ros Morgan from Monash Health reported changes to waste and recycling practices initiated at Dandenong Hospital. Ros has been involved with waste segregation and recycling, implementing recycling of PVC IV bags and single use steel instruments. She has also been behind an effort to make the hospital polystyrene free, replacing polystyrene cups in patient and staff areas with reusable cups. These initiatives significantly cut the amount of waste going to landfill, enable reuse of materials, and save the organisation money. Barwon Health’s Bronwyn Alymer spoke about her workplace’s commitment to sustainability and their extensive recycling program. Their biggest project has been the introduction of Closed Loop Organics composting. The health service provides 3000 meals per day and was sending 54 tonnes per year of food waste to landfill. The composting system now produces organic compostable soil treatment from all the service’s food waste, which local farms use. They have saved around 50 tonnes of CO2 emissions per year by diverting food waste from landfill to composting. Koo Wee Rup Regional Health Service’s Aileen Thoms is working to reorientate the service to be health promoting and community focused,

Speaker Ros Morgan from Monash Health

taking it from a medical to a social-ecological model. They have built a community garden, a Men’s Shed, installed solar panels, introduced waste segregation and recycling programs, and have a strong focus on collaboration and bringing the community together. The barriers to achieving environmental sustainability and strong action on climate change may seem insurmountable. However nurses and midwives are responding with practical and effective initiatives which are making headway in terms of waste and emissions reductions, cost savings and building community in their organisations. Like Ms Kearney’s hummingbird, they are doing what they can to improve sustainable practices.

Most parents fail to see a problem in overweight kids Two-thirds of parents of overweight children described their children as ‘proper weight’ and some expressed their concern about their children becoming underweight, in a major survey of over 16,000 children across Europe. The research was presented at the International Congress on Obesity in Malaysia last month, which involved over 1000 obesity experts from around the world, including Australia.

findings are concerning as parents do not recognise common weight deviations in children. “Repeated growth monitoring of children in health care and identify weight deviations, will raise parent’s awareness, and give them a possibility to act against threats to their children’s health.” Latest figures show almost a quarter (22.8%) of Australian children between 5 and 17 years of age are overweight or obese. Around half the Australian adult population (49.7%) are also overweight or obese.

Researcher Dr Staffan Marild from Gotenburg University told the conference the PAGE 9 April 2014 Volume 21, No. 9.

News Equal pay for women would boost the economy The Australian economy would be boosted by around $93 billion if women were paid equal wages to their male counterparts, according to the Women’s Electoral Lobby. Reporting rules on gender equality were introduced in 2012, requiring employers with over 100 staff to report on 30 or more items related to gender pay and employment. The Abbott government is considering to roll back the requirements in order to cut red tape and save businesses around $9 million. The Women’s Electoral Lobby (WEL) believes the move is short sighted. WEL Chair Melanie Fernandez said research by the National Centre for Social and Economic Modelling (NATSEM) showed the economic benefit of addressing the gender pay gap far out-

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News weighed the cost to business. “NATSEM has modelled the impact of the equal pay gap on women’s working hours and found that if women earned the same as men, the impact on their hours worked would see GDP grow by around $93 billion.” Ms Fernandez said research by Access Economics also demonstrates the economic benefits of having more women in the workforce. “Access Economics has estimated that halving the gap between men and women’s participation in the fulltime workforce would result in a 2041-42 per capita output of $3,385, equivalent to a gain of $98.4 billion in real output.” Ms Fernandez said most employers had already completed their reporting so scrapping the scheme was a wasted opportunity. “It would be crazy to abandon these reporting rules now when business has already done the hard work and we are just about to receive benchmark data to give them in return.”

Ms Fernandez said the government had promised to consult widely on any changes to the gender reporting process but had flagged these changes with very little time for consultation. “We must do better. If the government insists on rolling back gender reporting rules it must outline how it will close the gap in gender equality and facilitate real change in our workplace.” Australian Council of Trade Union president Ged Kearney agrees breaking the glass ceiling and ensuring pay equity and representation in leadership positions was important and that much progress was still to be made. “We know that despite great progress fought for by working women over the decades, women today still face barriers in the workplace. “These include a lack of flexibility to accommodate caring commitments, pregnancy discrimination, higher rates of casualisation and fewer opportunities for training and promotion.”

Ms Kearney said unions are fighting to address these issues but the bedrock of fairness for women workers is a living minimum wage on which women can support themselves and their families with dignity. “Australians are lucky that we have secured a minimum wage that means a full-time worker doesn’t have to work three or four jobs to cover food and rent, but each year the gap between low-paid workers and the rest of the workforce widens.” Ms Kearney said bridging the pay gap is particularly important for women since they account for nearly 60% of the 1.5 million Australian workers reliant on the minimum wage. “Ensuring our minimum wage keeps pace and prevents low paid workers from falling further and further behind is key to ensuring fairness for all Australian women.”

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PAGE 11 April 2014 Volume 21, No. 9.

News Helping nurse graduate coordinators

Update your details

In the four years since it was formed, the Victorian Graduate Program Coordinators Network has grown to include members from right across the state. The group provides a forum for both public and private graduate program coordinators to talk to each other about issues around recruitment, retention and education for graduates.

Nurses and midwives are being urged to update their email contacts with the Australian Health Practitioner Regulation Agency (AHPRA) leading up to annual registration renewals.

“We’ve got a broad network base. We currently welcome anyone in division one graduate programs in midwifery, mental health and general programs, both regional and acute, as well as services like RDNS,” said Victorian Graduate Program Coordinators Network chair Owen Billington. Before the network was formed, graduate coordinators found it very difficult to get feedback about specific problems they might be facing, said Mr Billington. “But now even between meetings they are able to email the group and say: can anybody help me with this particular issue, or has anyone faced this, or has anyone got solutions to this problem already? So they find the networking aspect very helpful.”

Mr Billington said there tends to be a lot of movement in the educational workforce so the network is particularly valuable for people who are new to the role. “There is not often a great deal of preparation for positions for graduate education so it’s a resource for people to say well I’m new in the job, what generally do I need to do, how do I go about getting involved in a nursing expo or what processes am I putting in place for recruitment and reporting and those kinds of things.” Mr Billington said members find it useful to be able to provide practical support for one another with answers to those kinds of problems. “As well as the overarching objective of the group, which is to contribute towards better outcomes for graduates.”

Nearly 354,400 nurses and midwives across Australia are due to renew their general or non-practising registration with the national board by 31May. AHPRA is encouraging all nurses and midwives to update their email addresses with the board so that they don’t miss out on reminders to renew their registration. To update your contact details go to: www.ahpra.gov.au. For more information go to: www.nursingmidwiferyboard.gov.au or enquire on: 1300 419495

The Victorian Graduate Program Coordinators Network meets quarterly at rotating hospital venues. Contact Owen Billington for more information at: owen. billington@healthscope.com.au or phone: (03) 8431 3490.

Nurse response to a natural disaster By Karen Hammad

A Flinders University study looking into the response of nurses working in the emergency department during a natural disaster is looking for participants. With the impact of disasters increasing in frequency worldwide, no community is immune. Recent flooding and bushfires in Australia and the experience of our neighbours with natural disasters in New Zealand and Philippines serve as a reminder of the devastation caused by disasters and the impact on the health care system. Hospitals play a vital role in the response to disaster events within a community. People affected by disasters will present to the nearest hospital often before a coordinated response from the emergency services PAGE 12

has been instigated. Hospitals have the potential to become overwhelmed equally by acutely unwell or injured patients and walking wounded, media, curious onlookers and friends and relatives. Additionally, hospitals may also be directly impacted by the event, affecting infrastructure creating substandard working environments and necessitating evacuation. Working in the emergency department (ED) essentially places staff at the forefront of the hospital response to a disaster. Nurses working in the ED play an important role in the care of patients presenting to the hospital for treatment following a disaster. However, current literature suggests a low level of disaster preparedness, confidence and knowledge and discusses limitations in disaster training and education for this group.

A new research study through Flinders University to address the preparedness of nurses during such a response is being conducted. Nurses (of any specialty) who have worked in the ED during a disaster response within the past five years are required for the study. Nurses interested in being involved and sharing their experience will be required to participate in two interviews via Skype and must be fluent in spoken English. For further information about this study or to register your interest contact: disaster.study@flinders.edu.au A better understanding of the experience of nurses who have worked in these circumstances will help to inform preparedness of this group and may guide policy and practice to enhance future disaster response in the ED setting.

News Nurse led clinic a success

From (L) Dr Samarth Rao, nurse Jenny Leung, nurse Terri Budge, nurse practitioner Saroja Nazareth and head of liver service Professor Wendy Cheng

A nurse led clinic is successfully improving the lives of those with cirrhosis of the liver and other hepatic diseases. The clinic, based at the Royal Perth Hospital, is led by nurse practitioner Saroja Nazareth. According to Ms Nazareth, the nurse practitioner role and the clinic was set up due to the large increase in hepatitis patients. “When I joined the service in 1999 we treated 20 to 40 patients. By the time I got my qualification as a nurse practitioner in 2005 we were treating 150-200 patients and the waitlist was huge.” As a consequence the nurse led clinic was launched in 2010 and now includes a telehealth service, which is the first of its kind in Australia. “We now have many nurse led clinics. Some of them run by clinical nurse consultants or senior nurses and I oversee the whole service because

as a nurse practitioner I can prescribe, order pathology and refer as well. It’s like a one stop shop - it works really well,” Ms Nazareth said. Benefits of the clinic to patients include early detection of liver cancers, when curative treatments are possible, and support and follow up for patients with lengthy and difficult treatments for viral hepatitis. “We needed to improve access to treatment and by having nurse led clinics allows for more appointments so that patients can be seen. Patients therefore get into treatment much earlier rather than being put on long waiting lists. We can also treat hepatitis C and B as a chronic disease and put these patients under chronic disease management, which is what we need to be working towards” Ms Nazareth said. Ms Nazareth said patients were also very satisfied with the service. “We have done many patient satisfaction surveys and they all come back as really positive.”

One of the reasons why the service had remained so successful was because of the collaboration and backing of the medical staff, Ms Nazareth said. “To be able to lead all these initiatives you must have a very strong supportive medical team. You must have very good medical backing. The head of my service is Dr Cheng who is a great mentor and supporter of nursing initiatives and nurse led programs. She is the one who has been championing the nurse practitioner role in Western Australia and Australia.” Ms Nazareth said the success of the nurse led clinic and the nurse practitioner role was proof that such initiatives work to ensure patients’ needs are met under tight health budgets and increasing demands. “I am very passionate about the role and extending the role because I feel that it really improves the quality of care we give our patients.” PAGE 13 April 2014 Volume 21, No. 9.

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News Initiative for e-mental health A new national initiative to encourage the uptake of e-mental health resources in primary care is being conducted. The initiative, e-Mental Health in Practice (eMHPrac), is a collaborative project between the Queensland University of Technology, the Australian National University and Black Dog Institute.

Funded by the Australian government, representatives from the universities plan to work with mental health and general practice nurses as well as other relevant allied health workers to deliver training and promotional material specific to the use of e-mental health resources. Training will include face-toface workshops, online training modules, an online group and webinars.

New app targets remote and rural bullying A new smartphone and tablet app targeting bullying has been launched by CRANAplus Bush Support Services.

There are three award categories including individual, team and organisation. The awards aim to find aged care professionals who demonstrate excellence, leadership and innovation. “People working in this sector provide emotional support to their clients and families, as well as delivering services in innovative ways to help preserve the independence and dignity of older Australians,” said HESTA CEO Anne-Marie Corboy.

The app provides definitions and examples of bullying as well as resources people can tap into if they need help, said Dr Wilson. “It also provides a description of some of the psychological and emotional consequences of being a victim of bullying.”

The chronic nature of the work, demands on practitioners, long work hours and difficult environmental conditions also contribute to the issue, said Dr Wilson. “I think all those factors really contribute to the potential for bullying

Search for best in aged care Do you know someone working in aged care who deserves to be recognised for their leadership and dedication? Then nominate them for the 2014 HESTA Aged Care Awards, and they could share in a $30,000 prize pool.

The app was designed in response to the sheer number of calls to the phone counselling line from remote area health workers struggling with the issue, said Bush Support Services senior clinical psychologist Dr Annmaree Wilson. “We really felt the need to respond in a positive and proactive way because of the large percentage of callers on the line who want to talk about being bullied.”

Dr Wilson believes isolation plays a big part in the prevalence of bullying in the bush. “I think in larger regional and urban settings there is more opportunity to debrief and discuss and think through with other people things that might be going on, whereas I don’t think there’s always that opportunity in the rural and remote context.”

Nurses and allied health workers will be annually surveyed in relation to the initiative. Additionally, the views and experiences from a wide range of nurses and allied health workers across Australia will be sought. To read about or participate in the 2014 survey go to: https://mentalhealth.anu.edu.au/survey

“We are keen to hear about the work of outstanding individuals as well as the work of health teams and organisations that have found new ways to deliver services that enhance the wellbeing of older Australians.” For more information about the awards or to nominate go to: www.hestaawards.com.au Nominations close on 30 May 2014. to occur, people get stressed and they don’t have good coping strategies.” The CRANAplus Bush Support Services app is free and available in both android and iphone versions.

PAGE 15 April 2014 Volume 21, No. 9.

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World Nurse apprenticeships WHO recommends halving daily sugar intake to fight obesity launched in UK Health care assistants already working in hospitals in the UK will be able to skip doing a traditional nursing degree and train on the job instead.

The World Health Organization (WHO) wants to halve the recommended daily sugar intake in an effort to fight obesity and tooth decay.

The UK government has announced a new plan for degree-level apprenticeships, which it says will boost the number of nurses. UK Skills Minister Matthew Hancock said the program will be targeted at the brightest and best health care assistants who have proven they can give high quality care to patients, but do not have the academic qualifications necessary to get a nursing degree. “We want the new norm to be for young people to either choose to go to university or begin an apprenticeship. This announcement is another step forward in making this case.”

The UN agency has maintained the current 2002 recommendation that sugars should make up less than 10% of total energy intake per day. However, its new draft guideline on sugar intake recommends a reduction to below 5% of total energy intake per day as preferable.

The UK government has given the go ahead for a working group to develop a brand new apprenticeship standard, which was one of the recommendations in the review carried out after the Francis Inquiry into patient neglect and abuse at the MidStaffordshire NHS Foundation Trust. UK Health Minister Dr Dan Poulter said NHS and social care support workers have a long history of delivering high quality, compassionate care to patients and their families. “This new apprenticeship will help health care support workers who have a demonstrated track record of delivering high quality care to get on in life, and break through the glass ceiling that has in the past prevented people from poorer backgrounds from entering nursing and other health care professions.” As part of the requirement that all new nurses must have a nursing degree, the apprenticeship will have the degree at its core. The UK government says the group who are developing it will be looking at how ensuring that on completion, apprentices will have all the skills, knowledge and confidence they need to perform nursing duties well and confidently, meeting their employer’s and professional registration requirements.

That means adults with a normal body mass index (BMI) should eat less than six teaspoons of sugar per day, compared to the current recommendation of less than 12 teaspoons per day. The suggested limit includes all sugars that are added to food or beverages by food manufacturers, including fructose and glucose, as well as sugars that are naturally present in honey, syrups, fruit juices and fruit concentrates. The WHO warns that much of the sugars consumed today are ‘hidden’ in processed

foods that are not usually seen as sweet. For example, one tablespoon of tomato sauce contains around one teaspoon of sugar, while a single can of soft drink contains up to 10 teaspoons of sugar. The WHO says the draft guideline was formulated based on analyses of all published scientific studies on the consumption of sugars and how they relate to excess weight gain and tooth decay in adults and children.

Better educated nurses equals fewer deaths A study carried out across nine European countries found that a 10% increase in the proportion of nurses holding a bachelor degree is associated with a 7% decrease in the risk of death. Researchers from the University of Pennsylvania School of Nursing in the USA collected data from more than 420,000 patients in 300 hospitals across nine European countries for the study. The study also found that every extra patient added to a nurse’s workload increases the chance of surgical patients dying within 30 days of admission by 7%. In hospitals where 60% of nurses had bachelor degrees and nurses cared for an average of six patients, the patient mortality rate was 30% lower than in hospitals where only 30% of nurses had bachelor degrees and

nurses cared for an average of eight patients. “This study consolidates the growing quantity of proof from different regions of the world and confirms what nurses already know – that quality nursing education and safe staffing levels have a direct impact on patient survival,” said International Council of Nurses president Judith Shamian. “While this study was carried out in Europe, the lessons learned are similar to findings from other countries and applicable in all countries and all settings,” said Ms Shamian. Lead investigator for England on the study, Professor Anne Marie Rafferty said the evidence demonstrates that it is not only quantity but the quality of the workforce that counts. “Hospitals should take notice because when budgets are tight, cutting back on nurses is often the first step, but the study has shown that this can have disastrous consequences for patients.” PAGE 17 April 2014 Volume 21, No. 9.

Industrial Debbie Richards, Federal Industrial Research Officer

Lies, damn lies and the federal government’s industrial relations agenda to characterise conditions leading to the massive job losses. We expect to hear much more of this talk in the coming months, (and years), continuing the theme as the government sets the scene to introduce its so called labour market reforms which is simply code for cutting wages and conditions. It is clear from the outset that recommendations from the plethora of government reviews currently underway or in the pipeline will pave the way for the government to push their agenda which includes a wide ranging attack on unions, employee wages and conditions including penalty rates and allowances, your rights at work and the ability of unions to negotiate enterprise agreements.

When Tony Abbott blamed the so called ‘over generous’ wages and working conditions of SPC workers for the company’s problems he was called to account by one of his own government members, Sharman Stone. The company also responded quickly, stating its problems had nothing to do with employee conditions. Around the same time, the Employment Minister Eric Abetz announced that Australia was risking a ‘wages explosion’. This too was contrary to the facts. Recent ABS data shows that overall wages growth was only 2.5% for the year to December 2013, the lowest annual increase since 1997 when this information was first collected. The government’s response to announcements by Ford, Holden, Toyota, Alcoa and now Qantas continues this pattern of blame, pointing the finger at employees’ wages and conditions and using terminology such as unsustainable, uncompetitive and inflexible PAGE 18

Already the government is supporting business groups in advocating changes to modern awards to reduce the safety net for wages and conditions. The government’s submission to the ‘Four year Review of Modern Awards’ to be conducted by the Fair Work Commission (FWC), suggests that it will be targeting hours and days of work, overtime, penalty rates and allowances and asks the FWC to consider whether the additional pay provided for working particular times and days is appropriate. It also urges the FWC to take into account “the impact of employment costs on employers’ decision to hire workers over the next four years”, and consider reducing the content of modern awards. If the alarm bells are not already ringing, proposed amendments to the Fair Work Act introduced to Parliament in February this year provide further confirmation of the government’s agenda to target wages and conditions. Included among a raft of amendments are changes to the flexibility term in awards and agreements and to the enforcement and termination of individual flexibility arrangements. This is just another means to achieve an end which is to cut pay and conditions. The amendments would allow individual flexibility arrangements to buy out penalty rates and overtime for no monetary

compensation at all. That is, provided the arrangement is done under the guise of greater flexibility, the current ‘better off overall test’ will be satisfied and the criteria under the legislation met. The amendment also seeks to remove any capacity for the negotiating parties to an enterprise agreement to limit the range of matters that can be covered by an individual flexibility term. It will be a requirement that flexibility terms in Agreements cover, (at a minimum), arrangements about when work is performed, overtime rates, penalty rates, allowances and leave loading. If all this sounds familiar, it is. It may not be ‘WorkChoices’ by name but if it quacks like a duck… While the terms of reference for the government’s reviews are not publicly available as yet, the FWC is about to commence hearings in relation to the Award Review. The ANMF will be closely involved in this process, particularly as the modern Nurses Award and the Aged Care Award operate as a safety net of wages and conditions for nurses and carers working in the public and private sectors in Victoria, Northern Territory, Australian Capital Territory, and the private sector in all other States. Most nurses are covered by agreements negotiated between the ANMF and the employer however the wages and conditions contained in Awards are still very relevant to agreement making for nurses in the national system, as an agreement will not be approved by the FWC unless employees will be ‘better off overall’ under the terms and conditions of the agreement as compared to the Award. The Nurses and Aged Care Awards currently includes specific arrangements around rostering, hours of work, overtime, shift work, weekend work and public holidays that reflect the seven day, 24 hour operation of the health industry. Health industry employers have already, in the ‘two year Review’ of Awards, argued to reduce entitlements to penalty rates and other allowances and it is expected there will be further applications to do so under this exercise. In the current environment ANMF members and other union members will be facing a tough battle to defend long standing entitlements. This will be a long hard struggle but there is an awful lot to lose.

Lee 4am reflection There is a high pitched squeal in my right ear. It’s a slightly familiar noise but... ah yes it’s the alarm, but why is it going off? It feels like the middle of the night... I roll over and hit snooze open my eyes and it’s very dark. Suddenly I remember I’m on a 6.15 flight to Sydney - it’s 4am. I sit on the side of the bed and in my sleepy stupor my mind wanders to all the shift working nurses and midwives at work right now. Most nights would be busy irrespective of the area in which you work. This mad idea that nurses sit down all night and knit or hand embroider table cloths is offensive. Sadly it is a view held by ignorant people who have never done a night shift or been a patient. It’s a position often put by employers during bargaining in a poor attempt to drive down the night duty penalty rate again - how offensive. I can’t sit on the side of the bed much longer - I’ve got to get moving. I don’t think much more about anything (except getting to the airport) until I’m ready to board my flight. It’s a packed flight with no room to move. Last time I wrote to you from a flight I had legs eleven sitting next to me. You know, the guy that sits with his legs so wide apart he takes up all three seats. Well today it’s elbows... some god given right to use both

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arm rests. And then of course next to him is sniffy, yep you guessed it, sniffed for the first 15 minutes of the flight. I offered a tissue, it was refused with a no thanks don’t need it!!!! My immediate response - oh yeah you definitely need to blow your nose. The tissue is begrudgingly taken. My mind drifts back and I start thinking about how we will counter any moves by the federal government or anybody else for that matter trying to do away with penalty rates. It’s estimated that between 25-40% of a nurse or midwives’ wage is made up of penalties. Lates, weekends and public holiday rates are all up for grabs through the industrial relations review being held by the Productivity Commission. Now you wouldn’t need your crystal ball hooked up to the car battery to guess what the outcome might be. Who would work on Christmas day or any other day for that matter and be away from their families and do it for flat rate? I reckon we have a fight on our hands, keep watching our website and my twitter for regular updates about this, it’s hugely important that we fight to maintain penalty rates for everyone’s sake. Now the reason I’m going to Sydney today is to meet with the newly appointed Assistant Federal Secretary. You will recall last edition we farewelled Yvonne Chaperon. This month we are welcoming Annie

Butler who was appointed by the Federal Executive in late February. Annie is a former campaigner and former professional officer for the NSW Branch. I’m really excited about Annie commencing with the Federation. We will make a good team, a team that along with the branch secretaries and staff will continue to represent and advocate for your rights. Well I’m now in Sydney so remember watch twitter, Facebook and our website for updates about penalty rates. Lee Thomas Federal Secretary Australian Nursing & Midwifery Federation


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PAGE 19 April 2014 Volume 21, No. 9.

Ethics Megan-Jane Johnstone

Caring about the unbefriended elderly Question of nursing ethics The above cases are not isolated and are symptomatic of a breakdown in civic values and engagement. As a passerby reflected in response to the Brisbane case, ‘your neighbours couldn’t care less about you. I could go in my backyard and fall over and no one would know I was there. Years ago everybody knew everybody and you could say hello and have a yarn. That’s all gone’ (Arnold and Sandy 2012).

In 2011, the skeletal remains of an elderly woman were discovered on the bedroom floor of her Sydney home eight years after she had apparently ‘vanished’. A recluse who had become estranged from her relatives, the woman died without anyone noticing - not her neighbours, the city council, utility providers, her bank. Not even Centrelink, which continued to pay benefits into her bank account, recognised that something was amiss. Although the cause of the woman’s death remains undetermined, a police statement to the coroner suggested she suffered a stroke near her bed and couldn’t get up (Munro 2014). Her remains were discovered just one month short of what would have been her 87th birthday. In 2012, the bodies of a woman aged 83 and her carer son aged 51 were found at their Brisbane home 10 days after their deaths. It is believed the mother, who suffered from dementia, was confined to her bedroom and was unable to get out and seek help when her son died, possibly from a cardiac arrest. She died shortly after from natural causes. Described as ‘keeping to themselves’ and living a life of ‘self-imposed solitude’, the deaths of those two people stood as a ‘sad end to a story of suburban isolation’ (Arnold and Sandy 2012). PAGE 20

At first glance the above cases might seem to have only indirect relevance to questions of nursing ethics. On closer examination, however, it is clear that the issue of isolated elderly highlights an important dimension of nursing ethics that has largely been overlooked, notably, nurses’ individual and collective moral responsibility for civic engagement – in this instance, to make a positive difference to the lives of isolated older people.

Unbefriended elderly The majority of older Australians have active involvement with the people around them. Even so, it has been estimated that 20% of older Australians are socially isolated and lonely. A significant number of those may also fall into the category of what has been described elsewhere as the ‘unbefriended elderly’ – ie. elderly people who are loners and who literally have no-one to care about or for them. There are many reasons why people might find themselves ‘unbefriended’, including: separation and estrangement from family, divorce, bereavement, never having married or had children, living alone, chronic illness and a related decline in the ability to maintain social networks, loss of meaningful relationships through immigration and asylum seeking, changes to demographic living areas, insufficient income, poverty, lack of knowledge or understanding of community services, homelessness, and growing old in prison. It is well documented that social isolation in older people can lead to numerous health problems, including an increased risk for ‘all-cause mortality’ (Nicholson 2012). It can also affect detrimentally older people’s overall sense of wellbeing and quality of life. Less well appreciated, however, is that social isolation in older people can, paradoxically, undermine the very processes that have been designed ostensibly to assist them to maintain a modicum of control

and to feel less isolated. For instance, many of the mechanisms that have been operationalised to support older people make life choices (eg. appointing a power of attorney, appointing executors and trustees in a will, advance care planning) all presume that there is an ‘other’ whom the older person can appoint to act on their behalf. Even emergency response personal alarm systems, designed to enable older people to remain safe and independent in their own homes, presuppose that the client has a contact person who is well known to them, who they can trust and entrust with a key to their home, and who is willing to be contacted day or night in the case of an emergency. For the unbefriended elderly there simply is no-one whom they can ask to step up to this role. Thus, when vulnerable and in a time of need, their life interests will ultimately be decided by strangers who have no intimate knowledge of who they are as individuals, what the meaning of their lives is, or what ‘really’ is to count as being in their best interests.

Civic engagement Professional nursing ethics involves more than upholding ethical standards of care at the bedside. It also encompasses community collaboration and nurses fulfilling various civic responsibilities as engaged citizens. The issue of unbefriended elderly warrants attention as a public concern. Nurses both individually and collectively are in a prime position to work with others in the community to draw attention to this issue, to engage in community building, to volunteer, to advocate for better social support systems, and to foster mindful awareness and compassion for older people whose circumstances have left them friendless, isolated and alone. To succeed in this task, however, nurses will need to improve their civic literacy, civic courage and civic virtue both as professionals and as private citizens.


Arnold, R & Sandy, A. 2012. Left to die a lonely death as bodies of mother, son found in Enoggera. Courier-Mail, 2 March, http://www.news. com.au/national/left-to-die-a-lonely-death/storye6frfkp9-1226287006838 Munro, P. 2014. Natalie Wood: The woman Sydney forgot. Sydney Morning Herald, 6 February, http://www.smh.com.au/nsw/natalie-wood-thewoman-sydney-forgot-20140204-31ywh.html Nicholson, N. 2012. A review of social isolation: an important but underassessed condition in older adults. Journal of Primary Prevention, 33: 137-152.

Megan-Jane Johnstone is professor of nursing in the school of nursing and midwifery at Deakin University in Victoria. Professor Johnstone has extensive interest and expertise in the area of professional ethics in nursing.

ANZAC Day Fight for justice

Dot Angell was 26 years old when she returned home to Melbourne in 1967 after three and a half years working overseas. Restless and ready for a new adventure she signed up to volunteer as a civilian nurse in the Vietnam War. Forty seven years later and Dot is still fighting for the federal government to recognise that service by awarding veterans entitlements to the civilian nurses and doctors who answered that call of duty. About 450 Australian medical staff volunteered to serve in Vietnam under the South East Asian Treaty Organisation (SEATO), including about 120 SEATO nurses. “The conditions were pretty raw,” Dot remembers. “You had patients on stretchers on the floor, or just on mats on the floor, double decking on beds with stretchers over the bed ends, so you had a patient up the top and you might have had three children underneath and you spent your life really walking on the side of stretchers.” SEATO nurses experienced the same traumas of war and have been struck down by a range of similar physical and mental conditions experienced by other Vietnam veterans, with many of the illnesses due to their exposure to Agent Orange chemicals, yet they are not eligible to access the same veteran entitlements. “We believed that having volunteered to go,

Dot Angell (left) with SEATO nurses on ANZAC Day 2012

the government would look after us on our return,” said Dot. The federal government considers SEATO teams as civilians so they are covered by the public service worker’s compensation scheme, Comcare, instead of the Veteran Entitlements Act (VEA). “It’s fine for the public servants if they trip over a waste paper basket and fracture their ankle but it has nothing to do with war related conditions and that is the basic problem,” said Dot. Hearing loss, thyroid conditions, arthritis and all cancers are recognised under the VEA but not under Comcare, said Dot. “There are a few cancers that are being recognised such as non-Hodgkin’s lymphoma, which they dare not recognise because it’s a common condition amongst the military veterans, but most of the cancers are being knocked back.” At 73-years-old, Dot has been fighting for over a decade to have SEATO nurses rec-

ognised under the VEA. With the support of the Australian Nursing & Midwifery Federation (ANMF) she has campaigned and lobbied the government but has always been opposed by the RSL, until now. The RSL has recently changed its position to support SEATO nurses having access to veterans’ entitlements. General Peter Cosgrove, former defence force chief and Australia’s next governor general, has also given his public support for the SEATO teams. Yet despite this high profile military support, the federal government has refused to act. So as Dot Angell and her fellow SEATO nurses march on ANZAC Day, they will remember their fellow nurses who are no longer here and vows Dot, they will keep pushing the government to ensure no other Australian nurse who volunteers in a disaster or war zone ever has to face the same battle for recognition and entitlements. “That’s why we keep on fighting.”

Lest we forget

A handful of surviving WWII nurses will be among those commemorating ANZAC Day at services around the country this month. Aged in their 90s, those who do attend will take part in the parade by car, said Returned Nurses RSL sub-branch president Jan McCarthy. “I think for most returned nurses it’s a day of reflection and remembrance and meeting up with their friends.” Retired Colonel McCarthy served in Vietnam from 1968-69. “We weren’t briefed very well, we knew we were going to Vietnam but we had no idea really what it was going to be like and I remember arriving and thinking, oh goodness.” The training for military nurses at the time did not prepare them for what to expect in a war zone, said retired Colonel McCarthy.

Retired Col Jan McCarthy, ANZAC House

“It’s very, very busy. You work six days a week and you’re on call so sometimes you don’t get a day off for weeks on end. You’re in an area of conflict and that’s just your role.” That experience lead Jan McCarthy to develop a field nursing training program upon

returning home from Vietnam, which is still used in the Australian military today. ANZAC Day services will be held around the country on 25 April.

PAGE 21 April 2014 Volume 21, No. 9.


Flying under


the radar:


The health of refugees and asylum seekers in Australia Asylum seekers and refugees have complex and multiple health care needs, requiring specific attention. Cate Carrigan investigates the state of refugee health in and out of detention centres and the role of the nurse in addressing these needs. When five-year-old Syrian boy Ahmed (not his real name) was getting ready for his first day in a Sydney kindergarten it was not fear of missing his mother or whether he would make new friends that worried him, but whether or not his school would be bombed. That was what had happened the last time he went to school in Syria and he feared he and his school mates might be hurt. The simple story of this young boy, who, according to the nurse manager of the NSW Refugee Health Service (NSWRHS) Sandy Eager, returned home happy and excited to return to kindergarten the next day, is a reminder the traumatic past of Australia’s refugees and asylum seekers and highlights one of their key health needs - ongoing assessment and treatment for psychological stress. In 2012, the former Gillard/Rudd Government increased the refugee intake under the Humanitarian Programme by around 7,000 places to 20,000 but that number has now been cut back by the Abbott Government to just over 13,000. According to the Refugee Council of Australia, 2012-13 saw over 26,000 onshore applications, including over 18,000 from boat arrivals of which only 33 per cent were successful. Since July 2013, all those who arrive by boat seeking refuge are sent to facilities at PNG’s Manus Island (single men) or on Nauru (families) with the federal government saying any of these that are determined to be refugees will be settled in other countries and not Australia.

An Amnesty International report released in December last year gave a damning critique of the Manus Island detention facility, finding asylum seekers were detained without any individual assessment of the need for detention, without any release date, and no means to seek review of their detention. It also found they were often woken in the middle of the night at the Christmas Island Detention Centre to be sent to Manus Island and that once in the PNG facility they were subject to overcrowded accommodation, little privacy and limited access to medical treatment. Medical staff at Christmas Island have also raised concerns, sending a letter to management detailing issues including gaps in health assessments, the speed and subsequent inadequacy of initial health checks, delays in transferring patients requiring treatment at mainland facilities, the reallocation of doctors away from the centre, poor standards of paediatric and antenatal, and poor management of chronic diseases. NSWRHS’ Sandy Eager, who until recently was the Australian College of Nursing’s representative on the now disbanded Immigration Health Advisory Group, echoes the criticisms, saying there is inadequate child health assessment, both physical and psychological as well as inadequate antenatal facilities on Christmas Island and in the Darwin Immigration Detention Centre. “A lot of the staff who work in these centres are good clinicians and decent people but when you are in a system where people are referred to as numbers rather than individuals the cultural shift in the management has to percolate down.” PAGE 23 April 2014 Volume 21, No. 9.


“ For all these people: those assessed as refugees and settled in Australia, asylum seekers already in Australia and waiting a determination on their long-term status, and those held in on-shore and off-shore detention facilities, the health needs can be acute and require complex solutions, according to Professor Nicholas Proctor, the Chair of Mental Health Nursing at the University of South Australia. “There are multiple needs but the most significant one for asylum seekers in and out of detention is uncertainty in relation to the processing of their claims, not knowing what awaits them if they are forced to go back, and whether or not they will be able to reconnect with their families if they are granted refugee status as the current policy gives no priority to family reunions.” Professor Proctor, who has worked with asylum seekers and refugees for over 15 years, says the challenges for asylum seekers have worsened over the past six months with the federal government‘s decision that boat arrivals will never be settled in Australia. He says this means around 30,000 people in this category will continue living in Australia on bridging visas or special humanitarian visas until their claims are determined. For Professor Proctor the unanswered questions about their fate pose a challenging problem for those trying to meet the mental health needs of these asylum seekers. “I think it’s very hard to respond to someone who doesn’t have certainty. For those recovering from trauma there is no substitute for a safe and secure place.” Working as a Refugee Health Nurse (RHN) in the Victorian city of Shepparton, Tessa Speller deals with the results of this anxiety every day. Many of her clients are Afghani men on bridging visas who have come to the Victorian “fruit bowl” to work in orchards while being paid a special allowance through the Red Cross based on around 85% of the Centrelink unemployment benefit. “They have fled Afghanistan or Pakistan, leaving their families in the belief they would be able to bring them over once they were established in Australia. Now this is looking more like a pipe dream than a reality.”

A lot of people come here thinking they are okay and are then diagnosed with conditions they weren’t aware they had. Also in their home countries they may have treated the symptoms with their own traditional medicines or been able to access medicines without going through a doctor and pharmacist as we do here.

Working with two trauma counsellors and in conjunction with other health services, Ms Speller assesses her clients’ physical and psychological health and can refer them on to the counsellors, GPs or specialist services. In addition she helps coordinate communitybuilding activities such as exercise classes. Ms Speller’s work in Shepparton, is part of the state government Victorian Refugee Health Nurse Program established in 2005 which employs the equivalent of 44 nurses across eight Melbourne metropolitan and eight regional community health centres. Based near the larger refugee communities in the southern, outer western and outer northern suburbs of Melbourne, and in regional centres of high refugee settlement, the RHN undertake and facilitate comprehensive health and social needs as-

Ms Speller explains that the waiting is the hardest thing for these asylum seekers as they do not know when a decision will be made. She says the mental health of many means they have poor memories and will often seek help at the last minute, complaining of stomach ache or other physical symptoms. “Many who have emotional and mental health issues present with physical symptoms such as headache, back ache and stomach ache. They are all fairly well documented as being presentation of someone who is also severely anxious or has post-traumatic stress or depression or tension.”

sessments, and make appropriate referrals to other health and community service providers. Allied health workers have recently been funded as part of the refugee focussed teams in the Community Health Centres (CHC) and interpreting services are also included to ensure clear communication with clients and participate in case allocation, care planning and review meetings.

“It’s easier to say I have a bad stomach ache than to say I am really worried about my family overseas or my visa status,” Ms Speller says, adding that these men may feel shame in admitting to a mental health issue because culturally it shows a lack of personal strength.

The nurses also work with staff in community health to develop health promotion strategies and activities that are targeted specifically at refugee populations in areas of need such as child nutrition programs, women’s and men’s health education programs,



Asylum seekers sit behind the wire of the Manus Island Detention Centre. Photo Kate Geraghty

school education programs regarding basic health, family planning programs and management of chronic diseases such as diabetes and hypertension. The coordinator of the program Lindy Marlow says the nurses often work with the Department of Immigration’s settlement workers who are assigned to help newly refugees establish themselves in the community. “The RHNs meet the clients in their homes and do a basic health assessment and check how well they understand the system and assist with appropriate referrals. It’s really about working, in partnership, with the GPs who are based in community health centres and in some situations with private GPs as well.” Ms Marlow says the RHN has a community health rather than a clinical role, although in many of the CHCs the RHNs are conducting comprehensive initial assessments, initiating early pathology screening prior to the clients being referred into a GP. Part of the initial health assessment is done by the RHN and then completed in the GP practice. The nurses work not only with the families, but also with other health providers, such as staff in GP practices and allied health workers, to build an understanding of people from refugee and asylum seeker backgrounds. “They liaise with settlement services, participate in care planning, case allocation and review meetings. All of these community health centres might have different systems but the nurse is the go-to person for these clients.” One of the main challenges for the RHNs is to explain a complex health system to people who may have come from countries where there is very little preventative health, or have used traditional medicines and have no knowledge of going to GPs for prescriptions or being referred to specialists. “They have a major role in increasing health literacy to enhance self-empowerment of their clients in order to navigate the health system. Community consultation and feedback is important in identifying gaps in service delivery to the refugee and asylum seeker groups”.

Ms Marlow says while the program was set up to work with refugees, asylum seekers have become more of a focus in the past eighteen months. “There are many people out there with no support, no work rights and very little money, so managing their health is a challenge. In a lot of ways the nurses are advocates for these people and because they are working in community health they can come and see them without charge.” In the Northern and Southern regions of Melbourne a health triage system has been operating for over twelve months. RHNs see groups of asylum seekers who have been recently released from detention on bridging visas. They review their discharge medical summaries, conduct interviews using interpreters and make referrals to other health providers such as GPs, dental clinics or mental health agencies, or, if necessary, to hospital emergency departments. These triage services are conducted in partnership with the case managers from settlement agencies such as Adult Multicultural Education Services (AMES) and the Red Cross. When Suzanne Willey, a lecturer in the School of Nursing and Midwifery at Monash University, worked as one of Victoria’s first RHNs she confronted a lot of psycho social issues involving cultural differences, language barriers, separation and dislocation from friends and family, as well as health problems. “Negotiating the health system can be a big thing for these people who often come from countries where the health care is very different.” “A lot of people come here thinking they are okay and are then diagnosed with conditions they weren’t aware they had. Also in their home countries they may have treated the symptoms with their own traditional medicines or been able to access medicines without going through a doctor and pharmacist as we do here. So that can create a lot of barriers for people to be able to access care and treatment.”

PAGE 25 April 2014 Volume 21, No. 9.

Feature Ms Willey says for someone who has come from a background of torture and trauma, it is not always easy to understand a system where they are told to take this or that medicine or undergo different procedures for their health. “This, without any support or counselling, can be quite challenging and quite difficult.” As to mental health needs, Ms Willey says unless it is something that presents itself in the early assessment stages, it falls through the cracks. “Often there’s a honeymoon period at the start where people feel that they are safe and they are here and everything is great. Then the realities of life start to hit and mental health issues can then start to come out.”

Ms Eager says before being given a refugee visa applicants are checked for TB and HIV. The NSWRHS also conducts intensive screening for conditions commonly found in refugees such as hepatitis B, vitamin D deficiency and gut parasites in addition to doing dental checks. Additionally, nurses conduct psychological testing to check mental health with some people picked up early while others might not display any symptoms until months later. “Some people may arrive traumatised, particularly if they have come out of places like Syria, and ask for help straight away, while others want to look forward and not think about the past. That’s fine but we know that often further down the track (seven or eight months later) they may need that psychological support. The flurry and excitement of being in a new country, settling into the life and getting the kids into schools has all calmed down and they may start to have nightmares and flashbacks and realise all is not right.” For Ms Eager the old adage “an ounce of prevention is worth a pound of cure” is essential in treating the health needs of refugees and asylum seekers. She explains that things such as vitamin D deficiency are easily treated and can turn someone’s life around within 24 hours. “A lack of vitamin D can leave you with aching bones and extremely fatigued but with the right treatment they can be better in no time which is a huge thing for these people.”

In New South Wales, a nurse-led model of care for newly-arrived refugees was introduced by the NSW Refugee Health Service (NSWRHS) in late 2012. Under the Sydney-based program, physical and psychological assessments are conducted in addition to some evidence-based pathology screening, with clients then referred on to other services if necessary.

The NSWRHS, which has eleven clinics across Sydney, adds a triage and intervention service with part of the outcome being “the gentle education” of GPs in the health checks needed for refugees, with letters of introduction, along with pathology and other results sent to the doctors along with the refugee clients. “And these GPs now know that if they see a refugee that we haven’t seen, or a newly arrived migrant that these are the tests they need to do.”

Nurse manager with the service Sandy Eager says since the program started nurses have seen 3,800 refugees, mainly Christian Iraqis who’ve fled Syria, but also Afghanis, Iranians, Burmese and Africans. The service is mainly for refugees as Ms Eager explains the asylum seekers who come in by boat usually have health checks on Christmas Island.

The service also links clients in with early childhood nurses who, in turn, can link families through to early intervention programs and screening for hearing or eyesight problems. There are also referrals for women’s health such as breast checks and Pap smears, with refugee women having one of the highest mortality rates from cervical cancer of any community group in Australia.

NSW refugee clinic PAGE 26



One of the main challenges for the RHNs is to explain a complex health system to people who may have come from countries where there is very little preventative health, or have used traditional medicines and have no knowledge of going to GPs for prescriptions or being referred to specialists.

NSW refugee clinic

Asked about the needs of a typical refugee family, Ms Eager says the most common client group at present are Iraqi Christian families who have fled the civil war in Syria after earlier flights out of their home country. As to the individual needs of the family, the father will often bear the burden of the psychological stress of the family. Feeling responsible for their predicament, and usually being middle-aged the father might have untreated diseases such as hypertension, undiagnosed Diabetes Type 2, and be suffering from the affects of torture and trauma such as badly mended fractures or chronic muscular-skeletal injury. “I had a family recently where the dad had been severely tortured over a number of days, being hung by his arms until both his shoulders had dislocated and left with permanent rotator-cuff injury so he can’t raise his arms above his shoulder level”. The mothers may have extremely low iron stores, and had little access to preventative health screening and all the family may be vitamin D deficient. Ms Eager says one family she saw recently had been hiding in a basement for a year so the kids had not seen the sunshine.

they don’t come saying I am suffering from post-traumatic stress ‘can you help me’. Most of the time they have issues such as very poor sleep patterns and have difficulty regulating their emotions.” Ms McEvoy says they can find themselves getting angry very quickly for no apparent reason, breaking into tears and can have very poor concentration skills, making school work difficult. “So initially my focus is on trying to help them with these very practical things and bearing witness really to their experiences both prior to coming to Australia and since coming to Australia. “The continuing uncertainty has a huge impact on their day to day functioning and I have grave concerns for them. There’s a lot of self-harm, from head banging to cutting themselves to relieve the stress.” Ms McEvoy believes all she can do is “bear witness to their distress and try to help where we can” even though she finds it very distressing at times and wonders at the lack of compassion shown to asylum seekers. The University of South Australia’s Professor Nicholas Proctor says it is crucial that there is an integrated response to the mental health needs of refugees and asylum seekers. “I strongly believe we are all in this together, so nursing, allied health, and medicine all come together to collaborate to create a community-wide mental health response. No one agency can do this, we need a collective response.”

For teenagers, there is the cultural battle of fitting in to a new society on top of negotiating the regular dilemmas of puberty. Ms Eager says family tensions can bubble over as bi-lingual teenagers start to hold increasing power in the family, upsetting the old familial structures. South Australian nurse practitioner Monica McEvoy works with unaccompanied asylum seekers under 18 years of age. Most are mainly boat arrivals who came before or just after July 2013 when the policy changed to prevent maritime arrivals coming to the mainland. Many live in community detention in Adelaide and Monica says “the biggest impact for them is living with uncertainty. Most of the time PAGE 27 April 2014 Volume 21, No. 9.

Issues Jan Edwards and Catriona Diedre Moffat

Otitis Media in remote communities Otitis media (OM) is a common health problem in children living in remote Australian Aboriginal communities. Children living within these communities are being diagnosed with OM at similar rates to children living in developing countries (Doyle & Ristevski 2010).

Their exposure to recurrent bacterial infections associated with their daily living conditions is exacerbated by a lack of understanding of hygiene and current medical treatment. The challenges associated with the prevention and treatment of OM can be managed effectively through health promotion and education to raise awareness of the disease process and its management. Currently the management of OM has been antibiotic therapy. However, organisms have now developed resistance to the commonly used antibiotics and health practitioners are reexamining the use of drugs as the only effective form of treatment for OM (Hare et al. 2012, Binks et al. 2011, Feldman & Anderson 2011). An awareness of the causes of OM will contribute significantly to the prevention of OM and help reduce the need for expensive treatment. Health practitioners and Aboriginal Resource and Development Services (ARDS) need to work together to constructively develop health literacy programs in a culturally safe and sensitive format which is recognised within the Australian Aboriginal culture. Systems that are effective for non-Aboriginal Australians in managing and preventing chronic diseases may be unsuccessful in Aboriginal communities if respect is not given to the specific needs of individuals and groups (Taylor & Guerin 2010). Health promotion is urgently needed to raise awareness of and change behaviours towards the management and control of otitis media. The poor standards of basic hygiene practice in remote Aboriginal communities is a major concern and hygiene education should been highlighted as a priority (McDonald & Bailie 2010). Many parents and carers living in remote communities have a poor understanding of the relationship between hygiene and infection. Although disease transmission is recognised for some illnesses, nasal and ear discharge are not considered a health problem by the majority of individuals living in remote communities (McDonald & Bailie 2010). PAGE 28

Unsanitary living conditions have been identified as a major source of infection and an important factor contributing to sickness and disease. Aboriginal children in rural/remote areas of Australia often live in makeshift accommodation which they call home. Parents and carers need to understand the connection between unhealthy living conditions and poor child health outcomes. Ill health is the direct result of sub-standard living conditions in which there is overcrowding, passive smoking and communal sleeping arrangments (Bailie et al. 2010). Providing education to Aboriginal peoples living in remote communities is a complex task (Doyle & Ristevski 2010). The goal is to improve their understanding of the long-term damage that otitis media (OM) and chronic suppurative otitis media (CSOM) can cause to the ears. To establish a working relationship and learning environment where change can be introduced,the effects of colonisation and the feelings of disempowerment need to be overcome. In a review of successful health programs within Aboriginal communities Brady (2007), believes that genuine community participation in deciding their own health priorities and consumer involvement in program activities is the model most likely to succeed. Nurses and other members of the health care team need to help the Aboriginal peoples make the connection between the aetiology and progression of OM and the subsequent complications to childhood development. Bacterial and viral infections in the nasopharynx are major causes in the development of ear disease which may lead to permanent hearing impairment and learning difficulties (Binks et al. 2011). Streptococcus pneumoniae, the bacteria commonly implicated in the development of OM, has demonstrated resistance to many forms of antimicrobial treatment (Feldman & Anderson 2011). In a Northern Territory study of children with OM, there has been a reported increase in resistance to the drug azithromycin, used in the treatment of OM (Hare et al. 2012, Binks et al. 2011). Recurrent episodes of OM have resulted in increased resistance to antibiotic therapy which has led health professionals to review management strategies (Hirst & Neill, 2013, Gunasekera et al 2009). The use of probiotics is suggested as an alternative in preventing the development of OM (John

et al. 2013). While this may be perceived as a significant breakthrough in controlling the disease, adherence to any form of therapy must reflect current knowledge. A culturally sensitive educational program supported by Aboriginal Resource and Development Services (ARDS), can be developed using positive reflection to engage carers in simple hygiene techniques that promote health. Doyle & Ristevski (2010), reported that ear toileting, the use of tissue spearing, and the breathe, blow, cough (BBC) technique is an example of a well-constructed health program that resulted in both physical and social benefits. The effects of regular ear and nose toilets, and the reduction of ear odour, raised the confidence and self-esteem of the children and their carers. This positive outcome reinforces the value of developing similar programs in neighbouring communities. Whilst a program of education that demonstrates the effectiveness of treatment may reduce the number of cases in the long term, barriers to the success of the program need to be considered. There are many different Aboriginal languages used throughout Australia and health literacy has been reported to be a problem (Vass et al. 2011). Translation of complex medical terminolgy may lead to misinterpretation however, with the support and collaboration of Aboriginal services and community groups, the communication barrier can be overcome. Teamwork, relationship building, the development of communication skills, and demonstrating the effectiveness of treatment for OM, will empower individuals within communities to bring about change. A health education program formatted to effectively communicate the disease process of OM to all Aboriginal peoples is a priority. Management should include prevention as well as treatment of the disease. A collaborative effort between health professionals and Aboriginal Resource and Development Services (ARDS) can deliver a culturally sensitive program aimed at improving the health of Aboriginal children living in remote areas. The program will empower Aboriginal Australians to achieve positive health outcomes.

References on request Dr Janice Edwards is a lecturer/coordinator Indigenous Health, School of Health Professions at Murdoch University Catriona Deirdre Moffat is a student nurse

Reflections Julia Taylor

Mentoring in nursing: an invaluable exchange The practice of mentoring in nursing has existed as long as the profession itself (Fields 1991). Florence Nightingale, often credited as the founder of modern nursing, has herself been referred to as the ‘mentor of matrons’ (Lorentzon & Brown 2003). Mentoring has been a key element to the development of nurses and the nursing profession for centuries and over this time has seen significant change. Prior to the 1970’s mentoring in nursing was largely informal and generally occurred at the mentors’ discretion (Ehrich & Hansford 2002). This resulted in only personally selected protégé’s having the benefit of senior mentors (Ehrich & Hansford 2002). Over the past four decades the concept of mentoring in nursing has gained momentum and consequently has been the topic of numerous research projects and publications in both popular and scholarly literature (Ehrich & Hansford 2002). Mentoring in nursing has become a more formal practice with the understanding that there are benefits for both mentor and mentee and that equity in availability of this resource is vital (Andrews & Wallis 1999; Ehrich & Hansford 2002). Nursing mentors assist less experienced nurses to understand their profession and advance their career (Fawcett 2002). A mentoring relationship extends over a long period of time and should be mutually beneficial for both mentor and mentee (Ehrich & Hansford 2002; Fawcett 2002). Mentoring in nursing is clearly distinct from precepting, which requires the senior nurse to take on a teaching role in order to ensure development and competence in certain settings (Fawcett 2002). In contrast, mentoring involves not only the transferring of knowledge but the ability to be patient with, have respect for and enthusiasm about the mentee’s career and future career goals (Fawcett 2002). Mentoring is a practice that has potential benefit at all levels of nursing practice, from the student nurse to the senior clinician (Ehrich & Hansford 2002).

Reflections of a mentor During 2013 I had the privilege of mentoring three undergraduate nursing students

through a program available to University of Tasmania alumni. With my passion for nursing in both clinical and academic contexts, and experience in both acute and primary care settings, I felt that I had something to offer. I entered into this experience with many hopes and plans of how I wanted to assist my mentees to become enthusiastic, ambitious and ultimately happy nurses. I had completely underestimated how very much my mentees would provide that same rich learning experience for me. We met as a group approximately once per month in various settings. Our meetings were directed largely by the mentees, however at times I would share knowledge or resources with them that I felt would have benefited me when I was an undergraduate student embarking on a career in nursing. I spent time encouraging the mentees to develop their own ideas of health and health care, and endeavoured to highlight the exciting career possibilities that would be available to them within this profession.

This experience allowed me to develop my skills as a mentor but also improved my clinical confidence and reinvigorated my enthusiasm for nursing as a profession. Within this small group we discussed how to get a career in a nursing specialty area, job applications and interviews, joining professional associations, networking, professional development, graduate positions, post-graduate degrees and work-life balance. We also spent significant time examining stress management techniques to avoid burn-out. At the end of the program each mentee was given the opportunity to express their thoughts on the experience. All three were very positive about the opportunity to be part of the program and stated that they would recommend the program to others. They talked about the increase in their level of confidence in relation to their career and the benefits of having a more senior nurse available to answer any arising questions. They also expressed their increased feeling of optimism at gaining employment and reaching their long-term career goals of working in specialty nursing areas.

From left to right: Julia Taylor (Clinical Nurse Specialist – Youth Health/mentor), Karen Boschma (student nurse/mentee), Danalea Connell (student nurse/mentee) and Janeann Roles (student nurse/mentee). demic and professional institutions. After my recent experience of providing mentoring to undergraduate nursing students I would strongly encourage my nursing colleagues to take part in these programs where they exist and develop new programs where none are available.


Andrews, M. & Wallis, M. 1999. Mentorship in nursing: a literature review. Journal of Advanced Nursing. 29(1):201-207. Ehrich, L. & Hansford, B. 2002. A review of mentoring in education: some lessons for nursing. Contemporary Nurse. 12:253-264. Fawcett, D. 2002. Mentoring – what is it and how to make it work. Association of Operating Room Nurses Journal. 75(5):950-954. Fields, W. 1991. Mentoring in nursing: a historical approach. Nursing Outlook. 39(6):257-261. Lorentzon, M. & Brown, K. 2003. Florence Nightingale as a ‘mentor of matrons’: correspondence with Rachel Williams at St Mary’s Hospital. Journal of Nursing Management. 11:266-274.

Julia Taylor is a Clinical Nurse Specialist at the Youth Health Service, Tasmanian Health Organisation - North West

Many mentor programs exist within the profession of nursing through both acaPAGE 29 April 2014 Volume 21, No. 9.

Research Stethoscope more contaminated than palm of hand Although health care workers’ hands are the main source of bacterial transmission in hospitals, a new study shows physicians’ stethoscopes also play a role.

In the study published in Mayo Clinical Proceedings, 71 patients were examined by one of three physicians using sterile gloves and a sterile stethoscope. After they completed the examination, the tube and diaphragm of the stethoscope, and the back of the physician’s hands, fingertips and palm were measured for the total number of bacteria present. The stethoscope’s diaphragm was more contaminated than all regions of the physician’s hand except the fingertips. The study also found the tube of the stethoscope was more heavily contaminated than the back of the physician’s hand.

Depression impacts teenage brain development Similar results were found when contamination was due to methicillin-resistant S.aureus (MRSA) after examining MRSAcolonised patients. The study is the first to compare directly the level of contamination of physicians’ hands and stethoscopes. Lead investigator Didier Pittet is the Director of the Infection Control Program and World Health Organization (WHO) Collaborating Centre on Patient Safety. He said the study shows that stethoscopes are potentially significant vectors of bacterial transmission. “From infection control and patient safety perspectives, the stethoscope should be regarded as an extension of the physician’s hands and be disinfected after every patient contact.”

Brain stimulation could help treat permanent dizziness It is not uncommon to take a little time to find your legs after being on a boat. The sensation of being off balance or still rocking with the waves can last for minutes, hours or at most, a few days. However, for some people this feeling lasts for years with debilitating consequences. The little known condition is called Mal de Debarquement Syndrome (MDDS). “MDDS is a balance disorder where people experience symptoms of continual unsteadiness and dizziness and find it difficult to keep their balance,” said neuroscientist Dr Alan Pearce from Deakin University. “The condition is extremely debilitating and prevents sufferers from doing the simplest of tasks such as hanging out the washing, showering or going to the supermarket. It’s also difficult to diagnose and has no known treatment,” he said. PAGE 30

Dr Pearce is looking for people to take part in the trial of a potential treatment. It involves sessions of Transcranial Magnetic Stimulation (TMS), a safe and painless way of delivering electromagnetic pulses into select areas of the brain. “All we currently understand about MDDS is there seems to be some changes in brain activity, particularly in the sensory and motor areas, that is affecting balance. So we are looking at ways of altering the activity of the brain by using TMS.” For the trial, Dr Pearce is looking for people who have the symptoms of MDDS (persistent dizziness, feeling off balance etc.) and have not been diagnosed with other conditions such as inner ear infections or Meniere’s disease (excess fluid in the inner ear). For more information about the study, or to register as a participant, phone (03) 9251 7224 or email alan.pearce@deakin.edu.au.

An Australian study has found that the brain develops differently in adolescents who experience depression. Melbourne University researchers used Magnetic Resonance Imaging (MRI) scans to measure the volume of particular brain regions of interest in 86 adolescents at age 12 and again at age 16, when rates of depression were beginning to increase. Researchers also interviewed the teenagers at four different points between age 12 and 18, with 30 of the participant experiencing a first episode of a depressive disorder during the follow-up period. “We found that the pattern of development (such as changes in brain structure between 12 to16) in several key brain regions differed between depressed and non-depressed adolescents,” said research lead Professor Nick Allen. The brain regions involved include areas associated with the experience and regulation of emotion, as well as areas associated with learning and memory. Professor Allen said the findings are an important breakthrough for exploring possible causes of depression in adolescence. “They also suggest that both prevention and treatment for depression in adolescence (even for early signs and symptoms) is essential, especially targeting those in the early years of adolescence aged 12 to 16.” The study also showed some differences between males and females. For males, depression was associated with less growth in an area of the brain involved in processing threat and other unexpected events that is a critical part of the brain’s fear circuitry. The opposite was found for females, with greater growth in this area associated with depression. “This is important information because depression becomes more common amongst girls during adolescence and these findings tell us about some of the neurobiological factors that might play a role in this gender difference,” said Professor Allen. The findings were published in the American Journal of Psychiatry.

Wellbeing Bron Watson

Four steps to beating overwhelm Being a part of the nursing profession means you are no doubt familiar with multi-tasking, and having to get loads of things done at the same time, or so it seems. Not only are you busy at work, meeting your patients’ needs, your students or your units needs every day, there is a lot going on in your world. You have your home life, you have your relationships and of course there is work. How do you manage all the fragile balls of life and keep them in the air…successfully? At some point, you have all experienced that feeling of overwhelm, where not only is your brain in chaos, you also react physiologically and it can become simply too much. This feeling of overwhelm is likened to paralysis, to feeling stuck; what needs to be done, far outweighs the minutes in your day to achieve it. Sargeant & Laws-Chapman (2012) state that stress is a fact of life, the work and home environment are constantly changing, and it is critical that an understanding of stress and how it effects behaviour and emotions, plus having the tools to deal with stress, are key to a resilient pathway in life. According to Boorman (2009) cited by Sargeant & Laws-Chapman (2012) there are three clear links between wellbeing and health and its influence on patient safety, the effectiveness of patient care and patient experience. Research and statistics prove that everyday stress can be debilitating and destabilising, affect attention to detail, focus, and behaviour and productivity. It is essential to understand what constitutes stress to an individual, eliminate what we can control and become more resilient to the things we cannot change, of which there are many in the nursing profession (Sargeant & Laws-Chapman 2012). We know what the problem is, we know the effects of stress and overwhelm on patient outcomes. The tools for organisational change are available, but what can you do today, for yourself, right now to get your day, the way you want it to be? Here are four simple steps to beat overwhelm and improve your productivity.

step one: Get clear on your outcome; know what your outcome is. I speak to many nurses who drift along, doing what needs to be done, without a clear outcome. They exist and allow life to carry them along, rather than take control. This is about you, and what you really want from your year, your career and more.

step two: Start your day with the intention for the day, which means you have intention for your life, which means you have a plan and something to focus on. Your intention means you have something to focus on, why you do what you do, rather than simply ‘drift’.

step three: With so much happening at work, in your personal life and more, there is a lot of talk and thoughts filling your head every minute of every day. Do a brain dump; get your thoughts and ideas out of your head and on to something visual. Write down everything on your mind; just get them out of your head. It could be applying for annual leave, finishing that application for study, taking your jacket to the dry cleaners, or going for a walk after work. It could be to take courage and apply for the promotion, or report horizontal bullying, whatever it is, just write it down and get it out of your head. The reason why this is so important is it allows your mind to do what it does best, to focus on your outcome, it allows creativity. This means your mind will look at other ways to get around what needs to happen, rather than the brick wall you may be seeing now. When the thoughts are whirling around in your head, the energy to organise what needs to happen is draining. The worry thoughts, the anxiety thoughts of not enough time or not having enough knowledge, leads to being overwhelmed, which of course leads to...nothing, nothing gets done. Keep your notebook with you, when something comes to mind, write it down. You never know, it may be a best seller just waiting to happen. As a mother of five busy boys, an educator and business owner, things can get pretty hectic. This step will get you results right from the start, as it is a reminder of what is happening, and more importantly, what you would LIKE to happen.

step four: The final step to get your ‘in-flow’ day started is to prioritise what you have written down. What are the ‘must do’ items, what can you delegate and what are things you really don’t need to do at all? Finally, by knowing your outcome, and why you do what you do, will keep your intention for the day clear and right out front. Process your thoughts and ideas by taking a few moments to brain dump. Doing this everyday will improve your level of productivity, and keep those feelings of overwhelm away. Wishing you a great month and as Yoko Ono said; ‘Healing yourself is connected with healing others’. Bron


Sargeant, J, Laws-Chapman, C, 2012, ‘Creating a positive workplace culture’, Nursing Management, vol. 18 (9): 14-19.

Bron Watson is a registered nurse, educator, mentor and founder of Nurse Power. Email: bron@nursepower.com.au

PAGE 31 April 2014 Volume 21, No. 9.

Clinical Update Anne Marie Assiri

Asylum seekers and mental illness in Australia: a nursing response This literature review examines the mental health needs of asylum seekers who arrive in Australia and explores the role of nurses in the prevention of mental illness in this population. This review will examine in detail triggers and stressors that are contributing to psychiatric disorders in this population.

It will further explore who is at greater risk and what factors contribute to this vulnerability to mental illness. It will also examine the role the nursing profession has to play in the process of preventing mental illness and suggests an appropriate response in caring for this population. This will be further explored by analysing the literature in light of the Australian Nursing and Midwifery Council competencies (ANMC) and the Code of Ethics (COE) for nurses in Australia to the literature in order to gain a nursing perspective. The nursing competencies and the COE are central to the professional nursing practice in Australia and are governed by the statutory body, the Nursing and Midwifery Board. These codes are an integral part of achieving the standards expected by consumers for registered nurses practising within Australia. Increasingly, there is more evidence revealing that in some circumstances nurses may have their ethics challenged and even their own practice called into question when operating within the nursing framework required in Australia. This literature review reveals solutions that will be presented through evidence based programs that have been promoted and proven successful in improving the acceptance of refugees into the community. These programs address the fears and prejudices that may exist in the community, while also providing a holistic approach to health care.

Seeking asylum and mental health The reality of increased hostilities globally, such as acts of terrorism, war, ethnic cleansing and genocide has increased the number of refugees worldwide. The United Nations High Commissioner for Refugees (UNHCR) estimates there are over 12 million refugees around the world with more than half of these being children (Crowley 2009). Some of these refugees inevitably arrive in Australia. Although those fleeing war, torture and death may arrive with some form of post traumatic pre-existing mental illness, it is the research demonstrating that the asylum seeker process is producing adverse mental health effects in those seeking refuge in Australia (Kalt et al 2013). As these revelations come to light, it is important that the nursing profession responds by advocating for mental illness prevention along with promoting health in accordance with the ANMC competencies (ANMC 2006 1.2 1.3 2.4). PAGE 32

The COE outlines the nursing profession’s commitment to uphold the fundamental rights of people in need of health care (NWB 2013). This is particularly relevant for those in this population that are seeking refuge in Australia who are suffering mental illness.

Seeking safe refuge and detainment When an asylum seeker begins the long journey of seeking safe haven in Australia, they are at an extremely high risk of developing a psychiatric illness with long term poor outcomes (Patterson et al 2013). Upon arrival in Australia, those seeking asylum are immediately placed into mandatory detention by the Australian federal government (Mountz et al 2013). They rationalise this detainment by maintaining a ‘reasonable suspicion’ of criminality with the asylum seeker being unable to secure release until they obtain sufficient proof of their legitimacy (Mountz et al 2013). The harsh treatment of refugees who enter Australia begins before they arrive. They are vilified and branded with names such as ‘queue jumpers’ and ‘illegals’ by the media, politicians and the community at large regardless of there being no actual queue for those seeking asylum and the fact that they have a basic human right to seek safety in Australia in accordance with the UNHCR (Dudley et al 2012). Jureidini and Burnside (2011) points out that the term ‘illegals’ may be politically effective but inaccurate. It is clear that the nursing profession has a pivotal role to play in intervening to ensure those seeking asylum in Australia are treated with dignity and that their human rights are not violated (ANMC 2006. 2.3). Moreover, when applying the nursing competencies to the current status quo, the response needs to be one of advocacy and promotion of interventions for these individuals and groups, particularly since the evidence points to conduct

Clinical Update that is adversarial and harmful to the health of refugees (ANMC 2006. 1.2, 2.3, 2.4, 2.6). Refugee detainment has extremely negative effects on children that are indisputable (Davidson et al 2004). Given these findings, it is impossible for the nursing profession to ignore this and not mobilise a proactive response (ANMC 2006. 3.2, 2.6, 2.4).

assault by detention centre officers during their detainment (Kalt et al 2013). Even more concerning are the reports of sexual harassment by staff in detention centres towards refugees (Kalt et al 2013). According to Sirriyeh (2010) minor female asylum seekers in particular are at greater risk of exposure to this type of violence. The responsibility of the nursing profession in light of the competencies is to ensure that human rights are not being compromised and to recommend changes to policies and procedures when the evidence reveals that harm is occurring (ANMC 2006. 2.4, 3.2).

Transfers between locations Another interesting method used by the government is the frequent transfer of asylum seekers between facilities. This tactic has also proven to separate detainees from access to services including legal support, and family and community support, while also causing efforts in proving their legitimacy as an asylum seeker more difficult, which in turn increases the threat of deportation (Mountz et al 2013). The competencies require intervention in such circumstances where these unsafe practices exist in order to prevent further harm (ANMC 2006. 1.3, 1.2). The transfer of detainees between remote locations is restricting their access to adequate health services and legal support which is creating more psychological distress and therefore requires intervention in order to prevent deportation and allow the refugee to seek safe haven.

Detention centres There is a strict control of all information and communication that leaves these detention centres (Mountz et al 2013). The facilities themselves are situated in remote locations, sometimes either on islands or in remote or rural areas that have insufficient access to specialised mental health services (Mountz et al). These distant locations limit their activities from external scrutiny as well as restricting access to services for detainees, including mental health services (Newman et al 2008). The engagement of ‘private for profit’ contractors by the Australian government ensures detention centres are managed like prisons (Newman et al 2008). This recruitment is proving to contribute to a culture of discipline and punishment in these institutions (Newman et al 2008). This is particularly alarming given that pregnant women, children and unaccompanied minors are part of this population. Evidence reveals that detainees are being subjected to physical

“The harsh treatment of refugees who enter Australia begins before they arrive. They are vilified and branded with names such as ‘queue jumpers’ and ‘illegals’ by the media, politicians and the community at large regardless of there being no actual queue for those seeking asylum and the fact that they have a basic human right to seek safety in Australia in accordance with the UNHCR (Dudley et al 2012).” tions along with questioning the treatment of those that are being threatened, particularly children (ANMC 2006. 2.3, 2.4, 3.2, 3.3, 9.3).

Lengthy detainment

Appropriate health care and human rights abuses

The process of seeking asylum in Australia can be extremely lengthy for the refugee. The prolonged uncertainty for those who have suffered past trauma and are dealing and living with mental illness is a significant clinical issue (Procter 2013). The reports show that this lengthy process can directly impact upon the deterioration in the mental state of an asylum seeker (Drozdek et al 2013). According to Procter (2013), detainees face a worsening of their mental health when subjected to lengthy detention periods in these facilities. In fact, the prolonged detention process is contributing not only to overall mental health deterioration but also suicidal tendencies in the detained population (Newman et al 2008). Furthermore, within the asylum seeker population, it is the unaccompanied minors who are found to have higher levels of ‘pre-arrival trauma’, and inevitably suffer elevated levels of post traumatic stress after their detainment (Barrie & Mendes 2013). From a nursing perspective, the response should be based on the competencies in order to advocate for improvement in condi-

The evidence clearly demonstrates a resistance to external scrutiny and a lack of accountability, which exacerbates the mental illness that exists in detainees within these facilities (Newman et al 2008). There is a desire to manage mental health issues internally even in the absence of appropriate expertise and treatment (Newman et al 2008).

According to a study conducted by Savy & Sawyer (2008) there is evidence to demonstrate a complete abandonment of appropriate treatment and care for those refugees suffering acute mental illness in Australia. Newman et al (2008) reveals a culture that devalues the psychological distress of detainees and that self-harm behaviours are being negated as politically motivated (Newman et al 2008). The fact that these behaviours are not being taken seriously and referred to qualified mental health professionals who are able to diagnose and assess individuals raises a serious breach in the duty of care. It is clear that these institutions have been operating outside of the accountability of the health system.

PAGE 33 April 2014 Volume 21, No. 9.

Clinical Update

refugee families have adults in detention centres that have experienced major depression and suicidal ideation.

Of greatest concern to health professionals is the mismanagement of observation/isolation rooms when a detainee exhibits disruptive or self-harm behaviours (Newman et al 2008). The body of evidence reviewed clearly demonstrates that it is inevitable that detained refugees will experience deterioration in their mental state due to the overwhelming adverse circumstances in which they are being held (Newman et al 2008). The studies are revealing that individuals who feel rejected by host countries are shown to be at increased risk of suicidal behaviours and psychiatric illness (Iliceto et al 2013). Newman et al (2008) found that 10 out of 11 refugee families have adults in these detention centres that have experienced major depression and suicidal ideation. All the children in these families were found to have been diagnosed with at least one psychiatric disorder (Newman et al 2008). A quarter of these children were found to have engaged in some type of selfharm (Newman et al 2008). For this reason, a need for sensitivity and advocacy for refugee families and their children is required.

Nurses’ role The nurse in Australia that practices ethically and professionally whilst treating and caring for asylum seekers may place their own practice at risk when their ethics and principles are in direct conflict with government policy (Newman et al 2008). The nursing competencies also address this issue by ensuring the nurse is able to identify interventions that prevent or compromise the care being given or where the law is being contravened and to then act accordingly (ANMC 2006.1.3). In circumstances where the government is directly breaching and committing human rights abuse by not providing adequate access to appropriate health services and creating harsh living conditions that are shown to create PAGE 34

psychological distress, it knowingly breaches international law in addition to Australian law. In fact, there have been numerous decisions by the UNHRC that have indicated that the mandatory detention policies of the Australian government are contrary to international law (Newman et al 2008).

Building trust Procter (2013) raises the importance of building trust when entering into therapeutic alliance, especially when treating and caring for a suicidal asylum seeker. Procter points out that it is more difficult to obtain this trust and engage in a beneficial level of communication with those in suicidal crisis (Procter 2013). Studies reveal that parents, in particular, may distrust health professionals due to negative experiences already encountered whilst being detained (Davidson et al 2004). Prolonged detention has shown to have an adverse effect on child development (Newman et al 2008). There have been serious breaches where health professionals have advocated for not sending a sick child back into a detention centre and the Government has gone against the advice of specialist clinicians (Newman et al 2008). If the asylum seeker is to trust the nurse, there needs to be a demonstration that the nursing profession is involved in protecting the rights and needs of asylum seekers, even if that position conflicts with the current government policy.

Resettlement Australia has a history of explicitly selecting migrants based on country of origin, race and religion. Asylum seekers are perceived as a threat to that process (Newman et al 2008). Jureidini and Burnside (2011) state that the use of harsh treatment as a deterrent for the purpose of achieving migration control is unethical. The stressful journey continues for the asylum seeker once transitioned into the community. This is due to asylum seekers and refugees being viewed as ‘scapegoats’ for everything that is wrong in Australia (Spinney & Nethery 2013). The evidence reveals that those who have transitioned into the community are now at high risk of deterioration in their overall health, not just mental health, within two years of arrival (Kim et al 2013). This is also demonstrated by Slewa-Younan and Radulovic (2013) who, when examining Iraqi refugees resettled into western Sydney, found that those seeking psychological treatment for post-traumatic stress disorder or a major depressive episode were also shown to have had an elevated heart rate than those who were not depressed.

Based on the evidence, there is a clear need for the development and implementation of health promotion programs, both prevention and early intervention. The COE calls on nurses to ‘work with colleagues to create a culture of safety’ (NWB 2013. p.5). This can be as simple as networking between non-government organisations and charitable agencies, and by being aware of programs that are offered that promote health and holistic care. Sports programs have shown to be a part of successful holistic models in building relationships across ethnic, religious and socioeconomic lines (Nathan et al 2013). These types of programs improve feelings of self-worth and happiness amongst individuals and also promote cross-cultural relationships with peers.

Discussion There is overwhelming evidence that uncovers the adverse psychological effects of mandatory detention on asylum seekers. It could be argued that those fleeing government abuse and torture in one country flee to Australia for asylum and are then subjected to an out-of-sight existence which appears to subject asylum seekers to further abuse. One of the major concerns is that a host country such as Australia is charged with protecting refugees, but instead is harming them and thereby failing in their duty of care. The deterioration of a person’s mental health in the detention centres needs to be addressed and the nursing profession can play a role in calling for reforms. The evidence reveals that these detention centres are places that resist scrutiny. They are secretive, distant and remote, and these conditions appear to be creating mental illness. The literature has exposed these places as hostile to asylum seekers where they are suffering abuse with reports of assaults, both sexual and physical. There can be no doubt based on the literature, that children are at a higher risk of suffering from mental illness when placed into these unsafe environments. The major ethical concerns for nurses are the human rights violations occurring under the watch of the Australian Government. The reports of assaults in detention centres and sexual harassment cannot be ignored. Based on the nursing professions codes and competencies, the profession collectively and individually has a role to play in advocating for this population. In order to successfully achieve this, nurses need to be informed and educated regarding the treatment of asylum

Clinical Update “If the asylum seeker is to trust the nurse, there needs to be a demonstration that the nursing profession is involved in protecting the rights and needs of asylum seekers, even if that position conflicts with the current government policy.” seekers in Australia. The message should be clear that the nursing profession will not sit silently and passively while human violations are occurring on their watch. The current culture of secrecy that exists is promoting mental illness and violating human rights. The louder the rhetoric and bigoted misinformation being promoted in Australia against asylum seekers, the louder the voice of the nursing profession needs to be in protecting and promoting health. This can be achieved by calling for greater transparency for detention centres. Nurses also need to be unified in their voice and networked within the community. There also needs to be a greater role by nurses in the creation, implementation and promotion of programs that provide holistic care in the community.

Conclusion The evidence shows that systematic abuse is creating mental illness for those being held in detention. Unfortunately, it is inevitable that refugees who enter Australia seeking asylum will potentially suffer poor health and mental illness when placed in detention. What the literature has revealed is that those who are most affected by this abuse, and who are most vulnerable to further exploitation, are children and unaccompanied minors. The nursing profession cannot support the mistreatment of human beings under any circumstances. Dialogue and direct action needs to continue in order to protect the vulnerable that are seeking asylum and require the protection and advocacy of nurses in Australia.


Australian Health Practitioner Regulation Agency www.ahpra.gov.au/Search.aspx?q=competency %20standards, accessed 16 September, 2013. Barrie, L. and Mendes, P. 2011. A critical review of the literature: The experiences of unaccompanied asylum-seeking children in and leaving the

out-of-home care system in the UK and Australia. International Social Work. 54(4):485–503. Crowley, C. 2009. The Mental Health Needs of Refugee Children: A Review of Literature and Implications for Nurse Practitioners. Journal of the American Academy of Nurse Practitioners. 21(6):322-331. Davidson, N. Skull, S. Burgner, D. Kelly, P. Raman, S. Silove, D. Steel, Z. Vora, R. and Smith, M. 2004. An issue of access: Delivering equitable health care for newly arrived refugee children in Australia. Journal of Paediatrics and Child Health. 40(9-10):569-575. Drozdek, B. Kamperman, A.M. Tol, W.A. Knipscheer, J.W. and Kleber, R.J. 2013. Is legal status impacting outcomes of group therapy for posttraumatic stress disorder with male asylum seekers and refugees from Iran and Afghanistan? BMC Psychiatry. 13(1):148-150. Dudley, M. Steel, Z. Mares, S. and Newman, L. 2012. Children and young people in immigration detention. www.co-psychiatry.com. 25(4):285-292. Iliceto, P. Maurizio, P. Candilera, G. Borges, G. Lamis, D.A. Serafini, G. Giardi, P. 2013. Suicide risk and psychopathology in immigrants: a multigroup. Soc Psychiatry Epidemiol. 48:1105-1114. Jureidini, J. and Burnside, J. 2011. Children in immigration detention: a case of reckless mistreatment. Australian and New Zealand Journal of Public Health. 35(4):304-306. Kalt, A. Hossain, M. M, Kiss, L. and Zimmerman, C. 2013. Asylum Seekers, Violence and Health: A Systematic Review of Research in High-Income Host Countries. American Journal of Public Health. 103(3):30-42. Kim, I. Carrasco, C. Muntaner, C. McKenzie, K. and Noh, S. 2013. Ethnicity and Postmigration Health Trajectory in New Immigrants to Canada. American Journal of Public Health. 103(4):96-104. Mountz, A. Coddington, K. Catania, R.T. and Loyd, J.M. 2013. Conceptualizing detention: Mobility, containment, bordering, and exclusion. Progress in Human Geography. 37(4):522-541. Nathan, S. Kemp, L. Bunde-Birouste, A. Mackenzie, J. Evers, C. and Shwe, T.A. 2013. We wouldn’t of made friends if we didn’t come to Football United: the impacts of a football program on young people’s peer, prosocial and cross-cultural relationships. BMC Public Health. 13(1):1-16. Newman, L.K. Dudley, M. & Steel, Z. 2008. Asylum, Detention and Mental Health in Australia. Refugee Survey Quarterly. 27(3):110-127. Nursing and Midwifery Board, 2008. Code of Ethics for Nurses, www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Codes-Guidelines. aspx#codeofethics, accessed 26 September, 2013 Nursing and Midwifery Board, 2006. Registered Nurse Competency Standards, www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD1 0%2f1342&dbid=AP&chksum=N5ws04xdBlZijTTSdK nSTQ%3d%3d, accessed 26 September, 2013 Patterson, B. Kyu, H.H. and Georgiades, K. 2013. Age at Immigration to Canada and the Occurrence of Mood, Anxiety, and Substance Use Disorders. Canadian Journal of Psychiatry. 58(4):210-217. Procter, N. 2013. Engaging refugees and asylum seekers in suicidal crisis. Australian Nursing Journal. 20(9):44-45.

Savy, P. and Sawyer, A. 2008. Risk, Suffering and Competing Narratives in the Psychiatric Assessment of an Iraqi Refugee. Culture, medicine and psychiatry. 32(1):84-101. Sirriyeh, A. 2010. Sexual exploitation of young asylum seekers. Community Care. (1813):22-23. Slewa-Younan, S. and Radulovic, M. 2013. Emerging data on Resettled Iraqi Refugees in Australia: 10 years after the 2003 Iraq Conflict. Australian Nursing Journal. 20(11):42. Spinney, A. and Nethery, A. 2013. Taking our Houses: Perceptions of the Impact of Asylum Seekers, Refugees and New Migrants on Housing Assistance in Melbourne. Social Policy and Society. 12(2):179-189.

Anne Marie Assiri RN, BN is a Master of Mental Health Nursing Student at Flinders University and Registered Nurse at the Department of Psychiatry at the Royal Hobart Hospital, Tasmania

PAGE 35 April 2014 Volume 21, No. 9.

Men at the Men’s Shed


Primary & Community Health Care Two hats, one aim: nurses in partnership for better Indigenous health By Dr Glenda McDonald, Leanne Hunt and Sandra Kelty As nurses and academics working in separate areas and contexts of health care, but with similar aims of improving Aboriginal and Torres Strait Islander health, we knew the need for connecting with each other as well as with the wider Indigenous community. In 2013 a chance encounter allowed us to meet and we recognised the value of combining our knowledge, experience and resources to influence Aboriginal and Torres Strait Islander health outcomes and the cultural competence of future nurses and midwives. Joint visits to ‘The Shed’ were the beginning of a collaborative partnership project that led to better understanding of our roles and how we could work together to improve health outcomes. The Shed is a suicide prevention project. It is a turning-point place for men to reflect and reorient life and meaning, offering a safe place to be. It is a significant location of cultural exchange that not only supports Indigenous men to deal with mainstream

services, but challenges those services to adopt more relevant and culturally competent approaches to men. The Shed forms a vital part of a mental health education, promotion and mental illness prevention strategy. This strategy addresses issues such as identity, suicide, self-harm, family violence, inter-generational effects of the Stolen Generations, anger, incarceration, re-integration, drug and alcohol issues. Working together at The Shed allowed us to meet and listen to Aboriginal and Torres Strait Islander people first hand and see the inclusive way they interacted. We experienced respect for Elders, the willingness of people to share their life experiences and accept ‘whitefellas’ like us; despite facing disadvantage. The visits provided insights of the way that government and health service providers work together to improve access and outcomes for the community. Greater understanding developed of the backgrounds of Indigenous clients and the effects of long-term oppression on health and health engagement.

The knowledge we gained from The Shed was applied in both clinical and educational settings. It assisted us to recognise the complex differences between the Aboriginal and Torres Strait Islander peoples and other Australians living with chronic illness. It informed the best practice approach when dealing with Indigenous people as they encounter the health care system: being more inclined to ask questions about Indigenous identity, linking patients with Aboriginal Liaison Officers and including extended family. Our hope is that a positive experience for Indigenous community members with the nurse or midwife at the bedside will change their perceptions of engaging with health care in future. Dr Glenda McDonald is Lecturer and Leanne Hunt is Associate Lecturer in the School of Nursing & Midwifery at the University of Western Sydney in NSW Sandra Kelty is Clinical Lead Aboriginal Mental Health at the Sydney West Local District Health Service in Blacktown in NSW

The PCEHR’s role in primary and community care By Hayden Fisher and Kate Knapp The Personally Controlled Electronic Health Record (PCEHR) is having an impact on the day to day working lives of nurses and midwives, who are contributing to a better and more efficient health system. Along with their general practice colleagues, nurses and midwives across Australia are also accessing the PCEHR during the care of their patients and realising the benefits of improved clinical record keeping. Not only does the PCEHR provide access to clinical data from a range of providers across multiple locations, it can lead to improved data quality. In collaboration with the patient, who ultimately controls the information contained and decides who can have access, nurses and midwives can validate and update information to the record, thus improving the accuracy of data it contains.

In addition, the portability of the PCEHR enables nurses and midwives to access clinical data for patients that are new to a practice/ facility. Information that can be accessed may include prescribed medications, allergies, alerts, and medical history. In consultation with their patients, nurses and midwives also have the ability to upload a Shared Health Summary (SHS) and an Event Summary (ES) to their PCEHR, which other health care professionals in different organisations and locations can then view.

For instance, helping people to prepare for a long term trip around the country can be done easily through the PCEHR. A registered nurse can upload an SHS in conjunction with the patient receiving their travel immunisations. This enables registered health care practitioners nation-wide who may end up treating the person to get accurate and up-to-date information. When a person has their 75 year health assessment they can have their medical history checked and confirmed and an SHS or ES uploaded for viewing by other health

care providers as needed (eg nursing staff at a residential aged care facility).

Keeping track of a diabetic patient’s ongoing multidisciplinary care can be made simpler by incorporating an SHS or ES which keeps the whole team on the same page, so to speak. To start accessing or uploading to the PCEHR you need to ensure you have your individual health care identifier which is issued by AHRPA. Once access is granted, check with your employer to determine where your organisation is up to in their ehealth adoption journey. More information on how health care providers can use the PCEHR can be found at www.ehealth.gov.au Your Medicare Local’s ehealth team can assist in PCEHR registration, support and training. You can find your nearest Medicare Local at www.medicarelocals.gov.au Hayden Fisher is Senior Project Officer, eHealth Learning & Development at the Australian Medicare Local Alliance Kate Knapp is Field Adviser, eHealth at the Australian Medicare Local Alliance PAGE 37 April 2014 Volume 21, No. 9.

Focus Better mental health care hope for older rural people It is essential that service providers work collaboratively because of the complexity of mental health problems and the need for various services to be involved. Medicare Locals have been established to facilitate and manage collaboration between health and community services, however, methods for initiating and maintaining this process are unclear.

By Jeff Fuller

This project aims to tackle the problem by validating and testing a model for Medicare Locals to plan and manage the development of integrated primary mental health care for older people in a rural setting. Southern Adelaide-Fleurieu-Kangaroo Island (SAFKI) Medicare Local is part of the governance team for the project together with Country Health SA Local Health Network Mental Health Services and the Southern Fleurieu and Kangaroo Island Positive Ageing Taskforce.

Delivery of primary mental health care for older people living in rural areas could be improved following a project initiated by the School of Nursing & Midwifery, Flinders University.

Stakeholders will be engaged in a participatory ‘Plan, Do, Study, Act’ cycle, in which linkages will be explored. Participants will include consumers, carers and individuals working in primary care, subacute care (aged care and mental health) and non-government organisations.

Researchers hope their work will result in improved pathways to mental health care for older people and professional mental health links for staff working in aged care. The research could also lead to improved integrated care between primary, sub-acute and community care providers.

Qualitative and quantitative data will be collected to provide a description of the function and structure of the linkages between services. It is hoped participants will strengthen partnerships and provide more coordinated care for older people with a mental health problem.

Numbers of older people with mental health problems in rural communities are growing. In the older population they are frequently associated with comorbidities and poor outcomes, including early entry to residential care following lack of adequate treatment.

Anticipated outcomes include development of improved pathways to mental health care for older people and the strengthening of professional mental health links for staff working in aged care. It is hoped that the broader outcome will be a method that could be used by other organisations seeking to improve integrated care between primary, sub-acute and community care providers.

Various issues regarding help-seeking, service access and provision exist for this group. For the individual and their carer, negative views of mental health problems, stoicism, delayed recognition and lack of awareness of the availability of treatment can delay help-seeking and hinder access to treatment. PAGE 38

Jeff Fuller is Professor of Nursing (Primary Health Care) in the School of Nursing & Midwifery at Flinders University in South Australia

Supporting Aboriginal women’s health needs By Rose Cole The Mudang Mudjin, the Building Strong Foundations (BSF) team, is based at Cranebrook Community Health Centre and is also being created at Lithgow Community Health Centre. The team at Cranebrook is composed of Aboriginal health workers, social worker, child and family health nurses and a women’s health nurse (WHN). The BSF team works closely with the Aboriginal and Maternal Infants Health Service (AMIHS) to support Aboriginal children 0-5 years old and their families in the Penrith area. The WHN is a relatively new member of the team who responds to the impact of gender as a determinant of health and works in partnerships with general practitioners (GP’s), allied health professionals and community workers in providing community development, clinical, health education, health promotion and research and evaluation activities. Nepean Blue Mountains Local Health District (NBMLHD) indicators (2013) comparing Aboriginal and non-Aboriginal population report for Aboriginal people shows that there is an increase in socioeconomic disadvantage for Indigenous people. This includes increased risk health behaviours such as smoking, alcohol, reduced immunisation rates; maternal risk factors (mother younger than 20 years of age, delay in first antenatal visit and adverse perinatal health outcomes eg increased mortality, prematurity and low birth weight). Furthermore, Aboriginal people also experience more hospitalisations for chronic diseases, injury and poisoning than non– Aboriginal people. In addition to addressing these health issues for Aboriginal people, Aboriginal

Primary & Community Health Care women have been identified as a priority population according to the National Women’s Health Policy 2010, Australian Government Department of Health & Ageing 2010 and NSW Health Framework for Women’s Health 2013. Additionally, the NWHP also highlights the need for women to be free from violence. As a consequence clinical service provision by WHN’s involves early detection of women’s health issues. Cervical cancer rates are reported as being higher in Aboriginal and Torres Strait Islander women (Australian Institute of Health & Welfare 2011). Biennial Cervical Screening participation rates Nepean Blue Mountains LHD indicate that Penrith (48.8) and Lithgow (50.0) have a lower rate of participation than the NSW rate at 54.5 (personal communication, Anna Burham, Cancer Institute 2013). Breast cancer is the most common cancer amongst Aboriginal and Torres Strait Islander women and compared to nonindigenous women, experience poorer survival rates (National Breast & Ovarian Cancer Centre 2010).

“Breast cancer is the most common cancer amongst Aboriginal and Torres Strait Islander women and compared to non-indigenous women, experience poorer survival rates (National Breast & Ovarian Cancer Centre 2010).” Cardiovascular disease is the leading cause of death for women in Australia with 90% of women having at least one modifiable risk factor (Australian Institute of Health & Welfare 2010). Heart disease is therefore a priority for WHN’s and collaborative initiatives are being implemented across Australia, such as Heart Smart in Sydney South West Local Health District (personal communication, Lorena Schot, Clinical Nurse Consultant 16/11/2013). The BSF and AMIHS collaboration is an example of how innovative partnerships among Aboriginal women and their families, Aboriginal health workers, multidisciplinary community health workers and particularly Aboriginal community services can support building strong foundations for Aboriginal children and their families in the Penrith area.


Australian Government Department of Health and Ageing (2010). National Women’s Health Policy 2010. Canberra: Commonwealth of Australia. Australian Institute of Health & Welfare, Australian Government Department of Health and Ageing & National Cervical Screening Program. 2011. Cervical Screening in Australia 2008-2009, Cat no. CAN57, Canberra. Australian Institute of Health & Welfare. 2010. Women and heart disease: cardiovascular disease. Series no 33 Cat no CVD 49. Canberra: AIHW. National Breast and Ovarian Cancer Centre. 2010. Well women’s workshop community education resource. National Breast and Ovarian Cancer Centre, Surry Hills, NSW. NSW Department of Health. 2011. NSW Health Aboriginal Health Strategy, Centre for Aboriginal Health, Sydney. NSW Ministry of Health, NBMLHD. 2013. Aboriginal health. Population risk factors, births, deaths and hospitalisations. (DRAFT). Penrith: Planning, Strategy & Epidemiology, NBMLHD. NSW Ministry of Health. 2013. NSW Framework for Women’s Health 2013. North Sydney.

Rose Cole is the Women’s Health Nurse at Mudang Mudjin (Building Strong Foundations) at Cranebrook Community Health Centre in Cranebrook, NSW

Bringing the community into the classroom By Mark Browning and Ruth DeSouza

The Bachelor of Nursing (Community Health) at the Monash campus at Berwick is committed to being part of the community and bringing the community into the classroom. An annual highlight is the involvement of residents from the Woodlands Park Retirement Village (Berwick). In our first year nursing students’ clinical learning environment (CLE) session on health assessment, residents join us for two hours and are interviewed by small groups of two to four students. This gives students the opportunity to put their skills learnt in class into practice. These skills incorporate both health assessment and communication techniques.

“The benefits for all parties are significant. Students’ value learning from the lived experiences of older people and appreciate the opportunity to develop their communication skills in a ‘real world’ setting.” The benefits for all parties are significant. Students’ value learning from the lived experiences of older people and appreciate the opportunity to develop their communication skills in a ‘real world’ setting. The good health and robustness of the active residents also helps to dispel the myth that all older citizens are sickly or ill, which can be an unintentional consequence of teaching about the effects of ageing (McLafferty & Morrison 2004). The benefit for the residents is that they have an opportunity to contribute to the development of future nurses. The feedback that we have received is that they were particularly impressed with the care they received from students and their attention to detail. The maturity, kindness PAGE 39 April 2014 Volume 21, No. 9.

Focus and genuine interest that the students displayed were also noted. As educators we view this activity as being mutually beneficial to both parties and it serves to keep the recipient of care central to our teaching. The relationship reminds us of how important it is for universities to be inclusive and accessible to their local communities. We envision that this activity will continue for many years to come and appreciate the willingness of the residents of Woodlands Park Retirement Village to give of their time and experience.


McLafferty, I. and Morrison, F. 2004. Attitudes towards hospitalized older adults. Journal of Advanced Nursing, 47:446–453. doi:10.1111/ j.1365-2648.2004.03122.x

Mark Browning is a Lecturer and Ruth DeSouza is a Senior Lecturer in the School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences at Monash University (Berwick Campus) in Victoria.

Home-based palliative care and interdisciplinary teamwork By Margaret O’Connor and Gaylene Cowan Because of the holistic model of care and the diversity of individual patient needs, palliative care practice is inherently interdisciplinary. Thus in developed countries, one should expect to see a range of health professionals including nurses involved in an individual’s end-of-life care, who together aim to provide the best care possible. An interdisciplinary team of specialist nurses, counsellors, spiritual care workers, palliative care doctors, bereavement counsellors, trained volunteers and other allied care support, ensures a holistic rather than a medical model approach to care. Using a team signifies that no one health professional can meet all needs and recognises that the illness affects the whole person and their family/carer(s) in many ways: spiritually, emotionally, socially and physically. This approach requires that together, the team identifies and responds to the changing needs of the ill person and their family/carer(s),

which is especially pertinent in supporting a care environment in the person’s own home. Maximising quality of life is the goal for promoting dignity and independence through: • facilitating care which is directed by the person and their family/carer(s); • supporting the ill person and their family/ carers in their own home environment; • enabling those with changing needs to make choices about where they wish to receive their care (home, hospital or palliative care unit). The role of nursing is pivotal within the team, as anecdotally it is considered that no other needs can be met until the physical, symptom issues are addressed. For example, a person may be more able to discuss their hopes and fears for their remaining life, if they are pain free. There is an old saying that ‘teams don’t just happen; they slowly and painfully evolve – the process is never complete’ (Hodder & Turley 1989). Interdisciplinary

School of Nursing and Midwifery The School of Nursing and Midwifery offers high quality degrees in a vibrant and supportive learning environment to prepare students for a rewarding career in healthcare. One of the largest schools for the education of nurses and midwives in Australia, the school offers undergraduate, a range of research and coursework postgraduate courses and professional development programs. All courses and professional development activities are created in collaboration with the School’s professional partners to be responsive to the contemporary needs of the healthcare industry and are designed to be engaging for prospective students. for more information on all our programs visit www.med.monash.edu/nursing







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Primary & Community Health Care teamwork thus requires focused attention on the goal of working together and a commitment of time from all members of the team. At Melbourne City Mission Palliative Care (MCMPC), home-based care is supported by a number of strategies aimed at enhancing interdisciplinary practice including appointing an allied care professional as a team leader; employing nurses who are experienced in working with other disciplines; conducting team meetings in

“The role of nursing is pivotal within the team, as anecdotally it is considered that no other needs can be met until the physical, symptom issues are addressed.” an interdisciplinary manner; promoting the role of nurse practitioners in palliative care; and reviewing cases where interdisciplinary practice is evident and has had an influence on outcomes of care. In addition, an interdisciplinary model of professional supervision and support is being explored. Members of palliative care teams have developed much expertise in working with an overtly interdisciplinary model of care; they can attest to the strength of practice which then emerges as a result of working closely together to seek the best death for the terminally ill person and their family/carers.


Hodder P & Turley A. 1989. The Creative option of palliative care. Melbourne: Melbourne City Mission.

Professor Margaret O’Connor is the Vivian Bullwinkel Chair in Palliative Care Nursing, Palliative Care Research Team in the School of Nursing & Midwifery, at Monash University and Research Consultant at the Melbourne City Mission Palliative Care in Victoria Gaylene Cowan is the Coordinator of Nursing Services at Melbourne City Mission Palliative Care in Victoria

Do residential parenting education programs work? By Karen Berry and Jennifer Fraser Residential early parenting programs are aimed at making parenting a better experience by increasing parenting confidence and developing safe, effective child rearing practices. The goal of the programs is to have a positive effect on long-term health outcomes for children. In the case of families, who have complex and multiple vulnerabilities, this may lead to reduced risk for child abuse (Australian Government 2009, Johnson et al 2008). We asked: a) do these programs work and, b) what makes them work? Using mixed methods we evaluated a residential parenting program aimed at families referred from child protection authorities. In summary the qualitative results showed that nurses made this program work by using complex interpersonal qualities and skills to engage parents, many of whom were unwilling partners in the process. Nurses not only needed to engage with the parents but also provide high level surveillance in relation to parent-child interactions. This was to ensure both the safety of the child and to target parenting education and support. High level surveillance also needed to be accurately documented to support recommendations made by the nursing staff about the parents’ capacity to parent their children. Our evaluation revealed the toll that this type of work has on nurses, including the distress experienced by nurses observing poor parenting practices, in particular the observation of these practices on the child. Nurses also needed to put their own beliefs and biases about parenting to one side, which was demonstrated to have an adverse effect on the nurses’ emotional well-being.

Parent participants, although often unwilling to engage in the initial processes, were appreciative overall for the help and support given by nurses during their residence. A pre-post test of parenting confidence was conducted to augment the qualitative findings. By the end of the program parents overall felt more confident in their parenting role. Do these programs work? More evidence is needed to equivocally say that they produce long-term benefits, but what we do know is that the nurses are the linchpin to the program’s demonstrated success.

References Australian Government. 2009. A (draft) national framework for universal child and family health services. The Allen Consulting Group.Canberra ACT. Johnson, M A, Stone, S, Lou, C, Ling, J, Claassen, J, & Austin, M. 2008. Assessing parent rducation programs for families involved in child welfare services. Evidence and Implicaitons, 1-2, 191-236. Rowe, H J, & Fisher, J R. 2010. The Contribution of Australian residential early parenting centres to comprehensive mental health care for mothers of infants: a prospective study. International Journal of Mental Health Systems, 4(6). doi: www.ijmhs.com/content/4/1/6

Karen Berry is the Nursing Director at the Ellen Barron Family Centre, Child and Youth Community Health Services, Children’s Health in Queensland Jennifer Fraser is Associate Professor in the Sydney Nursing School at the University of Sydney, NSW

PAGE 41 April 2014 Volume 21, No. 9.

Focus Pap smear preceptor program By Sonia Harris-Bray

Cervical cancer is one of the most preventable and curable of all cancers. A Pap smear every two years can prevent the most common form of cervical cancer in up to 90% of cases and is the best protection against cervical cancer, according to the National Cervical Screening Program (2014). SHine SA, a state based health service, offers Pap smear provider training to nurses and midwives across South Australia. This training is the most popular course for nurses and midwives working in the community that is offered. However, until recently the only regulated clinical training that has been available was in the city.

This has been a prohibitive factor in rural and remote nurses/midwives completing the clinical training. One of the barriers women face in accessing a Pap smear is the lack of an acceptable Pap smear provider (Pap Screen Victoria 2013). Many women in rural and remote locations are under screened and experience higher rates of cervical cancer, in particular Aboriginal and Torres Strait Islander women (Pap Screen Victoria 2013). A key issue that we have tried to address at SHine SA is the ability to provide quality clinical training and ongoing support to

“Many women in rural and remote locations are under screened and experience higher rates of cervical cancer, in particular Aboriginal and Torres Strait Islander women (Pap Screen Victoria 2013).” nurses and midwives working in rural and remote locations. The project that has been initiated is a Pap smear preceptor training program based on a model that has been effective in other states. (Pap Screen Victoria 2014). The idea behind the program is to identify existing Pap smear providers in areas of high need and train them to support future nurses and midwives by


offering hands on clinical training and ongoing support in the workplace. A strategy that has been successful is to support the nurse/midwife preceptors in establishing a local women’s health network where they hold meetings and discuss clinical issues or difficult cases as well as providing each other with a sense of fellowship. SHine SA is optimistic that this program will grow in the future allowing a greater number of community health nurses and midwives to become Pap smear providers and receive local clinical training. The aim of this program is to provide women living in rural and remote locations with greater access to an acceptable clinician who is able to offer a quality screening service and improve health outcomes for previously disadvantaged women.


Key Statistics, National Cervical Screening Program www.health.gov.au/internet/screening/ publishing.nsf/Content/facts, viewed 23/01/14 Barriers to Screening, Pap Screen Victoria www. papscreen.org.au/forhealthprofessional/barrierstoscreening, viewed 23/01/14

Sonia Harris-Bray is Coordinator of Nurse and Midwife Education in the Workforce Development and Resource Team at Sexual Health Information Networking & Education SA Inc (SHine SA)

Primary & Community Health Care Nursing in general practice program By Stephanie Hille APNA has an ongoing interest in the Practice Nurse Incentive Program (PNIP) and its impact on the profession. APNA will work in partnership with AML Alliance to identify barriers to uptake of the PNIP and changes in the nurse role as a result of the PNIP; and develop resources to enhance uptake. Practical research and policy work to develop the role of the primary health care nursing profession is another key aspect of APNA’s work under the program. APNA will develop two major policy papers: one on undergraduate clinical placements in general practice and primary health care; and a second on transition to practice programs for nurses entering the sector. APNA will consult extensively with members and stakeholders to develop recommendations for further action. Top L-R: Murphy Woods, Administration; Weif Yee, Policy Coordinator; Cheryl Campbell, Professional Development Coordinator Bottom L-R: Samantha Moses, Nurse Consultant; Bronwyn Morris-Donovan, Program Director

The Australian Primary Health Care Nurses Association (APNA) is delighted to announce a partnership with Australian Medicare Local Alliance (AML Alliance) to jointly deliver the Nursing in General Practice Program in 2014 and 2015.

APNA will support work by the AML Alliance to roll out projects at Medicare Local level to develop nurse clinics, as well as promoting nurse leadership through workshops and other activities. This will include Leadership in Action Workshops at the APNA National Conferences in May 2014 and 2015.

The partnership offers a genuine opportunity to support and build capacity of the nursing workforce, and aligns with APNA’s strategic vision of a healthy Australia through best practice primary health care nursing. The program is funded by the Commonwealth Government, through the Department of Health.

APNA’s work under the program will also focus strongly on providing additional education and resources for nurses in general practice and other primary health care settings. APNA already has a strong track record in this area, and has made its one and two hour online learning courses free to APNA members from January 2014, as well as delivering an increasing portfolio of face-to-face education workshops on topics such as chronic disease management and emergency skills.

The Nursing in General Practice Program aims to: • increase the capacity of primary health care nurses; • promote recognition of primary health care nursing; • provide professional development opportunities; • support and cultivate nurse leaders in primary health care; • support improved uptake and implementation of the Practice Nurse Incentive Program.

The Nursing in General Practice Program will enable APNA to increase these offerings. A series of two-day multi-topic education workshops for primary health care nurses will be delivered across Australia in 2014 and 2015, and new online courses will be developed on topics including leadership and change management, population health and nurse clinics.

Work to strategically promote the profession is also a focus. APNA will work in partnership with AML Alliance on the development of a strategic marketing and communications campaign to promote nursing in general practice and primary health care. APNA has recruited a new Nursing in General Practice team to undertake this work: • P rogram Director Bronwyn Morris-Donovan, a podiatrist by training who has project management experience across a diverse range of primary health care related projects. • Nurse Consultant Samantha Moses, who was instrumental in establishing APNA back in 2001, and who brings a wealth of knowledge and experience to the program. •C  PD Coordinator Cheryl Campbell, a highly experienced registered nurse and midwife with experience in the Medicare Local sector. • Policy Coordinator Weif Yee, a physiotherapist by background, who has worked in programs and policy related to primary health care and population health. APNA is very keen to hear from nurses who would like to be involved in any way. Please email: bronwyn.morrisdonovan@apna.asn.au Stephanie Hille is the Communications and Policy Officer at APNA PAGE 43 April 2014 Volume 21, No. 9.

Focus Keeping Australia’s nurses safe: the importance of choosing and using gloves correctly By Dr Cathryn Murphy and manufacture in an effort to educate nurses about how to choose and use gloves safely.

Since the 1980’s Australian and international infection control directives have recommended that nurses and all health care workers (HCWs) in any health care setting including primary and community care settings routinely use disposable gloves as a protective barrier to prevent inadvertent exposure to blood and body fluids (National Health and Medical Research Council 2010; Loveday, Lynam et al 2014). Typically nurses wear either surgical gloves for invasive procedures where aseptic or sterile technique is followed or examination gloves for non-invasive procedures(Mylon, Lewis et al 2014). Experts recognise sensitivity to gloves as an occupational hazard of nurses. However, it is likely that few nurses fully understand the important differences between adverse reactions to gloves; specifically Immediate Type 1 and Delayed Type IV responses. The aim of this article is to discuss considerations used in glove selection including risk of cross contamination and barrier performance, impact of wearer’s skin as well as composition PAGE 44

Recent very specific infection prevention research highlights alarming facts about the risk of contamination and cross-transmission via HCWs’ hands. Loveday and colleagues report that in more than a third of all occasions when gloves were worn there was a risk of cross-contamination (Loveday, Lynam et al 2014). Regardless, staff nurses in the study used gloves appropriately only 45% of the time (Loveday, Lynam et al 2014). With less than half of all high-touch objects in Australian hospitals being cleaned properly (Murphy, Macbeth et al 2012) and inadequate levels of routine hand hygiene nationally (Hand Hygiene Australia 2013) Australian HCWs and nurses especially have an important professional obligation to use gloves as a barrier for self-protection. Gloves also reduce the risk of environmental contamination and transmission of infectious disease to patients, peers and visitors.

“Loveday and colleagues report that in more than a third of all occasions when gloves were worn there was a risk of cross-contamination (Loveday, Lynam et al 2014). Regardless, staff nurses in the study used gloves appropriately only 45% of the time.” Increased hand hygiene and glove usage can contribute to damaged skin with a recent large study of Australian and New Zealand HCWs indicating that up to 75% of all HCWs experience problems with either dry and/or damaged skin in any 12-month period (Flynn, Foxon et al 2005). Hand hygiene frequency, technique and product as well as routine skin care impact HCW skin condition (Flynn, Foxon et al 2005). Incorrect donning of gloves onto wet hands can also increase the risk of serious skin damage including irritant contact dermatitis (ICD). ICD differs from reactions to gloves that are allergic/immune responses

although many nurses fail to understand the differences and their respective solutions. ICD is more frequent, its symptoms are less severe and it can be reduced by improving skin care and wearing powder-free gloves as glove powder can have an abrasive effect on irritated skin (Murphy 2013). In contrast allergic/immune responses reactions are typically caused by contact with latex (Immediate Type 1 response) or with chemical residues/accelerators used in glove manufacture (Delayed Type IV response). Nurses experiencing either skin or systemic reactions to hand hygiene products or gloves should report their experience so that investigations can begin if required. In some cases change in hand hygiene or glove-donning technique eliminates the problem. In those rare but complicated cases where latex allergy is demonstrated, routine use of non-latex, powder-free gloves is a solution. Nurses with proven Type IV delayed response reactions to chemical residues/accelerators should routinely use gloves manufactured without accelerators. Latex and accelerator free gloves are currently available in Australia in both examination and surgical gloves. Infection risks exist in acute, community, long-term and primary care settings. Gloves provide an important barrier for nurses in any of those settings to reduce inadvertent exposure to potentially infectious material and contaminated equipment and surfaces. The ideal glove is comfortable, durable, elastic, strong and able to withstand long periods of use without microscopic failure or tearing (Loveday, Lynam et al 2014; Mylon, Lewis et al 2014; Mylon, Lewis et al 2014). New glove manufacturing processes and compositions including those discussed above as well as moisture retaining surfaces offer exciting and safe glove developments for nurses potentially at risk for either skin damage or allergic reaction. Australia’s current, overall poor infection prevention performance requires all nurses to be well protected as they perform their routine work. Choosing and using gloves correctly is a key part of that safety.

Primary & Community Health Care

References Flynn, J, E Foxon, et al. 2005. Skin condition and hand hygiene practices of Health Care Workers in Australia and New Zealand. Health care Infection 10(2): 59-66. Hand Hygiene Australia. 2013, June 2013. National Data Period Two June 2013. 2nd. Retrieved 2 December 2013, from www.hha.org. au/LatestNationalData.aspx Loveday, HP, S Lynam et al. 2014. Clinical glove use: health care workers’ actions and perceptions. The Journal of hospital infection 86(2): 110-116. Murphy, C. 2013. EPIC 2: Healthy Hands and Hand Hygiene Compliance, Can They Co-exist? EPIC: Essential Practices in Infection Control www.medical.ansell.com.au/epic-newsletterissue-2, retrieved 9/2/14 Murphy, CL., D A. Macbeth, et al. 2012. An assessment of high touch object cleaning thoroughness using a fluorescent marker in two Australian hospitals. Health Care Infection 16(4): 156-163. Mylon, P, R Lewis et al. 2014. A critical review of glove and hand research with regard to medical glove design. Ergonomics 57(1): 116-129. Mylon, P, R Lewis et al. 2014. A study of clinicians’ views on medical gloves and their effect on manual performance. American Journal of Infection Control 42(1): 48-54. National Health and Medical Research Council. 2010 Australian guidelines for the prevention and control of infection in health care.

Conflict of Interest Declaration Professor Cathryn Murphy is a casual consultant to medical industry and device manufacturers including glove manufacturers. Dr Murphy wrote this article independently with no external input from any member or representative of medical device or glove industries. Professor Cathryn Murphy works at the School of Nursing and Midwifery, Griffith University; Faculty of Health Sciences & Medicine, Bond University; Executive Director, Infection Control Plus Pty Ltd, Gold Coast, Queensland

Walking a tightrope: Women’s experiences of having an eating disorder while pregnant By Terri Burton Eating disorders are a global phenomenon and an escalating public health concern as they “carry the highest rate of mortality of any of the major mental disorders” (Urbancic & Groh 2009) and are a “common source of psychiatric morbidity in women of childbearing age” (Micali, Simonoff & Treasure 2007). Substantial extant literature demonstrates the aetiology, incidence and outcomes of eating disorders in women, with evidence showing the impacts on pregnancy, the fetus and parenthood adjustment. However, there is a paucity of research regarding how women make meaning of the experience and a phenomenological study provided a description of the pregnancy experience as perceived by a cohort of women with diagnosed eating disorders. Data was collected via interviews with women with a known diagnosis of an eating disorder either in the past or present and who had been pregnant within the previous twelve months. It was analysed using constant comparative approach seeking themes and patterns. There were 14 themes identified that described the women’s experience of living with an eating disorder while pregnant. These themes were a basic description of the pregnancy journey itself, the use of metaphor, perceptions of motherhood, concerns about the baby, body image, eating disorder behaviour, eating disorder status, secrets, wishes, misconceptions, support, emotions, health professionals interactions and health care improvements. Overall, the women described their pregnancies as traumatic experiences involving constant emotional struggles to prevent loss of control, concerns over the impact that their disordered eating behaviours were having on their developing babies and hiding their lived experiences from those around them for fear of stigmatisa-

tion or being perceived as bad mothers. They felt that most of their care contained deficits, was negative and impersonal,

“These themes were a basic description of the pregnancy journey itself, the use of metaphor, perceptions of motherhood, concerns about the baby, body image, eating disorder behaviour, eating disorder status, secrets, wishes, misconceptions, support, emotions, health professionals interactions and health care improvements.” however, they saw improvements in the therapeutic relationships, the employment of more midwives, continuous care and greater collaboration between care providers were a means to enhance care. Furthermore, printed matter, questionnaires, support groups and debriefing were seen as resources to enrich practice. It is important that health care providers have an awareness that pregnant women may undergo personal torment and to be sensitive to the specific needs of women with eating disorders. This study has raised awareness of this issue and provided a baseline for further research in the area. It is envisaged that the women’s voices will be a platform to improve maternity care.


Urbancic, JC & Groh, CJ. 2009. Women’s mental health: A clinical guide for primary care providers. Sydney: Lippincott, Williams & Wilkins. Micali, N, Simonoff, E & Treasure, J. 2007. Risk of major adverse perinatal outcomes in women with eating disorders. British Journal of Psychiatry, 190(3), 255-259.

Terri Burton is a Lecturer at Tabor College in Perth and a PhD Candidate at the University of Notre Dame Australia

PAGE 45 April 2014 Volume 21, No. 9.

Focus Midwives get set to prescribe medications For midwife Daniel Evans, receiving his prescriber number and script pad is recognition of the important role a midwife plays in society. A Newcastle-based midwife with ten years experience, Daniel is one of the first graduates from Griffith University’s new online course: Screening, Diagnostics, Pharmacology and Prescribing for Midwives program. The course prepares midwives with the skills required to prescribe medications and diagnostics/screening tests relevant to the midwifery scope of practice in a legal, safe and effective manner. “It is so exciting to now have the ability to prescribe medications to women rather than defer to another medical professional,” said Daniel. “Previously, midwives had to ask GPs

and specialists to organise not only medications, but also routine testing/screening such as ultrasounds and blood tests.” Recent research has shown that continuity of midwifery care has a profound and significantly positive impact on pregnancy and birth outcomes for women. Daniel agrees having professional midwives endorsed to perform these tasks is a real advantage. “We can provide more effective continuity of care and better outcomes for pregnant women and new mothers,” he said. “At the same time, midwife prescribers can help reduce the burden on our medial colleagues who are otherwise required to write prescriptions and request screening/diagnostic testing for pregnant women they may not know or perhaps have never met,” Daniel said.

Daniel is now aiming to open his own private midwifery practice with his colleague, Lynelle Hill, while continuing to work as a midwife for the Hunter New England Area Health Service in New South Wales.

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Primary & Community Health Care Supporting primary health care nurses to provide health care to men By Del Lovett

preventive health and health promotion for men and suggests that PHCNs make an important contribution. There is limited knowledge of men’s health services of the nature or extent of preventive health and health promotion provided by PHCNs in Australia. While there is widespread support for prevention as core business in primary health care, many health care professionals acknowledge that they lack the skills required to undertake preventive care effectively (Primary Health Care Reform in Australia Report 2009 p56). This problem is identified in the National Male Health Policy (2010) that recommends that primary care services better their responsiveness to men’s need.

I am currently undertaking a higher degree by research at the School of Nursing and Midwifery, Deakin University. My research is on ‘primary health care nurses’ (PHCNs) and men’s perception of the role of the primary health care nurse in providing men’s health services in the primary care setting in Victoria’. The study aims to explore PHCN’s perceptions and understanding about men’s health and describe men’s expectations of the role of the PHCN in delivering health care for men, as well as identify PHCN’s perception of facilitators and barriers to deliver preventive health and improved access for men to health care. The Australian primary health care nurse’s role has seen rapid development and expansion due partly to increased pressure created by the significant rise in the prevalence of chronic and complex conditions. These conditions require a nursing workforce that is skilled in preventive and health promotion activities. Furthermore, the National Male Health Policy (2010) highlights a need for a greater focus on

The current research study is therefore timely as it aims to firstly explore PHCNs perception of their role to provide health services targeted specifically to men.

“The National Male Health Policy (2010) highlights a need for a greater focus on preventive health and health promotion for men and suggests that PHCNs make an important contribution.”

Australian College of Nursing (ACN) offers a Graduate Certificate in Nursing Practice designed to enhance the knowledge and skills of primary health nurses working in diverse contexts and specialities. For more information go to: www.acn.edu.au


Commonwealth Government of Australia 2009. Primary Health Care Reform in Australia Report to Support Australia’s First National Primary Health Care Strategy. www.yourhealth. gov.au/internet/yourhealth/publishing.nsf/ content/nphc-draft Commonwealth Government of Australia 2010. National Male Health Policy: Building on the strengths of Australian Males, Canberra, Australia, DoHA: www.health.gov.au/internet/main/ publishing.nsf/Content/7935AC78159969D4CA 257BF0001C6B07/$File/MainDocument.pdf The Royal Australian College of General Practitioners 2012. Guidelines for preventive activities in general practice: 8th edition East Melbourne: The Royal Australian College of General Practitioners: www.racgp.org.au/download/Documents/Guidelines/Redbook8/redbook8.pdf

Del Lovett is a registered nurse studying at Deakin University, Victoria

Secondly, the study examines how men conceptualise the role of the PHCN in their health care. Currently qualitative data has been gathered by facilitating focus groups and interviews of PHCNs and men. The study hopes to uncover that there is a lack of preventive health and health promotion that specifically defines men’s health issues. Preliminary findings suggest that PHCN preventive health and health promotion for men is largely opportunistic and not specific evidence based preventive activities as those in the Royal Australian College of General Practitioner (RACGP) Red Book. If you are a primary health care or practice nurse who feels they lack the knowledge and skills required within men’s health or have an interest in advancing your career as a primary health or practice nurse the PAGE 47 April 2014 Volume 21, No. 9.


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Primary & Community Health Care Health literacy and nursing By Alison Beauchamp and Louise Sparkes

of preventive measures (Scott, et al 2002), higher mortality rates ; Sudore, et al 2006), increased health care costs (National Academy on an Ageing Society 1999) and poorer health outcomes (von Wagner, et al 2009). Suboptimal health literacy is likely to contribute to health inequalities (Howard, et al 2006; Sentell and Halpin 2006) as those with low health literacy are less able to make informed decisions about their health and participate effectively in self-care, than those who have high levels of health literacy.

Nurses spend more time than any other health professional with patients. They are responsible for the delivery of a variety of patient care activities including the provision of health information. Health education is important for those we care for, however health literacy is a more comprehensive concept that considers the health knowledge and skills required for our patients to engage with our health care system and participate actively in their own health care. Health literacy is more than just the ability to read and write. For our patients, it involves a complex set of skills and attributes that include: comprehension, the appraisal of health care information, social support, confidence and motivation to act as partners in management of their health. Health literacy is defined as a person’s ability to seek, understand and use health information to make well-informed decisions about their health (World Health Organization, 1998). Around one third of Australians have inadequate health literacy (Barer, et al; Australian Bureau of Statistics 2009). Lower health literacy is associated with higher rates of preventable hospitalisations (Baker, et al 2002; von Wagner, et al 2009), inadequate consumer-health professional communication (Schillinger, et al 2002), a lower uptake

“A person’s health literacy abilities are not always easy to estimate, with many patients ashamed to admit they don’t have the capacity to obtain or understand health information well enough to be able to participate in health care decisions or self-care.” A person’s health literacy abilities are not always easy to estimate, with many patients ashamed to admit they don’t have the capacity to obtain or understand health information well enough to be able to participate in health care decisions or selfcare. As nurses, developing an awareness of health literacy and changing our clinical approach may mean we can better support our patients with lower health literacy. Combined with organisational governance and evidence based policies that integrate and respond to health literacy needs, this provides an opportunity to improve health outcomes and reduce health inequalities. The Ophelia project is an Australian Research Council project, in collaboration with the Victorian Department of Health and Deakin and Monash Universities, which aims to measure the health literacy of Victorians attending health care centres. The project aims to develop successful and feasible interventions to improve the health literacy of Victorians using services at community health care centres that can be adopted by others.


Australian Bureau of Statistics (ABS) 2009 (June). Social Trends 4102.0. Baker, DW, et al. 2002 Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of Public Health 92(8):1278-83. Barber, MN, et al. Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool: results from a population-based survey.[Erratum appears in Health Promot Int. 2009 Dec;24(4):445]. Health Promotion International 24(3):252-61. Howard, D. H., T. Sentell, and J. A. Gazmararian. 2006 Impact of health literacy on socioeconomic and racial differences in health in an elderly population. Journal of General Internal Medicine 21(8):857-61. Peterson, PN, et al. 2011 Health literacy and outcomes among patients with heart failure. JAMA 305(16):1695-701. Schillinger, D, et al. 2002 Association of health literacy with diabetes outcomes. JAMA 288(4):475-82. Scott, TL, et al. 2002 Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care 40(5):395-404. Sentell, TL, and HA Halpin 2006 Importance of adult literacy in understanding health disparities. Journal of General Internal Medicine 21(8):862-6. Sudore, RL, et al. 2006 Limited literacy and mortality in the elderly: the health, aging, and body composition study. Journal of General Internal Medicine 21(8):806-12. von Wagner, C, et al. 2009 Health literacy and health actions: a review and a framework from health psychology. Health Education & Behavior 36(5):860-77. World Health Organization 1998 Health Promotion Glossary. Health Promotion International. 13(4):349-64.

Alison Beauchamp is a Research Fellow at Deakin Population Health SRC, Faculty of Health, Deakin University in Victoria. Louise Sparkes is a PhD candidate at Monash Department of Clinical Epidemiology, Cabrini Hospital; Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University and a Lecturer in the School of Nursing and Midwifery at Monash University in Victoria.

PAGE 49 April 2014 Volume 21, No. 9.

Focus Breast cancer during pregnancy By Dr Lea Budden A diagnosis of breast cancer is devastating news for any woman, none more so than when a young woman is pregnant. In Australia, it is estimated that women have a one in eight chance of developing breast cancer by the age of 85 years (Australian Institute of Health and Welfare & Australasian Association of Cancer Registries 2012) with this incidence continuing to rise. Breast cancer is more common in women over 50 years of age. Other risk factors for developing this cancer include a family or personal history of breast cancer and hormonal and lifestyle factors (Cancer Australia 2013a). It is uncommon for young women to develop breast cancer but it can happen. Breast cancer in Australian women younger than 40 years affects between 11 and 13 per 10,000 women (Australian Institute of Health and Welfare & Cancer Australia, 2012). The main types of breast cancer are Ductal carcinoma insitu (DCIS- non-invasive), Invasive or Lobular carcinoma (ducts or lobes in breast), Paget’s disease (breast nipple), and Inflammatory breast cancer (lymphatic vessels). The symptoms and treatment of breast cancer often depend on the location, size and rate of growth of the tumour (Cancer Australia 2012). Other important treatment factors relate to the women’s stage of pregnancy. One option

Would you like to contribute to our Focus section? Listed are our Focus topics and due dates for 2014. All topics are subject to change. Email Cathy: cathy@anmf.org.au if you would like to contribute.

given by specialists if women are in the very early stages may be termination of pregnancy. Women may be offered breast surgery and chemotherapy if they are past the first trimester of pregnancy. Radiotherapy therapy or hormonal treatment are not recommended options for women during this time (Cancer Australia 2012).

“The symptoms and treatment of breast cancer often depend on the location, size and rate of growth of the tumour (Cancer Australia 2012).” Women need to be able to access accurate information to assist them to make informed decisions related to treatment for breast cancer during pregnancy. Some of the treatments for breast cancer can affect future fertility of the women. A decision aid for fertility-related choices for younger women with early breast cancer is available online at: www.bcna.org.au/store/products/fertility-related-choices-decision-aid (Psychosocial Research Group 2011). The Cancer Australia website provides a comprehensive guide of questions for women to ask specialists about breast cancer treatment: http://canceraustralia. gov.au Breast Cancer Network Australia (BCNA) also provides some great resources and support for women with breast cancer and their families: www.bcna.org.au. Other information and support for women and their families can be obtained from the Cancer Councils and Breast Cancer Nurses.

Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. 2012. Cancer in Australia: an overview. In Cancer series no. 74. Cat. no. CAN 70. (Ed.). Canberra: Australian Insititute of Health and Welfare. Australian Institute of Health and Welfare & Cancer Australia. 2012. Breast cancer in Australia: an overview Cancer series no. 71. Cat. no. CAN 67. Canberra: AIHW. Breast Cancer Network Australia. 2014. About breast cancer. www.bcna.org.au/about-breastcancer,retrieved 06/02/2014 Cancer Australia. 2012. Treatment for breast cancer during pregnancy, http://canceraustralia. gov.au/affected-cancer/cancer-types/breastcancer/treatment/making-decisions-about-treatment/treatment-pregnancy, retrieved 09/01/14 Cancer Australia. 2013. Breast cancer, http:// canceraustralia.gov.au/affected-cancer/ cancer-types/breast-cancer/about-breast-cancer retrieved 07/02/14 Cancer Australia. 2013. Making decisions for breast cancer . http://canceraustralia.gov.au/ affected-cancer/cancer-types/breast-cancer/ treatment/making-decisions-about-treatment, retrieved 6/02/2014 Psychosocial Research Group. 2011. Fertilityrelated choices: A decision aid for younger women with early breast cancer. www.bcna.org. au/fact-sheets-and-booklets - fertility, retrieved 06/02/2014,

Dr Lea Budden is Senior Lecturer Student Experience Coordinator Honours Coordinator in the School of Nursing, Midwifery & Nutrition at James Cook University in Townsville Qld.


Focus Topic

Due date


Mental health



Women’s health



Oncology nursing



Infection control



Emergency nursing



Men’s health



Remote and rural health care


w PAGE 50


Clinical View Denise Cummins and Janelle Muldoon

Informing and educating undergraduates on HIV The Human Immunodeficiency Virus (HIV) epidemic has evolved in Australia, yet many nurses may have limited knowledge of HIV infection, which could impact negatively on patient care. As a Clinical Nurse Consultant (CNC) HIV Disease while providing education to recently graduated nurses, at a suburban hospital in Sydney, it became apparent to me that they had fears and limited knowledge of HIV issues and infection control. This triggered a pre-educational session quiz, which elicited some concerning results. Forty-one nurses at the end of their graduate program completed the pre-educational quiz. All had undergone infection control education and blood borne virus education at university. • 37% stated that insects can transmit HIV; • 17% thought HIV could be contracted from sharing a cup with a HIV positive person; • 12% said you could tell someone had AIDS because they looked tired and ill; • 66% were unaware of legislation related to HIV disclosure by a health worker; and • 71% were unaware of post exposure prophylaxis (PEP) for an exposure to HIV. These results prompted a quality improvement project for undergraduate nurses (UGN) on clinical placement in community health settings. The purpose of the program was to ascertain HIV knowledge and concerns of UGNs and provide education regarding issues pertaining to HIV during clinical placements with me in the community setting. Sydney Local Health District (SLHD) has five community health centres. A pilot program was developed for UGN whilst on clinical placement at one centre. Students were recruited over a four month period. Education focused on HIV issues including: transmission, infection control, legislation, issues for people living with HIV (PLWH) and post exposure prophylaxis. A pre and post test was applied. Twelve undergraduate students were enrolled in the program. Most had limited knowledge and only two had been provided HIV information in their course. Many (67%) were concerned about HIV transmission. None were aware of post exposure prophylaxis (PEP). Issues discussed during educational settings included:

What is HIV and AIDS?

• HIV damages the body’s immune system, which makes it more difficult to fight off infections; • someone who is diagnosed with HIV is HIV positive; • a person may be HIV positive for many years before deterioration in immune function and progression to Acquired Immune Deficiency Syndrome (AIDS); • treatment for HIV can prevent the development of AIDS. (Sexually Transmissible Infections Program Unit (STIPU).

How is HIV transmitted? HIV is in the blood, semen, vaginal fluid or breast milk of an infected person and can be transmitted: during anal or vaginal sex without a condom (this is known as unprotected or unsafe sex), by sharing drug injecting equipment and to an HIV infected mother’s baby during pregnancy, childbirth and breast-feeding (STIPU). HIV is not transmitted by kissing or cuddling; by day-to-day social contact such as shaking hands; by sharing cutlery, cups or glasses; by eating food prepared by someone with HIV; through toilet seats; or by mosquito or other animal bites (STIPU).

Post-exposure prophylaxis (PEP) PEP, which is a combination of anti-HIV drugs, is a treatment that may prevent HIV infection and is available to anyone likely to have been exposed to HIV. Early initiation of PEP is advised, as soon as possible after exposure. PEP should be prescribed and taken within 72 hours.

Period and frequency of follow-up HIV antibody testing is conducted at baseline, and at four to six weeks and three months after exposure. (National guidelines for post-exposure prophylaxis after non-occupational and occupational exposure to HIV, 2013). PEP is generally available from sexual health clinics or in the accident and emergency department and staff health at most hospitals. There is a 24 hour PEP Hotline: Tel: 1800 PEP NOW or 1800 737 669 (inside NSW).

Does PEP work? PEP will reduce the risk of HIV infection following an exposure to infected blood or

bodily fluids. In the case of occupational exposure in a workplace (eg. risk of exposure through needle stick injury or other sharps exposure- 1/440, and risk of exposure through mucous membrane and non-intact skin exposure <1/1000), PEP has been used for a number of years and has been effective in most cases. (National guidelines for postexposure prophylaxis after non-occupational and occupational exposure to HIV, 2013).

Post evaluation of educational session: • 100% had improved knowledge on all issues listed in pre education quiz; • the information they found most useful was regarding PEP, pathology results, issues for PLWH and HIV medications; • all students were willing to learn and most interested in PLWH and how they could improve the care in the future.

Conclusions/next steps: It is not practical to provide this level of education to each nursing student across the five community centres. The next stage is to develop an online education module to provide current, relevant information, case studies and media of PLWH sharing their stories. Each UGN will be given the opportunity to complete the module and contact me as required. This module will be piloted and evaluated prior to being made available online. A pre and post test will be attached to the education module and results evaluated to ascertain future areas of education and to establish evidence of change in knowledge. It is hoped this education will lead to enhanced care for the PLWH and confidence in caring for them by the UGN.


National Guidelines for post-exposure prophylaxis after non-occupational and occupational exposure to HIV. December 2013. http://www.ashm.org.au/ pep-guidelines/NPEP_PEP_guidelines_Dec_2013. pdf Accessed 2 February 2014 New South Wales Sexually Transmissible Infections Program Unit (STIPU) http://www.stipu.nsw.gov.au/content/ Document/HIVAIDS.pdf Accessed 3 February 2014

Denise Cummins is a Clinical Nurse Consultant at the Sydney District Nursing Service, Community Health, Sydney Local Health District. Janelle Muldoon is a Clinical Nurse Educator, Centre for Education Workforce Development Sydney Local Health District

PAGE 51 April 2014 Volume 21, No. 9.

Calendar APRIL

Lung Health Promotion Centre at The Alfred 28–29 April, Spirometry Principles & Practice Lung Health Promotion Centre at The Alfred Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au


APNA Continuing Education Workshops for Nurses in General Practice 2–3 May, Mercure Perth, WA. 9–10 May, Rydges Darwin Airport Resort and Hotel, NT. For more information and to register go to www.apna.asn.au/nigp Massage workshops for Nurses, Midwives and Carers (6 CPD hours per workshop) 5 May, Massage in Nursing – An Intro (ANMF Ed Centre). Contac t Angeline von Doussa, RN, RM, Dip Massage Therapies, Spa Therapies, Nurse Educator. Mobile: 0431994618 Email: angeline@nurses–healing.com http://nurses–healing.com World Congress of Cardiology 4–7 May, Melbourne Victoria. World leading experts will present over 150 sessions on cardiology, policy and public health with a spotlight on regional issues. The latest scientific findings will be featured in over 1,000 new abstracts on the prevention, diagnosis and treatment of cardiovascular disease. Take this opportunity to participate in an international congress on your doorstep www.worldcardiocongress.org Lung Health Promotion Centre at The Alfred 7–9 May/11–12 June, Respiratory Course 7–9 May, Respiratory Course (Module A) 29 May, Respiratory Update Lung Health Promotion Centre at The Alfred Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au 6th APNA National Conference Thriving through change 29–31 May, Hilton Sydney, NSW. APNA’s


Austin Hospital, Heidelberg, 74 1A&B reunion Would like to contact J Sherrin, A Strickland, S. MCGhee, J Ramm, G Halley, T Johannsen, S McConnell. Hope to hold a get together later this year. If interested please contact wendybrack@gmail.com or 0427 154 505 Royal Children’s Hospital past trainees and RCH Grads reunion 17 May at RACV PAGE 52

Club, Melbourne. Contact Chris Fautley Email: chrisfau@ netspace.net.au Ph: (03) 9347 3546 or Sue Scott Email: sue. scott@rch.org.au RMH operating theatre staff reunion/ social get together 18 May, 2-4pm, Princes Park Carlton Bowls Club, 109 Bowen Crescent, Carlton North, Vic. Please bring a plate of food to share. Drinks at bar prices. $10 per adult includes a glass

sixth exciting national conference will provide extensive opportunities to network with your nurses colleagues from around Australia, and a fantastic program to enhance clinical expertise and add to your personal and professional development. http://apnaconference.asn.au/

APNA Continuing Education Workshops for Nurses in General Practice 20–21 June, Stamford Plaza, Adelaide, SA. For more information and to register go to www.apna.asn.au/nigp


Lung Health Promotion Centre at The Alfred 15 July, Educating & Presenting With Confidence 16-18 July, Asthma Educator’s Course 24–25 July, Smoking Cessation Facilitator’s Course 30–31 July, Creative Behaviour Change Coaching For Chronic Illness Lung Health Promotion Centre at The Alfred Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au

Lung Health Promotion Centre at The Alfred 11–12 June, Respiratory Course (Module B) 13 June, Theory & Practice of Non Invasive Ventilation – Bi–Level & CPAP Management 18 June, Asthma Management Update 19–20 June, Spirometry Principles & Practice 25 June, Paediatric Respiratory Update Lung Health Promotion Centre at The Alfred Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au Massage workshops for Nurses, Midwives and Carers (6 CPD hours per workshop) Touch is one of the most essential and fundamental needs for human restfulness. These quality workshops give Nurses, Midwives and Carers, the skills, knowledge and confidence to help clients with their hands, their touch and presence of wellbeing. Glenelg S.A Boutique Training in Luxury Surroundings 13 June, Baby Massage (Afternoon Session) 14 June, Massage in Nursing – An Introduction 15 June, Spa and Wellbeing Day (relax, re energise, re balance in this whole day spa experience for you) 16 June, Massage in Midwifery Care (Women and Babies) – An Intro 17 June, Palliative Care and/or RelaxationMassage 18 June, TBA or Special Booking (book the facilities and/or spa hostesses for your own special group) 19 June, Reflexology for Health 20 June, Shiatsu and Acupressure Contact Angeline von Doussa, RN, RM, Dip Massage Therapies, Spa Therapies, Nurse Educator. Mobile: 0431994618 Email: angeline@nurses–healing.com http://nurses–healing.com

of wine/champagne. RSVP very important by 9 May. Please make this a fun get together, the more the merrier. Contact Helen Savage Ph: (03) 9342 7270 Email: helen.savage@ mh.org.au or Robyn Whiting Ph: (03) 9342 7270 Email: robyn. whiting@mh.org.au Austin Hospital Heidelberg, 74 2A/B, 40-year reunion 31 May. All nurses connected with this group welcome. Contact Angela Balon.

Email: angelaveysey@ optusnet.com.au Ph: (03) 9870 4801 Mobile. 0412 402 875 Royal Melbourne Hospital, June 1974 PTS, 40-year reunion 1 June, The Atrium Bar, Crown Casino, Southbank at 1230. For any further details please contact Jill Friedman (nee Darby) on Mobile: 0410 416 993 or Email: jfriedman@rdns.com.au John Fawkner Private Hospital/Sa-


APNA Continuing Education Workshops for Nurses in General Practice 25-26 July, Mercure Hotel Brisbane, QLD. For more information and to register go to www.apna.asn.au/nigp


Update’ study day with Kathy Mills, RN, MEd, Credentialled Diabetes Educator. This study day for enrolled and registered nurses covers contemporary and evidence based research on dietary, exercise, psychological and pharmacological management of diabetes mellitus. Date: Friday August 8 from 9am–4pm at Inner East Melbourne Medicare Local, 6 Lakeside Drive, Burwood East. There is free onsite parking. Morning tea, lunch and notes are provided. Eligible for 6 hours professional education. Cost: Early bird special (pay by Friday 25 July) is $220. Full registration fee: $250 All queries to Kathy via email only at diabetes. ed@optusnet.com.au


CATSINaM 16th National Conference Embrace the difference within our people 23–25 September, Perth WA. http://catsin.org.au/

cred Heart Hospital celebrates its 75th anniversary October. We are seeking memorabilia, old photographs, uniforms, books, instruments, stories etc. from past staff, doctors and students. An open day and other activities are planned for this milestone event. Contact Chris Papas, Executive Secretary at chris. papas@healthscope. com.au or Ph: (03) 9385 2501

Royal Adelaide Hospital Nurses Training, Group 895, 25-year reunion 29 November in Adelaide, at a venue to be announced. Please contact Julia Curley for further details Email: juliacurley@hotmail.com

Mail Australian Nursing & Midwifery Journal Volume 21, No. 8. March 2014

Letter of the month

Reflecting on past achievements This is the first time in 38 years that I will not be renewing my membership to the Australian Nursing & Midwifery Federation. I have retrained as a social worker and am now working in that field. Changing careers made me reflect on the achievements of the ANMF during those years as a member.

Nurses eat their own

Bullying and horizontal violence takes its toll www.anmf.org.au

The most important achievement I thought was the introduction of professional rates of pay after the 1986 strike. More recently the introduction and maintenance of patient ratio’s are also a laudable accomplishment. I would like to thank the ANMF for all that they have done for the nursing and midwifery profession over the years that I was a member.

I think the biggest challenge now and in the future is how nurses and midwives can deliver good safe care in a system where the throughput (both the volume and speed) of patients is too large and too fast. I would like to know on what basis is this volume and speed of patients through the system calculated. Despite being highly qualified to determine what good, manageable and safe care is, I would suspect that the views and opinions of the bedside clinicians are not sought on this matter. Finally, is there a finite value/number to the volume and speed of the patient throughput? Susan Nisbet, RN/ Midwife, Victoria

(The winner of the ANMJ best letter receives a $50 Coles Myer voucher. If you would like to submit a letter to the ANMJ email anmj@anmf.org.au. Letters may be edited for clarity and space)

Horizontal violence a living reality I would like to respond to the article ‘Nurses eat their own’ published in the March ANMJ. I decided early in my final year of university to pursue a career in aged care. I secured a graduate position in an aged care facility and started in February 2014. From day one I experienced horizontal violence from my ‘allocated’ preceptor/supervisor and other senior colleagues. A graduate nurse should expect to be supported and guided through their first year as a RN. Instead, I found I was ‘on the outer’ with the senior and older RN’s, and refused help when I asked. Professor Gerry Farrell’s comments in the feature almost brought me to tears. Almost everything he said is what is happening to me. How is a graduate who is new to an organisation supposed to ‘just know’ what they are expected to do? The withholding of necessary information and silence I experience daily are enough for me to return home after my shift and cry.

There is also no one for me to go to. I wonder sometimes if I have made the right career choice, because if the nurses who I work with currently are willing to try and push me out the door now, as a non-threatening graduate nurse, how will I be treated in four or five years from now? The sad part is that these senior nurses fail to see that by investing their knowledge and skills in me and my eager willingness to learn could actually benefit them in the long run. I could be the RN in charge caring for them one day in the future! Why would you not want to invest in the future workforce that will also impact on you? I’m so disappointed as this is not how I imagined my graduate year to be. I will stay strong and fight for my career, because every day a resident thanks me or smiles at me for looking after them, makes it worthwhile staying and putting up with the bullying. Anonymous graduate nurse

PAGE 53 April 2014 Volume 21, No. 9.

Mail Bullying perspective Your article on Bullies was timely and relevant. As a profession we have a poor track record. But most of our bullies are not pathological sadists. They are panic stricken people who are given the poorest of examples from those supervising them. If we have a bully at the top of the pyramid, the culture will trickle all the way down because those who try to change the culture will themselves be cast aside. The nurse is especially vulnerable because those above him or her are concerned with what they honestly perceive as good and economic governance, but she/he is concerned with another person’s welfare and sees the suffering resulting when this is inadequate. And when we feel we are failing in this regard, we turn in on each other because we see no point in trying to change the line culture.

Thank you from Tanzania The ANMJ kindly published a letter from me requesting second hand nursing text books to be donated for nursing students at a university in Tanzania, about 18 months ago. Since that time I have been in Dodoma, Tanzania, working at St John’s University of Tanzania. I would like to express gratitude to all those who kindly sent books in response to that request. Parcels have been arriving over several months and we have received a range of text books. These have been very gladly received by both teaching staff and students. To have access to current, good quality textbooks is still a luxury in this part of the

AHPRA experience To all nurses and midwives, I wish to share with you my experience with AHPRA. It was May 2013 and time to renew my registration. I chose to do it online and unwittingly decided to give up my general registration and keep my midwifery registration only, thinking I would save some money and not have to keep up with another 20 hours of general nursing CPD. I am nearing retirement and planned to be a midwife till then. Well did I regret it! Soon after I changed my mind and tried to register as an RN as well, but too late. I still had a few weeks to renew before it expired but there was PAGE 54

world. Both the value of the books, and the postage costs, even sea-mail, were considerable. The books are being extensively used by both lecturers and by students. To all those people who gave generously in this way, I am sending thanks and greetings from colleagues in the School of Nursing, St John’s University of Tanzania. You have provided and extended learning opportunities for many nurses and demonstrated the strength of international nursing as well as the generosity of Australians.

At the end of the day, the patient suffers more from bullying than any other person in the vertical or horizontal line. If we are serious about patient centred care, we must give those asked to help with governance both the training and material support to enable them to do this. Mick Hawkins, Community Mental Health, Adelaide

Thank you from Tanzania. Mary Reside, RN, M N Sc. Victoria no option to do so online. I called AHPRA and lo and behold it was registration time and it was impossible to talk to anyone there. Instead I got put through to a call centre overseas, twice.

letter dated 10 July confirming that my general nurse registration has lapsed and that if I wished to practise I would need to re-apply for registration and meet the requirements for registration in place at that time!

First I was told I could not speak to staff at AHPRA because they were too busy. I was also told that they would let them know and that I should call back again in a few days time just to make sure AHPRA had received my message. Then I got told to write. I then received a pile of forms that took my precious time to fill out. It wasn’t done in five minutes; it was like I was registering for the first time. After all that, there was no acknowledgement of my application, instead I received a

The moral of the story: There is no one available at AHPRA to answer queries during the registration period and call centres are of no help. So don’t do what I did. Thana Narayanan, registered nurse/midwife

Mail I can relate I refer to the article, Nurses eat their Own in the ANMJ March 2014 issue. Reading this article took me back to THAT emotional place where I escaped from just this year. I became very anxious just reading Elizabeth’s story. I am sure there are many more of us out there. My situation was very similar. My ordeal started with the change in upper management (DON) (NUM) and therefore the ‘restructuring’ started. Like Elizabeth it all started with small insignificant things which then grew to the DON and NUM forcing me to agree to a change in my employment contract which meant that I was in fact being demoted with a decrease to my salary. They ‘picked’ on everything I did, used everything I did or didn’t do or asked or said against me by turning it into a negative and then using that to ‘performance manage’ me, resulting in formal warnings. I was singled out from my colleagues employed in the same role. I was labeled as a ‘liar’, and allowed duties above my knowledge and experience in order for me to fail. I became very anxious going to work, not knowing what would be done/said to me. I developed depression and had suicidal thoughts. I informed our HR department, but nothing was done. I was advised by my GP and psychologist to put in a work cover claim. It felt like I was being forced out of my job. In my many years of service to the company and even more as a nurse I had never experienced anything like this. The insurer rejected the claim on the basis

Mandatory assessments? that my GP and allied health professional did not forward the reports as requested by the insurer. The treatment I received from the insurer was shocking and most definitely not according to legislation. The insurer lied about not receiving the reports, evidence suggests otherwise. They had no intention of assessing the claim correctly. I cannot even begin to describe how this has affected me. I have lost my confidence in my abilities as a nurse. As a result I have left the nursing profession as I don’t feel I want to be a nurse anymore. I have lost my passion and drive. To be quite honest I am terrified of working as a nurse again. We need a change in bullying in the workplace because it DOES EXIST. Anonymous, ANUM, Victoria

At my organisation, like many others, it is mandatory to complete annually an online basic assessment on falls, safe medication administration, medication calculations, aseptic technique, hand hygiene, safe manual handling and principles of infection control. I have never felt less like a professional when my nursing leaders have agreed to make mandatory these basic assessments frankly it’s insulting. I can only assume it has evolved from a need to show a commitment to clinical governance and in an accreditation process a quality report able to state ‘x% of nurses have completed basic training modules in…’ Clearly it is not enough to be able to say ‘x% of our nurses have a tertiary qualification and registered with APHRA! I think it is great these modules are available. But don’t ask me to complete basic training EVERY year. I am more than responsible to ensure my skills and knowledge in basic nursing are current so don’t reduce me to the ‘lowest common denominator’ so a report can be made stating ‘x% of our nurses have completed x, y, z.’

Tackling bullies Last month’s ANMJ feature, ‘Nurses eat their own’, although well written, does not add anything new to the debate on this intractable problem. Strategies in place to date, although well intentioned and seemingly comprehensive, are not on their own sufficient to address this age-old issue. To tackle bullies successfully bullying must attract a negative consequence. Possible negative consequences could include: compulsory training, reassignment to work under a mentor, financial fines, demotion, and in the worst cases, dismissal. A bully should most definitely not remain in the area where they practiced bullying. Until

In last year’s May edition of ANMJ, Robyn Johnston commented in a letter titled: ‘In danger of losing professionalism’ that, “It is unacceptable that experienced, professional registered nurses are to be reduced to the lowest common denominator of ability and judgement.” She saw the introduction of assessment of aseptic technique, introduction of colour designed observation charts to alert of deteriorating patients and hourly ‘rounding’ as eroding the professionalism of nursing.

bullies suffer consequences for their behaviour they will continue with it because it is a positive experience for them. The Australian Nursing & Midwifery Federation should be campaigning for bullies to pay a price for their behaviour regardless of their level in the organisation. Only then will I accept the ANMF is serious about ridding nursing of this scourge.

Robyn Johnston is right please don’t subject us all to ‘petty bureaucracy which ignores decades of progress and enlightenment within the nursing profession.’ Julie Barbetti RN, CCC, B.Ed, Master of Nursing Science, Victoria

Robyn Chen EN Div2, ACT

PAGE 55 April 2014 Volume 21, No. 9.

Sally Sally-Anne Jones, Federal Vice President

Complexity compression impacts us all Health is an increasingly complex environment to navigate through as a patient, and to work in as a nurse or midwife. The once straightforward bedside care given by nurses has exponentially blown out as technology, medical knowledge, diagnostics and treatment have grown through the 20th and 21st Centuries. The way in which we gather, interpret and use information to deliver nursing or midwifery care will always be evolving as humankind learns more about body function and the causes and management of disease. Further to the intricacies of clinical care are the patient safety imperatives, public accountability, mandatory training, reporting requirements and constant change which add demands on a nurse or midwife’s time, effecting not only intention to stay in nursing or midwifery but also impact on patients through missed care. This phenomenon is described in a study by Krichbaum, et. al (2007) as complexity compression. Complexity compression is defined as what nurses’ experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame. Although study continues in developing a methodology for measuring complexity compression in registered nurses, there is much already in nursing literature exploring the links between nurse job satisfaction, workload, patient satisfaction and outcomes. The themes identified in the study that contribute to complexity compression are incredibly familiar to us and seven years after publication are as relevant to us as ever: • Personal - work/life balance, fatigue, tiredness; • Environmental - physical surroundings at work – lack of room to do the work required, conflict with co-workers, physical or verbal abuse from patients, cultural issues such as lack of trust and respect, time clock pressures, decreased loyalty to institution; PAGE 56

• Practice - responsibility for oversight, assignment and coordination of tasks by others, competing demands of equal importance, unfamiliar tasks, time specifications, no system support, special cultural or emotional needs of patients, mentoring or preceptoring responsibilities; • Systems - system failures, multiple new processes or constant changes, no safety net, new forms, new regulations or legal requirements, budget, staffing, technology; • Administration and management inexperienced leadership, careless management and indifferent administrators, numerous and unpredictable changes at management level, mismatch of style and philosophy; • Autonomy and control - no input into decision making; input not valued. While this seems like a long and predictable list, it perfectly explains how nurses and midwives feel in every clinical setting. I believe that in Australia complexity compression is a very current and real concern as health reform agendas, reduction in health spending, the call for greater efficiencies and role substitution in every sector reshape the way in which health care is planned, resourced and delivered. At the same time, consumer expectations of health services are increasing. Our challenge as a profession is to think of ways to manage the excessive demands of our system upon us so that we can continue to keep the patient safe and at the centre of everything we do. Workloads can be monitored, measured and reported and the impact on patient outcomes is well documented. By being alert to the complexity of the environment we work in, staying abreast of the changes health policy and systems, working together, advocating for patient safety through ratios, skill mix, education and registration we can continue to keep patients safe.


Kathleen Krichbaum, Carol Diemert, Lynn Jacox, Ann Jones, Patty Koenig, Christine Mueller and Joanne Disch, 2007. Complexity Compression: Nurses Under Fire. Nursing Forum Volume 42, Issue 2, PP 86–94.

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