ANMJ March 2014

Australian Nursing & Midwifery Journal Volume 21, No. 8.

March 2014

Nurses eat their own

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

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Editorial Lee Thomas, AnMf Federal Secretary This month I am pleased to report the ANMF continues to be a robust and vibrant union. The latest figures show we remain the second largest union in Australia with the ANMF’s membership across the country standing at an astounding 232,709, a growth of almost 9,000 members in one year.

I commend every nurse, midwife, personal care assistant and student for creating the union we have become today. Your ongoing support and united belief that together we can continue to protect and develop our professions has been the backbone of our success.

This strength that we have created is needed now more than ever. As expected, and as I alluded to last month, the government has begun its unmitigated attack on workers’ entitlements such as penalty rates.

In no uncertain terms, we have made it clear to the government that we will fight any attempts to strip away existing awards that are detrimental to our workforce and to the future retention of nurses, midwives and assistants in nursing. We will continue to keep abreast of the situation and update you on this matter through our website, Facebook and twitter sites. I suggest you visit these regularly to keep informed.

In this month’s journal we are running our first ever Focus section on midwifery and maternal health since we changed our name to include midwives. In this section you will read an array of differing and interesting points of view from many of our midwives.

I hope you will enjoy this section as much as I do. The ANMF has also been working hard for our midwifery profession. The federal professional team discuss the work they have been doing in their column this month.

This includes the review of the midwifery accreditation standards and the review of the safety and quality framework for midwives.

Longstanding ANMF member Carmel Hurst talks about being awarded the Order of Australia in this year’s Australia Day Honours list for her work in establishing the Homeshare programs. In her guest column she emphasises the need for more women, particularly nurses and midwives, to be recognised for the outstanding work that many of them do.

While it is important our country and our communities recognise our invaluable contribution to society, it is also critical we respect each other within our own professions and workplaces. This month’s eye-opening feature highlights this need as our journalist Kara Douglas investigates horizontal violence that occurs within the workplace. Tragically this behaviour is not new and has become deeply entrenched within our culture. It is an unnecessary and appalling act that has affected almost all of us at some point in our careers. In some cases it has even destroyed lives and careers. At a time when we are trying to recruit and retain a nursing and midwifery workforce, it is imperative that this behaviour stop. Each one of us has a role to play in changing this culture and stopping horizontal violence dead in its tracks. We can do this by looking out for one another and giving each other the professional respect and support that we all deserve.

And finally we say good bye to Yvonne Chaperon Assistant Federal Secretary who has moved home to Tasmania to take up a new position at the Mental Health Tribunal.

Good luck Yvonne.

PAGE 1 March 2014 Volume 21, No. 8.

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

Editorial

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

Advertising

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

Victoria

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

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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

PAGE 2

Queensland

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

Tasmania

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.

CIRCULATION 94,687

Source: BCA verified audit, September 2013

Contents Volume 21, No. 8.

News 5 Books

17

World 19 Feature

20

Professional 25

News

Page 5

A fond farewell to Yvonne

Education

Page 26

Quality use of medicines

Education 26 Clinical Update

28

Tech Talk

32

Legal 33 Research 34 Research Perspective

35

Wellbeing 36 Reflections 37 Clinical View

World

Page 19

Poorly paid grads

Focus

Page 40

38

Issues 39 Focus

40

Calendar 53

Midwifery and Maternal Health

Mail 54 Coral 56

Feature: Nurses eat their own

Page 20

Bullying and horizontal violence takes its toll

PAGE 3 March 2014 Volume 21, No. 8.

April

Infection Control

Melbourne

2 April

2104

Clinical Nursing Assessment

Melbourne

3-4 April

2006

Defusing Disruptive Behaviours

Adelaide

3-4 April

1760

Everyday Medicine - Safety for all Nurses

Ballarat

3-4 April

2049

Medicines - Improving Your knowledge

Adelaide

7-8 April

1935

Cancer Chemotherapy Awareness for all Nurses

Adelaide

10-11 April

1749

Cardiac and Respiratory Nursing Basics

Adelaide

28-29 April

2103

Defusing Disruptive Staff Behaviours

Melbourne

28-29 April

1762

Midwifery and Mental Health

Melbourne

28-29 April

2091

Medical Nursing Conference 2014

Melbourne

1-2 May

2105

Clinical Nursing Assessment - Advanced

Adelaide

1-2 May

2012

Diabetes - Nursing Management

Adelaide

8-9 May

1802

Alcohol and Other Drugs

Melbourne

8-9 May

2033

Nursing People 85+

Melbourne

12-13 May

1958

Respiratory Nursing

Melbourne

15-16 May

1994

PTSD: Understanding Post-Traumatic Stress Disorder

Adelaide

15-16 May

1835

Rashes, Fevers and Infectious Diseases

Adelaide

19-20 May

1955

The Power of Simulation in Learning

Melbourne

19-20 May

2090

Tasmanian Nurses’ Conference

Hobart

22-23 May

1995

Caring for People with Chronic Mental Illness

Melbourne

22-23 May

2027

Nursing and the Law

Adelaide

22-23 May

2108

Advanced Palliative Care Nursing

Melbourne

26-27 May

1822

Acute Cardiac Care

Adelaide

26-27 May

1848

Nursing and the Law

Melbourne

29-30 May

2109

Diabetes - Nursing Management

Bendigo

29-30 May

1804

News May

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News A fond farewell to Yvonne Chaperon After a ten year career with the Australian Nursing & Midwifery Federation (ANMF), Yvonne Chaperon has resigned from her role as Assistant Federal Secretary to take a position closer to home as President of the Mental Health Tribunal in Tasmania, where she lives with her family.

ANMF Federal Secretary Lee Thomas thanked Yvonne for her dedication to the ANMF and the nursing and midwifery professions. “For the past decade Yvonne has worked tirelessly to represent the interests of nurses, midwives and assistants in nursing at both a state level with the ANMF Victorian Branch and at a national level in the ANMF Federal Office.”

Ms Thomas said she will be sorely missed.

“We wish Yvonne all the best in her new role and understand how important it is to balance family life and career. Yvonne has been an outstanding advocate for the nursing and midwifery professions and we know her skill and professionalism will benefit the mental health sector in Tasmania.”

Yvonne Chaperon began her career with the ANMF as a Professional Officer in the Victorian Branch in 2003. As a registered nurse and a qualified solicitor registered to practice in the state of Victoria, Yvonne’s knowledge and expertise made her an ideal advocate for nurses and midwives.

Prior to joining the ANMF, Yvonne was employed with law firm, Ryan Carlisle Thomas, representing registered nurses before the Nurses Board of Victoria, Coroners Court of Victoria and the Australian Industrial Commission, Magistrates Court and Federal Court.

After two years as a Professional Officer in the ANMF Victorian Branch, Yvonne became an Industrial Officer in 2005. She managed the successful negotiation of the Practice Nurses Enterprise Bargaining Agreements and worked with a team of Industrial Organisers and Professional Officers dealing with industrial and professional issues.

In 2007, Yvonne became the Assistant Secretary of the ANMF Victorian Branch.

In this role, she participated in the negotiations of the 2007 Public Sector EBA, the 2007 Psychiatric Services EBA and the 2007/08 Multiple Private Acute Hospitals EBAs. Yvonne also managed the aged care portfolio and the negotiation of approximately 600 Aged Care EBAs covering some 700 facilities.

In July 2010, Yvonne took on the role of ANMF Assistant Federal Secretary. Her portfolio involved aged care, lobbying the federal government and being a sitting member of numerous government advisory committees. Yvonne also became

a Director on the HESTA Superannuation Board shortly after taking on the Assistant Federal Secretary role.

“Yvonne has had a distinguished career as both a registered nurse and a lawyer but above all else, as an advocate for the rights of nurses and midwives,” said Ms Thomas.

“It’s been a great pleasure to work alongside Yvonne in the Federal Office for the past three years. She will be sorely missed and we wish her all the best in her new role.”

Hands off our penalty rates The Australian Nursing & Midwifery Federation (ANMF) has vowed to fight any attempt by the Abbott Government to abolish penalty rates and other workplace awards for nurses, midwives and assistants in nursing.

The federal government made a submission in January to the Fair Work Commission’s review of the award system, asking it to consider whether extra pay for working particular times of the day was appropriate.

ANMF Federal Secretary Lee Thomas said nurses and midwives cannot be living in fear of losing their penalty rates and loadings. “After all, they’re called to provide quality care at any hour of the day or night, weekends, public holidays and spe-

cial days like Christmas – being taken away from their family and friends.

“When they get to work, they’re experiencing dangerously high workloads, because there’s no mandated nurse to patient ratio.”

and midwives, let alone recruiting a future workforce, if the Abbott government takes away these long-held entitlements.

It is forecast that Australia will need 109,000 nurses by 2025, while in the aged care sector alone, 20,000 nurses are currently needed to meet the needs of Australia’s rapidly ageing population.

Given that nursing and midwifery are 24 hour a day, seven day a week professions, it is only fair and reasonable that they continue to receive fair and proper remunerations, said Ms Thomas. “Penalty rates and shift loadings make up to 40% of a registered nurse or midwife’s actual remuneration as a result of their 24/7 work hours. Therefore taking away their penalties would mean a huge cut to their minimum wage.”

Ms Thomas said it was crucial that Australia start building a nursing and midwifery workforce for the future. “But that won’t happen if the government makes nursing and midwifery less attractive by stripping away awards.”

Ms Thomas said there will be little hope of retaining the current generation of nurses

The ANMF will fight any attempt to change the existing awards system, said Ms Thomas.

PAGE 5 March 2014 Volume 21, No. 8.

News Nurse unfairly sacked over anti-racism paper Sharon Morunga was given a standing ovation after presenting her paper ‘I am not racist but…” at the International Council of Nurses (ICN) conference in Melbourne last year. Four months later she was sacked over it – a decision the Fair Work Commission ruled harsh, unjust and unreasonable.

While working at the Anyinginyi Health Aboriginal Corporation (AHAC) in the Northern Territory, Ms Morunga was given permission to present her paper at the ICN conference in May 2013, provided she did not identify herself as an employee of the corporation or refer to the Barkly and Tennant Creek region where it operates.

Despite taking approved personal leave and presenting at the conference independently, Ms Morunga, who is of Maori heritage, was sacked after an article about her presentation was published in the journal Kai Tiaki Nursing New Zealand.

ANMF Federal Secretary Lee Thomas

Don’t meddle with Medicare A new poll shows the majority of nurses, midwives and assistants in nursing (AINs) are opposed to plans to introduce a $6 co-payment for people to visit a general practitioner (GP).

More than 1,900 people took part in the Australian Nursing & Midwifery Federation (ANMF) survey, which asked: Do you support the introduction of a $6 co-payment for visiting your GP even if they are already bulk billed?

An overwhelming 79% of respondents answered no to the question. ANMF Federal Secretary Lee Thomas said the union’s members are extremely concerned about the plan. “They are genuinely fearful this will force low-income earners, struggling families and others who can least afford it, to rush to already overstretched hospital emergency departments to get checked PAGE 6

for routine or relatively minor ailments or worse still, not receive medical attention until it’s too late.”

As frontline health care professionals, members understand the ramifications on the demand for service, patient waiting times and the effect on their already dangerously high workloads, said Ms Thomas. “The message to the Abbott government is that nurses, midwives, AINs and the other members of the community want to keep health care free and universal for all Australians – they don’t want the government meddling with Medicare.”

The article summarised the presentation saying, “…Morunga questioned why the most vulnerable, impoverished people in Australia were subjected to such racism, by all members of the white community, including health workers, doctors, police and teachers.”

The Fair Work Commission heard the journal article received publicity that offended the corporation’s CEO Trevor Sanders, who sacked Ms Morunga in September 2013, accusing her of dragging Anyinginyi’s and the community’s name through the mud.

In a witness statement to the Fair Work Commission, the journalist said the paragraph was not a direct quote and that by the phrase ‘all members of the white community’ she meant and understood Sharon to mean ‘members from all groups of the white community’, rather than literally as every single member of the white community.

A letter the journalist wrote to Mr Sanders after the sacking said that she understood Ms Morunga was speaking at the conference as an individual and not as an employee. The letter

News also raised concerns about the right to freedom of speech, the right of health professionals to speak openly about significant health issues in professional forums and journalists’ rights to report such concerns. It said: “I believe the ICN would be deeply disturbed that a health professional speaking about a significant health issue, ie racism, at its conference, was dismissed for doing so. Sharon was speaking in her capacity as a health professional to an audience of health professionals about a significant health issue. That is her inalienable right.”

“The ANMF has a duty and a right to speak out on issues that affect nurses and midwives.”

That right was upheld by the Fair Work Commission which ruled there was no valid reason for Ms Morunga to be dismissed. In a decision handed down last month, Fair Work Commission vice-president Michael Lawler awarded Sharon Morunga over $25,000 in lost wages.

Mr Lawler said the nurse’s treatment was ‘manifestly unjust’ and that it was one of the clearest cases he had ever dealt with.

He said Sharon Morunga had done nothing wrong. “On the contrary, she was engaged in a laudable activity in presenting her paper to the ICN Congress.”

The Australian Nursing & Midwifery Federation (ANMF) represented Ms Morunga at the commission. “The ANMF has a duty and a right to speak out on issues that affect nurses and midwives,” ANMF Federal Secretary Lee Thomas said.

Ms Thomas said Sharon Morunga should be applauded for her actions. “It’s outrageous for an employer to think they can sack a nurse or midwife for doing what our professions demand, that is advocating for our patients.”

Milestone for nurse practitioners The number of nurse practitioner’s in Australia has hit the 1,000 mark, 14 years after the first nurse practitioner was endorsed in New South Wales in 2000.

Australian College of Nurse Practitioners (ACNP) President Helen Gosby said it was a significant milestone for the Australian nurse practitioner profession. “Our profession continues to grow and contribute to transforming the face of health care.

Health care consumers and communities recognise and appreciate the value a nurse practitioner brings to the care team.

This is reflected in greater recognition and utilisation of the role.”

According to the ACNP’s last national census in 2012, nurse practitioners were practising in settings ranging from rural and remote areas to large urban centres. Their skill sets range from generalists to specialists, working in areas such as primary health care, chronic disease management and emergency care.

Ms Gosby said there was still a long way to go for nurse practitioners to be able to practice at their full potential. “There

ACNP President Helen Gosby

are systemic legislative and local barriers in both the public and private health care sectors which have denied the profession from working to their full capacity.”

Financial barrier to HIV treatment Cost of HIV medication may prevent people taking up or continuing treatment, according to research from the Burnet Institute.

The report, commissioned by Positive Living Victoria and the Victorian AIDS Council/Gay Men’s Health Centre, found the current system of dispensing did not take into consideration the burden of cost for people living with HIV (PLHIV).

The financial burden people with HIV faced was more than $800 per year for their life-saving treatment plus additional costs for drugs to treat other health related conditions, the report suggests.

Moreover, many HIV patients were unaware they could access concession cards and the Safety Net threshold, said study lead for the report Anna Wilkinson.

“In addition the complex application process could be a potential barrier to receiving HIV medications at a lower cost, or for free.”

Living Positive Victoria President Ian Muchamore said to reduce the negative health consequences for PLHIV and the consequent rate of new infections, the cost and access of treatments needed to be made more equitable and easier to access. “We need to do whatever we can to ensure that those who need it can start treatment early and the access is easier to enable people to be successful on treatment. This means patient-friendly dispensing systems, cost recover mechanisms and policy that does not encumber the doctor needing to assess the patient’s ability to pay for HIV treatment.”

PAGE 7 March 2014 Volume 21, No. 8.

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News A cup of coffee adds up

Money too tight to vaccinate A report by National Seniors Australia has found half of Australians over-50 are too cash strapped to pay for a vaccination recommended to them if it is not funded under the National Immunisation Program (NIP).

In contrast 90% of seniors surveyed would consider vaccination if it were government funded, according to the Seniors and Immunisation in Australia: Awareness, experiences and attitudes report.

National Seniors Australia has used the findings to call for an increase in the availability of government funded vaccinations for older Australians. Australian immunisation guidelines recommend older Australians are vaccinated against four diseases – pneumococcal, flu, tetanus and shingles - but only pneumococcal and influenza vaccines are funded on the NIP. In comparison, vaccines for 12 diseases are government funded for children, with 90% of Australian children fully immunised.

Women are being urged to take action now to ensure a comfortable retirement. The average Australian woman currently retires with a superannuation account balance of just $112,600. It may seem like a tidy lump sum, but not when you consider that a single woman needs $40,000 a year retirement income to live at the lower end of what’s considered adequate.

The Australian Taxation Office (ATO) is encouraging women to take an active interest in their Super to help overcome this retirement savings shortfall. Assistant Commissioner Megan Yong said it was never too late for women to start learning about practical things they can do to make a difference to their super over time. “It surprises a lot of people that putting the

equivalent cost of one cup of coffee a day into your Super can add up to an extra $128,000 when you retire.”

The ATO has developed a five step online super check (www.ato.gov.au/5stepsuper) to give women practical steps to take to improve their retirement incomes in the long term. Ms Yong said the 5-step super check walks you through what you need to do in easy to understand language. “Including checking your statements to make sure you are getting everything to which you are entitled, that your super fund has your tax file number so you don’t pay too much tax, and determining if you are entitled to a government super contribution.”

Ms Yong said the most important thing to do is to put whatever extra you can afford into your account, “As the cup of coffee example demonstrates, it can pay you back many times over.”

Associate Professor Michael Woodward from Austin Health said extending the Australian Childhood Immunisation Registry to include adults would encourage a whole of life approach to immunisation.

“At a time when Australia’s population is ageing, preventative health measures to help protect the health of older Australians will only become increasingly important in coming years, and ensuring public health policy is geared towards reducing the burden of vaccine preventable diseases, regardless of age, cannot be stressed enough.”

Older Australians contribute over $40 billion dollars into the nation’s economy each year, as well as saving billions of dollars through unpaid disability and child care. Associate Professor Woodward believes shifting the focus towards whole of life immunisation is vital to not only protect the health of older Australians but to also provide an economic and social benefit to the nation.

PAGE 9 March 2014 Volume 21, No. 8.

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News Nursing, midwifery and social media Think carefully the next time you are about to blog about work or post on Facebook or twitter. The Australian Health Practitioner Regulation Agency (AHPRA) has released a new social media policy that applies to all health practitioners.

The policy states that social media posts should: • comply with professional obligations • comply with confidentiality and privacy obligations (such as not discussing patients or posting pictures of procedures, case studies, patients, or sensitive material which may enable patients to be identified without having consent in appropriate situations) • present information in an unbiased, evidence-based context; and • not make unsubstantiated claims AHPRA has also released revised Guidelines for advertising regulated health services and revised Guidelines for mandatory notifications. CEO Martin Fletcher said the documents have been published early to help practitioners, employers and members of the community understand what is expected from practitioners.

“It’s important that practitioners know and understand their obligations. By publishing these documents before they come into effect, practitioners, in particular, can start to be ready for when they come into effect in mid-March.”

The Social media policy and revised guidelines come into effect on 17 March and are available online at: www.ahpra.gov.au.

Nurses can help close the gap The Australian Nursing & Midwifery Federation (ANMF) believes nurses and midwives need to play a key role in reducing the health gap between Aboriginal and Torres Strait Islander peoples and nonindigenous Australians.

The sixth annual Closing the Gap report shows some progress has been made towards achieving this goal but much more work needs to be done, said ANMF Federal Secretary Lee Thomas. “It is encouraging to see the target to halve the gap in child mortality within a decade is on track to be met, but it’s concerning to see that the life expectancy gap of Aboriginal and Torres Strait Islander peoples still remains at a decade.”

Ms Thomas said that as frontline health professionals, nurses and midwives are ideally placed to engage indigenous communities. “Our members work in some of the most remote areas of the country. They have the trust of the communities in which they live and work and should be utilised in Aboriginal and Torres Strait Islander people’s health care strategies.”

The Closing the Gap report also showed little progress has been made towards halving the gap in reading, writing and numeracy within a decade and no progress towards halving the employment gap over the same period.

Aboriginal and Torres Strait Islander Social Justice Commissioner, Mick Gooda, cochairs Oxfam Australia’s Close the Gap

Campaign. He believes action on health will lead to change. “We are just starting to see reductions in smoking rates and improvements in maternal and childhood health.

We need to build on these successes.”

Close the Gap Campaign co-chair Kristie Parker highlighted that health services are the single biggest employer of Aboriginal and Torres Strait Islander people. “We know that empowering Aboriginal and Torres Strait Islander health services has broader benefits.”

Community controlled health services create jobs as well as train people in real vocations, Ms Parker said. “We can make real inroads in the national effort to close the gap if we continue to place a high priority on it.”

PAGE 11 March 2014 Volume 21, No. 8.

News Safety fears over cuts to pharmacy med checks New limits on the number of medicine checks pharmacists can provide have sparked concerns that patients may be at risk of adverse drug reactions or under-medication.

The Home Medicine Reviews (HMRs) program allows patients who live at home to have a pharmacist check their medications if they take a high number, are at risk of an adverse reaction or have difficulty managing their medications because of issues such as language barriers, literacy or poor sight.

The federal government and Pharmacy Guild of Australia have agreed to limit individual patient checks to one every two years and also limit the number of HMRs that can be provided by individual pharmacists to 20 per month.

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The Consumers Health Forum is concerned the cuts will impact patient safety. “Recent Adelaide research published in the Australian Health Review found that 16% of hospital admissions were related to adverse drug events. Many of these could have been avoided through medicine reviews,” said spokesman Mark Metherell.

“The risk to patients of confusion and medication mistakes is an unfortunate but avoidable reality of our universal pharmaceutical scheme. Programs such as Home Medicine Reviews and Residential Medication Review Program result in a reduction in medication misadventure – a key cause of hospital admissions,” said Mr Metherell.

the Government has made a ‘closed shop’ agreement on this issue with the Guild without consulting consumers,” Mr Metherell said.

The Pharmacy Guild will take over management of the program from the Department of Human Services from this month. National President George Tambassis said the changes are aimed at cutting red tape and streamlining processes. “The new capping arrangements for some medication management programs are necessary to ensure that the programs stay within budget.”

The changes to the program have been announced before two official reviews of the checks have been completed. “Consumers Health Forum is concerned that

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Constipation in Palliative Care

Dealing With Unhelpful Staff Behaviour

News Australians with dementia need better end of life care An Alzheimer’s Australia report shows there is a big difference in the way carers of people with dementia and health care professionals view end-oflife care for dementia sufferers.

the difficulties they have in getting access to palliative care services and hospices but this survey has also told us that many health professionals are not aware of the difficulties consumers faced.”

The End-of-Life Care for People with Dementia report surveyed both consumers and health workers to identify a number of barriers to quality end-of-life care for people with dementia. These include lack of advanced care plans, poor understanding of legal options, inadequate pain management, and lack of access to hospices, palliative care specialists or community palliative support.

In contrast to the views of family carers, three quarters of the care professionals surveyed believed people with dementia do have access to palliative care services, said Ms Buttrose. “It also concerns me that in many cases care professionals are unsure of what the legal options are for people with dementia at end-of-life. Nearly a third are not aware that people have a legal right to refuse food and artificial hydration.”

Alzheimer’s Australia national president Ita Buttrose said the survey results provide a clear indication of why the end-of-life wishes of many people with dementia are not carried through. “Carers often tell us

Palliative Care Australia has backed the call for action to improve end-of-life care for people with dementia. “People with dementia deserve quality palliative care

that respects their wishes and dignity,” said the organisation’s president Professor Patsy Yates.

“However, the current confusion around advance care planning practices cannot continue. We need to ensure all health professionals and consumers are provided with education around palliative care and advance care planning, and consistent advance care planning legislation and terminology would go a long way to reducing this uncertainty,” Professor Yates said.

In an attempt to address some of these issues, Alzheimer’s Australia and Palliative Care Australia have launched Start2Talk, a website to help people plan for their own or a loved one’s future financial, lifestyle and health care decisions.

Nurses and midwives caring for our farmers The QNU is encouraging their members and Australian Nursing & Midwifery Federation members (ANMF) from around the country to support their campaign to help farmers that are doing it tough.

QNU’s Secretary Beth Mohle said she wanted farmers and farming communities to know that the union’s nurses and midwives cared. “The Queensland Nurses’ Union understands many families throughout the state are facing severe hardship as a result of the drought. We are campaigning to raise funds in both Queensland and around Australia by encouraging our members and the Australian union movement to donate.”

The Queensland Nurses’ Union (QNU) has started a campaign to raise funds for drought impacted farmers.

Due to ongoing drought stricken conditions across regional Australia many farmers are facing extreme financial stress or ruin.

As a consequence the QNU Council has determined to donate $5,000 to non-profit organisation Aussie Helpers. The aim of the organisation is to fight poverty and lift the spirits of those severely affected by drought in the outback.

According to Ms Mohle the drought was taking a huge financial and emotional toll.

As a result of the recent drought it was believed 18 farmers had committed suicide, she said. “The conditions our drought impacted farmers are experiencing can only be imagined.”

For more information on Aussie Helpers or to donate visit: http://aussiehelpers.org.au

PAGE 13 March 2014 Volume 21, No. 8.

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News Maintaining self-health and wellbeing Nurses’ and midwives’ self-wellbeing is crucial but is often underrated.

But according to registered nurse/midwife and consultant remedial therapist Angeline von Doussa, nurses’ and midwives health needs to be a priority. “I don’t know if you have stepped onto a ward lately and seen the health of nurses, but it’s exceptionally poor.”

Angeline said because nurses focus on patients all the time they often neglect their own wellbeing. “I think the health system is very sick and it’s making people sick.”

According to Angeline nurses and midwives need to be supported in maintaining good health. “If the system is to stay healthy, nurses and midwives need to have a positive sense of wellbeing which will ensure optimal health care is provided.”

As a consequence of her belief in wellbeing for the professions Angeline has set up spa days exclusively for nurses and midwives.

“They can come in and have a day of receiving, engaging and learning about how important it is to maintain health for yourself.”

Set up in a luxury apartment based in the South Australian seaside town of Glenelg, the spa day consists of hand and foot scrubs, foot spas, massage and a facial. There is also time for a relaxing walk on the beach. “The feedback I have heard from those attending the spa day is that it is the most relaxing and rejuvenating thing they have attended,” Angeline said.

Angeline will also be running workshops specialising in massage combined with spa and massage in Bali early September.

A day at the day spa

Conducted in conjunction with Bali Bisa School of Massage and Spa Therapies, the workshop will help maintain passion in the health care environment as well as inspire self-wellbeing and wellbeing in others, clients and peers, said Angeline. “Through doing this workshop nurses and midwives can receive and learn how wellbeing applies to themselves and others. It is about focusing on nurses and midwives to reengage through the mind, body, spirit connection.”

While Angeline concedes she cannot change the state of the current health environment, she wants to help others to develop and look after their own wellbeing. “I can’t change the [health system] but I can change myself and plant the seed of health and wellbeing in other nurses and midwives so that they can start looking after themselves.”

Cancer the biggest global killer A new global report shows cancer is responsible for 8.2 million deaths per year and rising, making it the biggest cause of mortality worldwide.

The World Cancer Report also predicts cancer incidences will increase by 75% over the next twenty years, exceeding 20 million new cases a year in 2025.

Cancer Council Australia spokesman Terry Selvin said reasons for the increase varied in different countries. “Australia has one of the

world’s highest cancer incidence rates, third in the world behind Denmark and France, largely because of our ageing population.”

Mr Selvin said Australians are living longer than previous generations, thanks to improved infection and cardiovascular disease control. “Unfortunately cancer is a disease that is more likely to affect us later in life, so the longer Australians live, the more cancer cases we see.”

globally, Mr Selvin said. “Unfortunately, developing countries are also adopting the worst of our western lifestyle, such as smoking, poor diet and inactivity, which is significantly contributing to global cancer prevalence.”

Extended life expectancy in the developing world is also increasing cancer rates PAGE 15 March 2014 Volume 21, No. 8.

News More action on mental health The Australian Nursing & Midwifery Federation (ANMF) hopes the federal government’s review into the mental health system will lead to the better utilisation of mental health nurses around Australia.

could help boost the number of mental health nurses working on the ground.”

Ms Thomas said that while the ANMF welcomed the review, there had been many reviews of mental health in the past. “The ANMF hopes this review will make a meaningful difference in the lives of people who experience mental illness, as well as their carers. But what we really need to see is the government following through with genuine action.”

ANMF Federal Secretary Lee Thomas said nurses are the most geographically distributed health practitioners in the country. “From tiny outback towns to big cities, our members are on the ground and in touch with their communities.”

Ms Thomas said mental health nurses are already providing services to their communities but could be better utilised. “By removing the red tape that prevents some nurses with mental health experience from practising inOn-the-Go-app-ad-march-anmj.pdf the sector, the government

1

Under the terms of reference, the National Mental Health Commission will review all existing programs across the government, non-government and private sectors. The Health Minister Peter Dutton said the review should identify gaps in service delivery, inefficiency, duplication and excessive 18/02/2014 4:00 must pm red tape. “We work within the fiscal

constraints that are facing all Australian governments, getting maximum value for taxpayers’ dollars while ensuring people living with mental health issues get the support they need.”

Mental Health Council of Australia CEO Frank Quinlan said the terms of reference rightly identify the need to review spending in the sector: “But we also know that many areas of mental health have seen significant underinvestment for many years.”

ANMF Federal Secretary Lee Thomas agrees. “The review needs to produce meaningful change within the sector – and not just become a cost cutting exercise.”

The final report in due to be delivered to the government by 30 November.

C

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CM

MY

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CMY

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Earn Your CPD on-the-go ausmed.com.au/app PAGE 16

Books A Mouthful of Flies: The Explosive Diary of a Desert Nurse

By Sue Currie Publisher: Lyncon Pty Ltd ISBN: 978-0-9578449-5-7

If you have ever wondered what it is really like nursing in the most remote and deserted parts of Australia then A Mouthful of Flies: The Explosive Diary of a Desert Nurse is the ideal read. Author Sue Currie has worked as a nurse in remote communities in the Kimberley, Cape York and the Western Desert. She paints a picture of her life and work as a dedicated nurse in a Western Desert community in vivid and at times confronting detail. Drawing from

her highly detailed diary, Sue’s journey starts with an experience all too familiar to many nurses – job cuts in the public health sector. But instead of signaling the end of her career, it is the beginning of a satisfying, challenging, scary and at times lonely life in a culture so different from her own

Bi-polar disorder affects millions of people worldwide. Sharon Carruthers is a wife, mother and retired registered nurse who didn’t accept until halfway through her life that she was one of them. The Teeter Totter is an inspirational autobiography of Carruthers’ experiences, discoveries and life lessons, which she hopes will encourage others living with a similar condition to accept their situation and get help. The Teeter Totter covers topics such as proper

medications and treatments for Bipolarism, the importance of honesty with yourself and others when living with a mental health issue and the role faith plays in overcoming life’s challenges.

The Teeter-Totter

By Sharon Carruthers with Corrine Vanderwerff RRP: US$24.99 Publisher: West Bow Press ISBN: 978-1-4497-5528-7

Humanizing Healthcare Reforms

By Gerald A. Arbuckle Publisher: Jessica Kingsley Publishers (Australasian distributor: Footprint Books) ISBN: 978-1-84905-318-1

Looking at the current turmoil facing contemporary health care systems worldwide as a result of financially-based performance indicators, the author argues that a return to a values-based approach to health care will create a positive transformation. Writing from the fresh perspective of social anthropology, the book takes a highly pragmatic approach to practice, emphasising the importance of values such as compassion, solidarity and social

justice. This book is suitable not only for policy- makers and strategists in health care reform, but is also helpful for clinical practitioners, managers and students who are interested in leading cultural change in today’s turbulent world.

The Clinical Placement: An Essential Guide For Nursing Students 2nd Edition

By Tracy Levett-Jones and Sharon Bourgeois Publisher: Elsevier ISBN: 978-0-7295-3958-6

Based on the authors’ belief that the ultimate goal of clinical education is the development of confident and competent nurses, this book helps nursing students prepare and learn from their clinical placement experiences. It covers topical issues including patient safety, clinical reasoning, therapeutic communication, interprofessional communication, clinical handover and emotional intelligence.

international nursing, primary health care nursing and aviation and remote nursing.

Written in engaging, plain English, the book is designed to give students the confidence to integrate the material into their practice and encourages them to think deeply and critically about important professional and clinical issues.

This expanded 2nd edition also covers drug and alcohol nursing, emergency nursing, PAGE 17 March 2014 Volume 21, No. 8.

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World More palliative care needed globally Only one in ten people who need palliative care are actually recieving it, according to a global report.

The unmet need was mapped out for the first time in the Global atlas of palliative care at the end of life, published jointly by the World Health Organization (WHO) and the Worldwide Palliative Care Alliance (WPCA).

While the Atlas estimated more than 20 million patients needed palliative care at the end of life every year, only around 3 million patients received this care in 2011.

The report indicated palliative care was provided in high-income countries, but almost 80% of global need for the care was in low and middle income countries.

Only 20 countries worldwide had palliative care well integrated into their health care systems.

WHO Assistant Director General for Noncommunicable Diseases and Mental Health Dr Oleg Chestnov said the Atlas showed the greatest majority of the global need for the end-of-life care was associated with noncommunicable diseases such as cancer, heart disease, stroke and lung diseases. “While we strengthen efforts to reduce the burden of the biggest killers in the world today, we must also alleviate the suffering of those with progressive illness who do not respond to treatment.”

WHO has called on countries to strengthen palliative care and to integrate it into their health care systems.

The study, which investigated the knowledge and experience of nursing staff in relation to eHealth developments, found 85% of respondents felt very confident or confident using information technology (IT). However, 46% of respondents reported they received no consultation about the introduction of eHealth developments at their workplace, while 78% said they had little or no influence on eHealth use in their workplace.

The results also revealed 25% of nurses had to share computers with eleven or more others, while 35% stated they had insufficient access to IT equipment, or that the IT tools they used were inadequate for their roles.

Irish Nurses, Midwives and students against further cuts to pay Facebook page

Irish nursing students have launched a new campaign against poor pay for graduate nurses.

UK nurses need more influence in eHealth initiatives Significant numbers of UK nurses have had no consultation or little influence over eHealth use in their workplace according to a recent survey commissioned by the Royal College of Nurses (RCN).

Poorly paid graduates

results followed by nursing notes and recording assessments.

More than one-third of respondents were unsure about the properties and benefits of telehealth. However those with experi-

“35% stated they had insufficient access to IT equipment, or that the IT tools they used were inadequate for their roles” ence of telehealth were more likely to be positive about it and have more knowledge about its benefits.

The report advises that if nursing staff were to effectively embrace all the benefits afforded by the digital age a number of key factors needed to be addressed; particularly in relation to appointing nurses in positions of influence on boards and eHealth developments, IT support, tools and education.

The starting salary for newly graduate nurses is now €22,000, a drop of €4,000 from the past starting salary of €26,000. The same graduate can earn far more abroad, up to €43, 614 in Canada, according to the Union of Students in Ireland (USI).

The aim of the campaign, ‘Everybody Loves Nurses’, is to tell Minister James Reilly that graduates and students have had enough.

A number of demonstrations were held across the country to prove the students’ point last month.

“The message to Minister Reilly is loud and clear. Change the starting level back to €26,000 for newly graduate nurses,” USI President Joe O’Connor said. “The drop in starting salary is actively encouraging young graduate nurses to emigrate. Our hospitals need nurses to stay in Ireland to work. Understaffing is already a massive issue in the health care sector; conditions need to change now, starting with increasing the starting wage. Everyone has the right to a living wage, especially hard working nurses.”

IT at workplaces was mostly used for ordering laboratory tests and viewing PAGE 19 March 2014 Volume 21, No. 8.

Feature

Nurses eat their own Bullying and horizontal violence takes its toll PAGE 20

Feature

The familiar expressions ‘nurses eat their own’ or their ‘young’ spark a range of reactions among those in the profession: from sadness and anger, to acknowledgement, rolled eyes or a snort of laughter – but never denial.

Kara Douglas investigates the culture of bullying within the professions and the devastating toll it takes.

Elizabeth’s voice cracks as she fights to hold back tears. It has been two years since she was forced to leave her job as a nurse manager because of workplace bullying but the pain is still raw. “You feel like it’s your own fault, that it’s a direct reflection of your own inadequacy,” she says. “It‘s taken a long time for me to be prepared to say that this is what happened to me.”

What happened was persistent bullying by two senior colleagues that pushed Elizabeth* to breaking point, threatening her career, her health and her marriage. “I literally just couldn’t continue. I just couldn’t stop crying at work, I went home and my medico started me on anti-depressants and I went off to counselling.”

Elizabeth’s ordeal started during a restructure at her work in 2011.

Despite having years of experience at a very senior level, Elizabeth says the restructuring of roles led her to being consistently bullied by the DoN and another newly-appointed director for about two years.

“It wasn’t direct, aggressive stuff. It was more around withholding knowledge, giving of silly assignments, being excluded and not informed of what was required in my work - those sorts of things.”

Elizabeth says this covert bullying destroyed her confidence and ability to function at work. “It was subtle and it was difficult to pinpoint that it was going on, so it took some time to realise that you were being frozen out of information or selectively given information.”

“

You’re not protected by moving up the ladder.

It’s not just something that occurs when you’re an RN. It occurs at all stages

”

After breaking down and seeking help, Elizabeth tried to return to work under the condition that she would not have to interact with the two people she had been bullied by. Another DoN offered to act as an intermediary with the pair on Elizabeth’s behalf, but was refused. “So I was just at home using up all of my leave provision,” Elizabeth says.

“Then they offered me a position as an RN and that was not really acceptable or workable because of course I would quickly become a senior nurse in a situation that I was unfamiliar with, then I ran out of money and had to find work.”

Elizabeth took her case to the NSW Nurses and Midwives’ Association (NSWNMA). With the union’s help, she went through the workers compensation scheme. The case was resolved fully in her favour and she was awarded the maximum compensation payment.

But it is little consolation for Elizabeth. Her bullies remain at work, while she has been pushed out of a career she loved. She now has to live away from her Sydney-based family to work at a university in regional NSW for significantly less pay. “So despite having gone through the legal/industrial process, the outcome of that being in my favour, I’m still in a position where I’m separated from my family in order to earn an income. I received no apology and there’s been no change in the work situation that I’m aware of.”

Two years on from the experience, Elizabeth says she still struggles with anxiety and her confidence is destroyed. “You’re not protected by moving up the ladder. It’s not just something that occurs when you’re an RN. It occurs at all stages,” she says. *Not her real name PAGE 21 March 2014 Volume 21, No. 8.

Feature

Professor Gerry Farrell, La Trobe University

A culture of bullying Just about every nurse and midwife can recount an experience of being bullied or witnessing bullying at work. Known academically as horizontal or lateral violence, nurse-to-nurse bullying can take many different forms. “It’s a whole gamut of behaviours, from the fairly obvious of someone shouting or being verbally abusive, to very covert behaviours like not giving people the necessary information to do their job well, intimidating non-verbal behaviours, even things like silence,” says La Trobe University Professor of Nursing Gerry Farrell. “I remember interviewing someone years ago who said when they walked into the staffroom people just went silent, so there’s a whole gamut of behaviours and I think the hardest to deal with are the more covert, more nuanced type behaviours that occur in workplaces.”

Professor Farrell has conducted extensive research on the issue and estimates about one in three nurses experience bullying during their career.

He says it has a significant impact on the individual and their families, as well as the health organisation itself. “There’s the broader impact in terms of the reputation and the financial cost associated with having to recruit and replace staff and often it’s good staff, highly skilled staff that will leave because they know they can get a job elsewhere.”

“

There are some people who are, for want of a better word, evil and take delight in others misfortune, but they can only operate in an environment that allows it

”

Research by Professor Farrell found about 2% of nurses had left their job and left nursing all together because of abuse in the workplace.

“So in a situation where there’s a shortage, that’s got a huge impact.”

The student experience Not only does bullying cause experienced nurses and midwives to leave the professions, it impacts the ability to attract and retain graduates. Dr Brian Sengstock from the University of the Sunshine Coast says bullying of student nurses is prolific. “The research that I conducted and completed a few years ago suggests that 100% of nursing students experience horizontal violence in some form.”

Dr Sengstock says a number of students surveyed said they would consider leaving nursing if bullying behaviour continued once they graduated. “And given that we currently have a global shortage of nurses I would argue that yes, it is having a significant impact.”

PAGE 22

Dr Brian Sengstock, University of the Sunshine Coast

The type of bullying behaviour students reported included being blocked from undertaking specific tasks that are required to achieve competency or being isolated, says Dr Sengstock. “It’s not uncommon for nursing students, for arguments sake, in their second year of placement where you would expect to be undertaking some clinical skills, to be given maybe 15 patients for showering in the morning and then told that they’re not to have a break until such time that all those patients are showered and back to bed.”

Dr Sengstock says such treatment has a significant impact on the student. “They experience a kind of internal conflict and start questioning exactly where they fit and start questioning: what is my role, what am I here to do?”

He says this causes a significant degree of anxiety. “Because the students go in with the expectation of actually being able to do something, that they’ll be expected by the nursing staff and so on and they find the reality is that doesn’t happen.”

Dr Sengstock says there are particular facilities and wards where universities will not place students because of the bullying culture. He says students reported the worst experiences in the medical/surgical area.

“Whether that was because of the nature of the patient and the time task imperatives evident in that particular setting, I’m not sure. You have to do medication rounds at a certain time and you have to do other tasks at a certain time and that certainly came through in the data with nurses saying: I’ve got a student that slows me down so therefore I can’t get to complete these tasks in a given time.”

Dr Sengstock says part of the problem is that moving nursing to the higher education sector put student nurses outside of an organisation, so their role and skill levels are not clearly defined. “They sit outside the hierarchy of the profession and are questioning: where do I fit, what am I doing here? Similarly the facilitators and the facilities are saying: well, what can you do, where do you fit within this structure?”

Feature Dr Sengstock believes some of the issues could be alleviated if a governing body such as the Australian Health Practitioner Regulation Agency (AHPRA) created defined roles for students. “We need to consider a specific position for student nurses, whether that be that you go in as a nursing student level 1, level 2, level 3 - similar to the old hospital training days. I think that would clearly delineate exactly what this nursing student could do and where they fitted within the hierarchy.”

Bullying in the bush Working in the bush is not for the faint hearted, it throws up many unique challenges for health workers to deal with such as isolation, working with limited resources, being on-call 24/7 and living in inadequate housing. These stressors can also create an environment ripe for bullying.

Dr Annmaree Wilson is the senior clinical psychologist for CRANAplus Bush Support Services, a 24 hour/seven day a week telephone counselling service for remote area health workers. She says over 50% of calls to the line relate to bullying or workplace conflict.

“The sorts of things that people will talk about include that there are very unreasonable demands placed on them, that they’re expected to do too much in too little time, and when they’re not able to meet those expectations they feel like they’re somehow not good enough or they’re unprofessional.”

“

The earlier people ask for help or ask to through what they’re experiencing, talk the better off they are

”

Racial discrimination can also be a problem in the bush, says Dr Wilson. “We have a number of Aboriginal health workers and overseas trained doctors and nurses reporting that they are being bullied and that they’re often on the receiving end of under the breath insults or culturally inappropriate comments.”

Dr Wilson believes isolation can make the problem worse. “There’s very much that sense from callers that had they had this event occur in a larger regional area or in a large hospital, the impact wouldn’t be so magnified,” she says.

“But because there are not people around that they can bounce ideas off or talk about what they’re experiencing or how they’re feeling, it’s magnified in the bush.”

Working in remote areas also attracts different personality types.

“Health workers, nurses in particular, who choose to work out in the bush, I think very much share some characteristics with emergency service personnel in general,” says Dr Wilson.

“They have very high expectations of themselves, very high expectations of certain other people, they tend to like to take risks and they also tend to not seek help when they need it.”

Dr Wilson says this often leads to people denying that bullying is happening: “A belief that people should be able to cope, just pull their socks up and get on with it, when in actual fact our experience at Bush Support Services is that the earlier people ask for help or ask to talk through what they’re experiencing, the better off they are.”

Accessing support is also a challenge. “It could be that the only support might be a fly-in-fly out psychologist or counsellor that a nurse knows and doesn’t want to reach out to because they’re peers,” says Dr Wilson.

In an effort to address the lack of bullying support services for remote area health workers, Dr Wilson says CRANAplus Bush Support Services has developed a new phone app designed to give people practical information about how to handle bullying, which will be released later this year.

Dr Annmaree Wilson, CRANAplus Bush Support Services

Recognising the bully in you Everyone recognises bullying behaviour; some people will intervene while others turn a blind eye - but what if the bully is you? Workplace relations consultant Dr Jeannette Kavanagh believes everyone is capable of bullying. “We’re all bullies in the broadest sense, or potential bullies.

“When you actually look at bullying and the definition of it being deliberate behaviour that is meant to humiliate and distress, obviously putting pressure on the most junior nurse isn’t going to qualify, you’re not setting out to deliberately do that,” says Dr Kavanagh.

“But when you practice that sort of power imbalanced behaviour often enough, you come to have expectations of people that are unreasonable and the people who work with you, admire you, respect you and want to please you are often placed in exactly the same situation as if you were some sort of foul mouthed shouting stereotypical bully.”

Dr Kavanagh says the potential to bully is built into every leadership role. “You might just use a bit of extra pressure with the nursing assistant, people who are willing to go beyond the call of duty are often prime victims for the very thin line between subtle pressure and bullying.”

The pillars of good leadership are consultation and collaboration, says Dr Kavanagh. “In situations where decisions are made without consultation, without collaboration - what you get is a whole group of the staff who feel really hard done by, disempowered, disenfranchised and think: why bother, why am I here, why am I a professional when no one even asked my opinion?”

Dr Kavanagh says it is more important for organisations and individuals to promote a harmonious workplace, rather than having a checklist of traits that characterise a bully. “It’s much easier for people to say he’s a bully, she’s a bully, they’ve bullied me than it is for them to ever look at their own behaviour.”

“It’s also very rare for people to want to have that extra little bit of empathy that you sometimes need in order to reconcile with the bully.”

PAGE 23 March 2014 Volume 21, No. 8.

Feature

Counting the cost As well as the emotional impact on the individual, bullying has a significant financial cost. La Trobe’s Professor Gerry Farrell says it costs the Australian economy between $5 and $30 billion a year across all industries. “It’s not just in terms of replacing staff that leave because of bullying, but the cost of employers responding to bullying claims, just in terms of personnel and timeout for people – it’s huge.”

Professor Farrell says there are no state or federal surveys to track bullying and aggression in the workplace, so it is difficult to know whether it is worse in nursing and midwifery compared to other professions. “I suppose if you make mistakes in nursing the consequences [to patient care] are probably much more severe than in other professions so we may be particular attuned to it in nursing.”

He says stamping out bullying requires significant cultural change.

“It’s a culture that’s grown up and it’s been allowed to continue.

We need strong leadership and management responses if we want to reduce it or eliminate it.”

Organisations need to do a lot more in terms of realistic training for all staff and particularly for middle level managers, says Professor Farrell. “It may be that in some situations there are some people who are, for want of a better word, evil and take delight in others misfortune, but they can only operate in an environment that allows it.”

Know your rights New anti-bullying laws came into force at the start of this year. The national legislation gives the Fair Work Commission the power to make orders to stop bullying at work and requires the Commission to start dealing with a complaint within 14 days.

The laws only cover private sector and commonwealth workers so for nurses and midwives working in the state public sector there is no change to the existing processes for bullying complaints.

NSW Nurses and Midwives’ Association (NSWNMA) professional officer Mary McLeod handles bullying complaints on behalf of union members. She says it is important to understand the legal definition of bullying. “It has to be repeated, unreasonable behaviour.

The repeated part is very important and it has to adversely affect the health and safety of the person that is being bullied.”

Ms McLeod says there are many different kinds of unreasonable behaviour. “It could be micro management, it could be excluding people from information, it could be overlooking them for promotion, it could be over attention to detail or performance management for trivial matters.”

She says an isolated incident does not constitute bullying. “If you have a single event, or a gripe or people have differences of opinion, it will often be rejected as bullying because it doesn’t fit that definition of repeated, unreasonable and having an effect on health and safety.”

Ms McLeod advises nurses and midwives to look at their organisation’s policies in relation to bullying and grievance handling arrangements to know what resources are available.

If the bully is your manager, Ms McLeod says to find out how to report their behaviour to someone independent, “Be prepared before the event and if you have a problem and report it, you need to put it in writing and keep a copy. You also need to contact your union and be supported by your union.”

PAGE 24

What you said…

“About time this was brought to the forefront.

Unfortunately the bullies are not dealt with appropriately, as they know how to work the system. Is it any wonder we lose so many young intelligent nurses early on in their career?”

— Jacqueline

“Overseas and newly qualified staff are particularly at risk – they’re not told certain info, how to do procedures, not spoken to...” — Anon “I was bullied in the workplace during my midwifery training. The bullying was so bad that I suffered anxiety and felt physically sick as I approached the workplace. I made an official complaint to the management of the hospital yet nothing was done about it. I will never work in the birth unit of this hospital again.” — Vanessa “The most common I see is the way experienced nurses are treated when they arrive in a new job. All of them, even if they have decades of valuable experience up their sleeve, are treated like a new grad. Shameful.” — Rose “Once you’re marked, you’re marked in an organisation and it tends to go down the line because they all talk.” — Ann “I have read a lot about workplace psychopaths and now believe this nurse ticks all the boxes - I dread when she is on and try to avoid her.”

— Anon

“They were horrible and thought that humiliating a new nurse was the best way to educate them.

Now when I have students with me I encourage questions and teach as much as I can. I mean, why wouldn’t you?” — Michelle

Feature

Professional Julianne Bryce & Elizabeth Foley, Federal Professional Officers

Midwives - what we do for you July 25 2013 was an historic day for the Federation. That was the day our midwife members were officially recognised in our name: the Australian Nursing & Midwifery Federation (ANMF). The ANMF represents the largest number of registered midwives in the country, with over 19,000 members registered as midwives.

This is more than half of all registered midwives in Australia, according to the total number of 35,577 shown in the June 2013 statistics from the Nursing and Midwifery Board of Australia (NMBA). Fitting, therefore, that our name signifies both the nursing and midwifery professions.

Given that this month’s Focus section in the ANMJ is on midwifery we thought it timely to outline some of the work undertaken on behalf of our midwife members. Midwives have been an integral part of the Federation since its inception in 1924. Professional and industrial gains have been fought for and achieved for our nurse and midwife members alike, over the intervening years. Of particular significance has been improvements to wages and conditions; implementation of career structures; introduction of workload management arrangements for safe care delivery; and university based education for registered nurses and registered midwives, across the country.

Prior to the introduction of the National Registration and Accreditation Scheme in 2010, our union took a leadership role with the Australian Peak Nursing and Midwifery Forum, in ensuring preservation of regulatory entitlements for nurses and midwives (protection of title and recognition as separate professions). The ANMF undertook extensive work during the establishment of the Nurse Practitioner (NP) role and more recently that of the Eligible Midwife (EM). This has included the development of related legislation and regulations, to allow access to prescribing, the ordering of diagnostic and referral

by NPs and EMs. While the final outcome of this work was not all that we had desired, it gave us a basis from which to continue to advocate for the full rights of these experienced nurses and midwives who are the clinical practice leaders in our professions.

The ANMF professional team represents and advocates for our midwife members in all written and personal representational work relating to professional matters. The policy issues we’ve contributed to over recent months on behalf of our midwife members include the following:

Review of midwifery accreditation standards The Australian Nursing and Midwifery Accreditation Council (ANMAC) commenced the review of the Midwifery Accreditation Standards in February 2013. ANMF Federal Office has been represented on the Expert Advisory Group for this review by O’Bray Smith, a registered midwife member, from the NSW Nurses and Midwives Association Branch Council. Over the last 12 months the ANMF has provided a national response to two consultation papers; responded to, and circulated to members, two online surveys; attended and actively participated in three consultation forums, and four regional/rural/ remote focus groups. We have represented members’ views throughout ANMAC’s extensive consultation process. Our aim has been to ensure standards developed for accrediting midwifery programs in this country will be attainable for students in their preparatory content and produce registered midwives capable of delivering all aspects of maternity care. It is also our firm view that we need to prepare a workforce equipped and willing to work in regional, rural and remote parts of Australia, to protect the viability of already vulnerable and fast disappearing midwifery services in these areas. Throughout the ANMAC consultation process we have maintained that midwifery programs need to prepare safe and competent registered midwives through attainable requirements which reflect contemporary practice in the Australian context. We now await the result of the review following consideration by ANMAC Board, the NMBA, and finally, Health Ministers through the Standing Council on Health (SCoH), over the next few months.

document Safety and Quality Framework for Privately Practising Midwives attending homebirths, to extend applicability to all midwives. The midwife can best ensure safety and quality by focussing on the needs and safety of the woman and her infant(s), as well as their own professional obligations, when making decisions, recommendations and options for care.

Draft position statement on bed-sharing and co-sleeping The information contained in the draft statement from the Australian College of Midwives covers several issues around mothers’ and caregivers’ rights in making informed choices about bed-sharing and co-sleeping. The ANMF expressed concern the draft statement did not wholly align with current expert, evidence-based guidelines (for example, those provided by SIDS and Kids, UNICEF UK, directives and guidelines from Australian health departments, and coronial recommendations).

Eligible midwives The ANMAC is consulting on the Accreditation Standards required for Eligible Midwife Programs. This review will revise and update the Standards. The ANMF is responding as this column is being written.

For more information about the work of the ANMF federal professional team, including the submissions outlined above, go to the ‘Professional’ section at: www. anmf.org.au

Revision of the Safety and Quality Framework for midwives The ANMF commended the NMBA for making the necessary changes to their PAGE 25 March 2014 Volume 21, No. 8.

Education Quality use of medicines The following is an excerpt from the NEW Quality Use of Medicines tutorial available on the ANMF Continuing Professional Education (CPE) website.

About two million people every six months experience an adverse reaction to medicines and this has a flow on. It leads to about 400,000 extra visits to the doctor and almost 200,000 hospitalisations a year.

• In up to 30% of patients > 75 years of age.

• In 27,000 in-hospital incidents 26% were medication-related.

• 85% of discrepancies in medication treatment stem from poor medication history taking.

• Up to 60% of medication histories have at least one error - up to 30% of these errors have the potential to cause patient harm.

• Previous allergic reactions to drugs may not be recorded more than 75% of the time.

• More than 50% of medication errors occur at transitions of care.

• Patients with one or more medicines missing from their discharge prescription are 2.3 times more likely to be readmitted to hospital.

Medication errors result in approx. 80,000 (2-4%) annual admissions to a hospital:

Quality Use of Medicines (QUM) is one of the central objectives of Australia’s National

Medicines make a significant contribution to the treatment of ill health, prevention of disease and improving health outcomes.

They can also, however, cause harm.

Medication error is one of the most common causes of unintentional harm in Australia (Evans et al 2009).

Medicines Policy (NMP). The definition of QUM applies equally to decisions about medicine use by individuals and decisions that affect the health of the population. The term ‘medicine’ includes prescription, nonprescription and complementary medicines.

Everyone has a part to play in Quality Use of Medicines based on a partnership approach with consumers (National Strategy for Quality Use of Medicines).

“Medication error is one of the most common causes of unintentional harm in Australia (Evans et al 2009).”

Practical Principles include: Selecting management options wisely; decide if medicine is the best way to treat and prevent illness and poor health; Choose the most suitable medicine if a medicine is

Over 45 topics available including Core, General, Critical Care, Midwifery and Mental Health. New tutorials include Ethics in Nursing Practice, Schizophrenia and Quality Use of Medicines. Members get 11 free topics, free professional development portfolio and mobile device friendly.

The ANMF provides affordable, best practice CPD online learning to ANMF, NSWNMA and QNU members to meet their CPD registration standards.

Topics are applicable to all areas of practice.

Non members can also access the online training at non member rates.

Hone your clinical skills through 3D simulated learning, practice ECG lead placement, NG and IDC insertion, injection techniques, IV cannulation and more. Website provides video, anatomy, text, practice mode for procedures and test to ensure competence. Only $10 each for members.

Aged Care Training Room

Access to over 60 aged care specific topics, learning reflections record, CPD record, certificates of completion, CPD prioritising and planning resourses and email reminders to keep you on track.

Members $110 per year.

For more information contact the Federal Education Officer, Jodie Davis at education@anmf.org.au or 02 6232 6533.

http://anmf.org.au/pages/online-education-programs

PAGE 26

Education considered necessary; and Use medicines safely and effectively to get the best possible results; following all instructions for taking the medicine correctly.

Using medicines safely and effectively includes monitoring outcomes, minimising misuse, over-use and under-use, improving people’s ability to solve side effect problems related to medication, and managing multiple medications.

The Australian Nursing & Midwifery Federation (ANMF) quotes the following issues as risks to quality use of medicines: • Polypharmacy and excessive use of tranquillisers and psychotropic agents; • Lack of processes for medicines review; and • The administration of medicines by unqualified or inappropriately qualified staff.

Registered nurses, midwives and enrolled nurses (who have completed the education to allow them to administer medicines), in consultation with medical practitioners and pharmacists, are the most appropriate health professionals to administer medicines to persons unable to perform this unaided. Assistants in nursing (however titled) cannot legally administer medicines.

Nurses and midwives have a responsibility to assist people to make informed decisions about medicines and all properly qualified Healthcare professionals managing medications are responsible for knowing and applying their competency, scope of practice and practice standard guidelines as well as maintaining contemporaneous knowledge and skills to utilise medicines appropriately.

Registered nurses and midwives are educated to be aware of the benefits and potential hazards in the use of medicines; administer medicines safely and legally; monitor medication efficacy and identify any adverse effects; and have the necessary skills to assess the changing needs of the person and their care. They are also responsible for evaluating the person’s response to medicines and accurately communicate that information.

Multiple QUM programs are continuously running and being developed, globally and locally. Some of these covered in detail within the tutorial include; Preventing adverse effects of medication; Medication Management Reviews (MMRs) whose aim is for the safe, effective and appropriate use of medicines. Residential Medicine Manage-

ment Reviews (RMMRs); Home Medicines Review (HMR); Medication reconciliation; Medication safety alerts; Medication documentation; National Medication Charts; National Labelling Recommendations; Electronic Medication Management; Quality Prescribing Incentive (QPI) of the Practice Incentives Program (PIP); National Aboriginal Community Controlled Health Organisation (NACCHO) QUMAX; Patient Education Resources; Resource for QUM Patient Teaching; and QUM Outcome Reviews.

Success of the National Strategy for Quality Use of Medicines is measured by:

and also contains a number of real life scenarios to put the knowledge gained from the tutorial into clinical practice.

To access this NEW tutorial go to anmf.org.au/pages/cpe Select either member or non-member login. Members pay only $7.70 for 12 months access to this fabulous new edition to the ANMF’s online professional development.

For further information contact Jodie Davis, Federal Education Officer at education@anmf.org.au or ph: (02) 6232 6533

formal quantitative and qualitative data on implemented QUM initiatives: their immediate effects; progress made towards strategy goals; and changes in health outcomes associated with medication use.

Australia is the world leader in this concept of an inter-disciplinary approach to medication management. Over 180,000 HMRs have been conducted since the inception of the program in 2003 and the RMMRs are now a requirement of all Aged Care Facilities (ACFs) for their accreditation. Hospital admissions due to medication mismanagement, especially following discharge, have decreased as a result of the medication review process.

Medicines are only one therapeutic strategy for promoting and maintaining health, managing ill health and alleviating discomfort and disease.

“Hospital admissions due to medication mismanagement, especially following discharge, have decreased as a result of the medication review process.”

Nurses and midwives, as regulated professionals, have a key role and responsibility to ensure the quality use of medicines.

Likewise, nurses and midwives have responsibility and accountability in accordance with the drugs and/or poisons legislation (however titled) of the state or territory in which they work.

The ANMF QUM tutorial is a detailed learning piece taking the nurse and/or midwife approximately three hours to complete. It is laden with resource links to ensure contemporaneous knowledge and enhancement of skills in relation to QUM PAGE 27 March 2014 Volume 21, No. 8.

Clinical Update Felicity Shaw and Simon Cooper

Stethoscope hygiene: A best practice review of the literature The aim of this study was to determine contamination rates of health professional’s stethoscopes and their attitudes toward routine disinfection.

Stethoscopes harbour pathogenic microorganisms such as MRSA, predominantly on the bell, diaphragm and earpieces.

National guidelines consider stethoscopes as low risk for infection; however contemporary evidence shows high levels of contamination.

Numerous studies reveal high levels of contamination due to disinfection failures. Standard measures for disinfection are adequate but health professionals fail to adhere to guidelines due to time constraints, absence of disinfecting material and insufficient visual reminders, but do disinfect when caring for existing MRSA cases. Best practice guidelines advise that stethoscopes should be disinfected between patient assessments. Ethanolbased cleaners and isopropyl alcohol have been identified as effective disinfectant aids, removing up to 94% of bacterial growth. Health professionals using ethanol-based cleaners during hand cleaning continued to clean the stethoscope in one action which is argued to be a more feasible approach compared to isopropyl alcohol swabs.

Evidence confirms stethoscopes to be moderate-to-high risk contaminates, acting as vectors for infection transmission.

However, stethoscope hygiene is infrequently practised, through failure to follow standard procedures. Improving health care professional attitudes towards stethoscope hygiene is imperative in today’s practice.

Prevention of contamination is undeniably feasible in conjunction with ethanol-based cleaners, positive reinforcement and improved infection control policies.

Background Stethoscopes attract a high to moderate threat of infection (Burrie 2011) particularly in the elderly susceptible patient.

The increasing proliferation of multi resistant ‘superbugs’ requires diligent hygiene of both hands and instruments between patients in order to reduce hospital acquired infections (Arias & Murray 2009). In clinical settings health professionals share stethoscopes omitting to clean the earpieces or diaphragm between users and between patients (Bandi & Conway 2012) enhancing the risk of cross infection.

Fomites can transfer bacteria to human skin through a brief touch of a surface with the risk that unconfirmed asymptomatic hosts and uncleansed stethoscopes could provide the transport to the next susceptible host. Antibiotic resistance is increasing and hospital acquired strains

“Stethoscope hygiene is infrequently practised, through failure to follow standard procedures.

Improving health care professional attitudes towards stethoscope hygiene is imperative in today’s practice.” of Klebsiella, Escherichia coli and Enterobacter are of great concern (Arias and Murray 2009). Further, Methicillin-resistant Staphylococcus aureus (MRSA) can live on inanimate objects for up to seven months, Escherichia coli for 16 months, and Clostridium difficile for five months (Russell, Secrest et al. 2012).

In this paper we aim to review the rates of stethoscope colonisation, attitudes to equipment hygiene and best practice guidelines.

PAGE 28

Clinical Update Design and methods

Stethoscopes and pathogens

A review of the literature to determine contamination rates of health professional’s stethoscopes and their attitudes toward routine disinfection.

In the 1970s stethoscope bells belonging to general hospital teams were found to be carrying pathogens in 13 out of 50 cases (26%) including penicillin resistant staphylococcus aureus (Mangi and Andriole 1972). Since then stethoscope ear pieces have been indirectly related to infections in a neonatal intensive care unit where a health care worker with chronic otitis externa and MRSA infected two neonates, possibly because the ear pieces were placed in the hands after auscultation (Bertin, Vinski et al. 2006; Burrie 2011). Another study in an Intensive Care Unit (ICU) identified 10 of 46 (22%) personal and bedside stethoscope ear pieces were colonised by Acinetobacter spp, MRSA, Pseudomonas luteola and Acinetobacter baumannii (Whittington, Whitlow et al. 2009). In this study cleaning failed to remove MRSA Pseudomonas species and Acinetobacter baumannii indicating the need for additional rigorous sterilisation processes. Russell et al (2012) also found high rates of contamination in 141 personal stethoscopes in ICU, but with no MRSA, and standard methods of disinfection were found to be effective. Finally in a recent systematic review of 31 reports, Burrie (2011) reported that 87% of diaphragms and bells where colonised with microorganisms and one in seven where colonised with MRSA, concluding that stethoscopes do harbour micro-organisms and are a potential vector for the spread of pathogenic organisms.

All levels of research evidence were included (NHMRC 2010) from multidisciplinary hospital teams in relation to stethoscope contamination and attitudes towards disinfecting. The search was restricted to studies published from 2001 to 2013, in English to keep within present day standards.

Databases The databases searched were CINAHL plus, PubMed and Google Scholar. Snowball sampling was performed from the identified papers reference lists.

Key words Primary search terms were: ‘stethoscope hygiene’, ‘stethoscopes’, ‘contamination of stethoscopes’, ‘hospital infections’, ‘stethoscopes as vector’, ‘nosocomial infections’, ‘infection from stethoscopes’

Inclusion/exclusion criteria Reports included were: peer reviewed empirical studies pertaining to stethoscope contamination and pathogen colonisation rates; Studies observing health professionals’ attitudes regarding disinfection of stethoscopes, and methods used for disinfection.

Reports excluded were: studies taking place on nosocomial infections not including stethoscope involvement, veterinarian and animal science studies using stethoscopes, and descriptive opinion/comment or narrative reviews.

“Failures in policy adherence have also been identified, Mitchel (2010) identified that a small number of respondents 13 out of 50 (6%) were unaware of the policy requirement to disinfect between patients.”

One hundred and six papers were initially identified through title review. Abstracts were then reviewed with the retention of 44 papers that initially met the inclusion criteria. These papers were read in full with 26 papers found to meet the inclusion criteria.

PAGE 29 March 2014 Volume 21, No. 8.

Clinical Update “Contemporary evidence confirms high rates of bacterial contamination and that regular cleaning with appropriate alcohol or ethanol based products diminishes the possibility of cross-infection between patients (Bandi & Conway 2012). ”

PAGE 30

Attitudes to disinfection

Disinfection – best practice

In a survey of 1,400 paediatric doctors and nurses on the barriers and enablers to stethoscope hygiene 76% acknowledged that stethoscopes were a potential vector for infection but only 24% used disinfectant after each use. Those that were aware of the infection risks were more likely to clean their stethoscopes but respondents’ reported barriers such as time constraints, absence of disinfecting material and insufficient visual reminders (Muniz, Sethi et al. 2012).

In a survey of a physiotherapist practice 2% reported cleaning stethoscopes once a day, 30% after every patient contact, 11% before coming into contact with a patient, and 2% cleaned with alcohol swabs before and after each contact. Further, 27% only disinfected their stethoscope where the patient had a confirmed MRSA infection (Fenelon, Holcroft et al. 2009). Failures in policy adherence have also been identified, Mitchel (2010) identified that a small number of respondents three out of 50 (6%) were unaware of the policy requirement to disinfect between patients. However of the remaining 47 who were aware of the policy nine (19%) stated they did not clean their stethoscopes regularly. Further, an observational study of 100 emergency department staff revealed only 8% of nurses reported cleaning in between and after every patient assessment arguing lack of time and forgetfulness (Worster, Srigley et al. 2011).

Cleaning intervals of doctors and shared stethoscopes in a neonatal unit was also insufficient and varied from once daily to never, with CFU counts significantly higher in those that were never cleaned compared to those that were cleaned sporadically (Bandi, Uddin et al. 2008).

The evidence indicates that between consultations the stethoscope diaphragm, tubing and ear pieces should be decontaminated (Alexis 2009). Comparisons of ethanol based cleaners and isopropyl alcohol have identified a 94% reduction in bacterial growth for both approaches (Zachary, Bayne et al. 2001; Schroeder, Schroeder et al. 2009; Bandi and Conway 2012; Vajravelu, Guerrero et al. 2012).

Health care professionals using ethanol based cleaners during hand cleaning have been observed to go on and clean the stethoscope in one action which is a more feasible approach than those who use isopropyl alcohol swabs and have to find the product and then locate a dustbin to dispose of the swab and wrapping (Lecat, Cropp et al. 2009). However others have found that disinfecting with hand rub is less effective than using alcohol wipes as swab friction was more effective (Mehta, Halvosa et al. 2010).

Disposable devices in the form of a sleeve that fits over the neck of the stethoscope are available at a cost of 13 cents each (Medguard Healthcare 2010) and silver infused antimicrobial covers (“Stethocap”) are available for the diaphragm at a cost of $1.00 (Stethocap Inc 2013). However high surface colony counts have been identified on these covers as users tend not to comply with the manufacturer’s instructions of weekly changes. (Wood, Lund et al. 2007; Michels, Noyce et al. 2009; Schroeder, Schroeder et al. 2009).

In national guidelines stethoscopes are considered non critical (WHO 2007; Standards New Zealand 2008; CDC 2010; NHMRC 2010; CHICA 2012).

However contemporary evidence confirms high rates of bacterial contamination and that regular cleaning with appropri-

Clinical Update ate alcohol or ethanol based products diminishes the possibility of cross-infection between patients (Bandi & Conway 2012). Taking into account feasibility of all approaches the combination approach of using an ethanol based cleaner for hands and the stethoscope appear to be well advised. Such approaches need to be reinforced for all health care workers through a combination of stethoscope hygiene and infection control policies.

Retrieved 14 August, 2013, from www.cdc.gov/ mrsa/prevent/healthcare/precautions.html.

Retrieved 15 August, 2013, from www.stethocap.com/Weekly_Use_Product.html.

CHICA. (2012). Routine practices and additional precautions preventing the trasmission of infection in health care settings. Infectious diesease prevention and control Retrieved 14 August, 2013, from www.chica.org/pdf/2013_PHAC_ RPAP-EN.pdf.

Vajravelu, R. K., D. M. Guerrero, et al. (2012).

Evaluation of stethoscopes as vectors of Clostridium difficile and methicillin-resistant Staphylococcus aureus. Infection Control & Hospital Epidemiology 33(1): 96-98.

Conclusion

Lecat, P., E. Cropp, et al. (2009). Ethanol-based cleanser versus isopropyl alcohol to decontaminate stethoscopes. American Journal of Infection Control 37(3): 241-243.

The evidence indicates that stethoscopes harbour pathogenic microorganisms, specifically on the bells, diaphragms and ear pieces. Contemporary studies identify that disinfection attitudes and practices are inadequate which raised significant concerns with the increasing incidence of antibiotic resistance ‘super bugs’.

The evidence demonstrates that ethanol based cleaners or isopropyl alcohol wipes disinfect stethoscope surfaces, eliminating bacteria by 94%, proving both methods are practical. Swabs do provide extra friction, however from a convenience perspective, ethanol based cleaners used in conjunction with hand cleaning are likely to be the most feasible in a practice setting.

Fenelon, L., L. Holcroft, et al. (2009). Contamination of stethoscopes with MRSA and current disinfection practices. Journal of Hospital Infection 71(4): 376-378.

Mangi, R. and V. Andriole (1972). Contaminated stethoscopes: a potential source of nosocomial infections. The Yale Journal of Biology and Medicine 45(6): 600.

Medguard Healthcare. (2010). Stethoclean Membrane Protection - 200 per pack. 8/08/13, from www.medguard.ie/stethoclean-membraneprotection-200-per-pack.html.

Mehta, A. K., J. S. Halvosa, et al. (2010). Efficacy of alcohol-based hand rubs in the disinfection of stethoscopes. Infection Control & Hospital Epidemiology 31(8): 870-872.

References

Michels, H., J. Noyce, et al. (2009). Effects of temperature and humidity on the efficacy of methicillin-resistant Staphylococcus aureus challenged antimicrobial materials containing silver and copper. Letters in applied Microbiology 49(2): 191-195.

Alexis, O. (2009). Providing best practice in manual blood pressure measurement. British Journal of Nursing 18(7): 410-415.

Mitchell, A., N. Dealwis, et al. (2010). Stethoscope or ‘Staphoscope’? Infection by auscultation. Journal of Hospital Infection 76(3): 278-279.

Arias, C. A. and B. E. Murray (2009). Antibioticresistant bugs in the 21st century-a clinical super-challenge. New England Journal of Medicine 360(5): 439-443.

Muniz, J., R. K. V. Sethi, et al. (2012). Predictors of stethoscope disinfection among pediatric health care providers. American Journal of Infection Control 40(10): 922-925.

Bandi, S. and A. Conway (2012). Question 2 Does regular cleaning of stethoscopes result in a reduction in nosocomial infections? Archives of Disease in Childhood 97(2): 175-177.

NHMRC (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia.

Bandi, S., L. Uddin, et al. (2008). How clean are our stethoscopes and do we need to clean them? Journal of Infection 57(4): 355-356.

Bertin, M. L., J. Vinski, et al. (2006). Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare worker with chronic otitis. Infection control and hospital epidemiology 27(6): 581-585.

Burrie, N. A. (2011). Stethoscopes as vectors of infections. Australian Medical Student Journal 2: 32-35.

CDC. (2010). Precautions to Prevent the Spread of MRSA in Healthcare Settings. MRSA Infections

Whittington, A. M., G. Whitlow, et al. (2009).

Bacterial contamination of stethoscopes on the intensive care unit. Anaesthesia 64(6): 620-624.

WHO. (2007). Standard precautions in health care. Epidemic and pandemic alert and response Retrieved 18 August, 2013, from www.who.int/ csr/resources/publications/EPR_AM2_E7.pdf.

Wood, M. W., R. C. Lund, et al. (2007). Bacterial contamination of stethoscopes with antimicrobial diaphragm covers. American Journal of Infection Control 35(4): 263-266.

Worster, P., A. Srigley, et al. (2011). Examination of staphylococcal stethoscope contamination in the emergency department (pilot) study (EXSSCITED pilot study). Canadian Journal of Emergency Medicine 13(4): 239-244.

Zachary, K. C., P. S. Bayne, et al. (2001). Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci. Infection Control & Hospital Epidemiology 22(9): 560-564.

Felicity Shaw is a registered nurse who has recently completed a bachelor of nursing (community health) at Monash- Berwick campus, Victoria Associate Professor Simon Cooper PhD, MEd, BA, RN, FHEA works at Monash University Faculty of Medicine, Nursing and Health Sciences, Victoria

Russell, A., J. Secrest, et al. (2012). Stethoscopes as a Source of Hospital-Acquired MethicillinResistant Staphylococcus aureus. Journal of PeriAnesthesia Nursing 27(2): 82-87.

Schroeder, A., M. A. Schroeder, et al. (2009).

What’s growing on your stethoscope?(And what you can do about it). Journal of Family Practice 58(8): 404.

Standards New Zealand. (2008). NZS 8134.3:2008 Health and Disability Services (Infection Prevention and Control) Standard. New Zealand Standards Retrieved 14 August, 2013, from www.infectioncontrol.co.nz/uploaded/file/ downloads/81343-2008.pdf.

Stethocap Inc. (2013). Stethocap and solutions.

PAGE 31 March 2014 Volume 21, No. 8.

Tech Talk Gurney Khera

Are nursing apps the flavour of the month?

The relatively new buzzword ‘app’ is bandied about by smartphone users much to the chagrin of others. It certainly can raise the green monster of envy, especially when those boast of their latest ‘app’, or you see an advertisement for a product with the obligatory small-print ‘download the app from the App Store’.

An app, short for ‘mobile application’ is basically a computer application program designed to run on smartphones, tablets and other mobile devices.

A smartphone is a small computer with a touch screen, combined with a mobile phone (eg an iPhone). A tablet (like the iPad) is a small computer with a bigger touch screen, but without the mobile phone hardware. These differ from laptops and desktop computers mainly in having different operating systems, reduced memory and exclude keyboards, but are far more portable and easy for browsing the internet.

Apps are usually available through ‘application platforms’ operated by the owner of the mobile system, such as Apple’s App Store or Google Play Store. Some apps are free, while others must be purchased, usually for smaller fees than desktop software. There is a huge growth in the number and variety of apps as many developers attempt to provide new and innovative mobile services across all professions and vocations.

Apps are downloaded via the internet to the smartphone or tablet. As this is cloudbased architecture, the app is run locally but the data is stored ‘in the cloud’ (see last month’s article on Cloud computing).

Standard apps exist for general use and include email, calendar, contacts, GPS, news and weather information. Usually these are preloaded onto the smartphone or tablet.

Apps have also been developed including games, automation, language translation, banking, point-of-sale, ticket purchases and recently, mobile medical apps.

There are now a plethora of apps to assist nurses, midwives, specialists, clinicians, and of course, patients. ‘Nursing Central’, by Unbound Medicine, is such an app that has been specifically developed for the nursing and midwifery profession. Comprehensive and very sophisticated yet user friendly, this is an app with a suite of different yet integrated functionalities. It is a subscriptionbased service, developed in the USA so the PAGE 32

content is designed to their regulations and standards, but is also very relevant for use in Australia. Despite this, it is recommended that the material be examined, analysed and certified by the relevant nursing/ midwifery and health industry authorities to ensure its use here is compatible with Australian standards and practice.

Nursing Central is targeted at nursing students, new graduates and those who wish to update their knowledge and keep abreast of latest medications, procedures and articles. The app is promoted as ‘the complete mobile solution for nurses and students.’

Nursing Central’s content includes: Davis’s Drug Guide: “The best-selling drug reference produced by FA Davis provides need-to-know information on thousands of brand name and generic drugs” Taber’s Medical Dictionary: “A comprehensive health science dictionary featuring over 65,000 terms, 1,200 full colour photos and illustrations and over 100 videos” Diseases and Disorders: “Complete coverage of more than 250 diseases and medical conditions encountered in nursing practice… to plan and deliver patient care.

Practical recommendations are supported by concise descriptions of how the human body is altered by disease and clear rationales for medications and tests.”

Davis’s Laboratory and Diagnostic Tests: “An easy-to-consult manual with over 400 entries, to quickly check pre-test requirements, intra-test procedures and monitoring, and post-test care.”

MEDLINE Search and Journals: “Search over 22 million journal articles from the PubMed database of medical journals.

Results contain abstracts, citations, and links to available full text articles, linking directly to view full text provided by the journal publisher, having tables of contents delivered directly to your mobile device” Another interesting and relevant app designed for the nursing community is ‘Mosby’s Nursing Consult’ by Elsevier Inc.

It is an app for registered nurses, midwives and nursing students, which consists of a compilation of various point-of-care and reference tools for nursing/midwifery professionals. It features information with monographs on brand name and generic drugs; drug calculators; patient education on conditions, treatments, medications, and emergency department (ED) discharge instructions, as well as evidence based nursing monographs. The drug calculators include body surface area, dose, volume, rate and delivery type.

According to Dr Ryan Shaw, reviewer with the Medical App Journal, “The Drug calculators are likely the best feature of the app. They are comprehensive and can be used without internet connection. The level of minute detail in the calculators makes them useful in acute care settings such as the intensive care unit where a nurse may be looking at IV dosage with calibrated tubing and IV dosage by rate and weight. The input of drug rate and concentration is simple and an answer is presented based upon the embedded algorithms.”

It is vital, given the nature and application of medical apps, that they are well researched and selected for use only if they are accurate, reliable and authorised by the relevant authority in order to minimise the very real risk of misinformation and misuse which can pose significant risks to the patient. Ensuring the credentials of apps before using will help deliver better and safer care within the new paradigm shift that technology is driving and changing, the nursing and midwifery professions.

For a more comprehensive review of both apps by Dr Ryan Shaw, see: http://medicalappjournal.com Gurney Khera B.E, B.Sc (computer scientist) is an IT Specialist and Consultant

Legal Linda Starr

Failing to render first aid – infamous or improper conduct?

On a dark evening in April 2002, 200km from Port Hedland in WA a person who was also a medical officer was involved in a near miss motor vehicle accident. The doctor reportedly stopped at an intersection when a speeding vehicle approached and veered toward her. She narrowly missed a collision by taking evasive action; neither she, her passenger nor the car suffered any damage.

Dr Dekker said she could no longer see the other vehicle, but her passenger said it sounded like ‘they rolled it’. Unfortunately the passenger in the other vehicle was killed. Rather than stop the doctor drove to the police station a short distance away to seek assistance.

At that time in her witness statement she said ‘...I was in a state of shock. I was terrified as I thought I had almost been killed. I was unable to think in a coherent manner. In that moment I feared for my life and personal safety.’ In 2013 the Medical Board of Australia alleged that Dr Dekker ‘may be guilty of infamous or improper conduct in a professional respect’ for failing to stop and render assistance on that night. At this point you might be thinking – health professionals are not obliged to stop and render aid to a stranger.

From a common law perspective that is generally true - there is no legal requirement for health professionals to stop and assist a person in danger nor to stop at the scene of an accident and render assistance where there is no prior relationship. However, this was not a civil but a regulatory matter. The core role of the regulatory authority is to protect the public, that is, to ensure that only competent and safe practitioners are registered and able to provide health care to the community. Thus, when any concerns about a registered practitioner’s conduct is brought to the authority’s notice they are obliged to investigate and take any necessary steps to protect the health and safety of the public.

Infamous conduct in a professional respect refers to conduct that ‘….a medical man, in the pursuit of his profession, has done something with regard to it which would be reasonably regarded as disgraceful or dishonourable by his

professional brethren of good repute and competency..’ (Allison v General Council of Medical Education and Registration [1894]1 QB 750).

Improper conduct on the other hand is conduct that professional colleagues would regard as improper conduct exercised in the pursuit of their profession - a less serious charge.

In challenging the Medical Board’s claims Dr Dekker argued that her actions, in the context of the circumstances on that night, were appropriate particularly given that she had no mobile phone, torch or medical equipment and that she was in shock and distressed. The tribunal disagreed finding her guilty of improper conduct in a professional respect holding that her professional duty as a doctor obliged her to put aside the ‘shock’ response and provide assistance to those that were injured.

They did not feel that a case for ‘infamous conduct’ had been made out, as although she failed to stop and assist she did go directly to the police for assistance. However, had she failed to stop and failed to seek other assistance the tribunal agreed it would be open to them to find that her professional peers of good repute and competency would regard her conduct as disgraceful or dishonourable and thus infamous.

Finding the doctor guilty of ‘improper conduct in a professional respect’ required the tribunal to establish that the conduct was ‘in pursuit of the practitioner’s profession’, which they contended was not limited to conduct in the carrying out of clinical practice but was inclusive of any conduct that had a sufficiently close link between the person’s conduct and the profession of medicine. In other words professional misconduct included behaviour that extended beyond mere clinical misconduct.

As such, the tribunal placed considerable weight on the core purpose and underpinning ethical framework of the skilled medical profession - to save human life and heal the sick and injured. This they argued provided the sufficiently close link between her conduct and the medical profession, satisfying the tribunal that her competent medical peers of good repute would regard her behaviour as improper.

Not surprisingly the tribunal’s decision was seen to be unreasonable by some including Dr Bird from MDA National who viewed this as placing extraordinary and unrealistic expectations on medical officers, particularly with respect to the expectation that a doctor should ‘overcome or at least put aside the shock and provide assistance.’ (Smith P 2013) Hence, whilst there may be no legal obligation to stop and assist there may be a professional ethical duty to do so. In these circumstances if the doctor had stopped to assist, as a good samaritan, she would have established a legal duty of care to those who were injured and be obliged to act reasonably in the circumstances according to her level of skill and expertise. Given that she had no equipment, torch or mobile phone at best she may have been able to render immediate first aid, assess the scene and establish what emergency services were needed. Perhaps a comforting thought is that in these cases good samaritans are protected under legislation in all Australian jurisdictions from incurring any personal civil liability for acts or omissions during the rescue or when rendering aid to someone in an emergency, particularly if they themselves were suffering from shock.

References

Medical Board of Australia and Dekker [2013] WASAT 182.

Smith P 2013. Crash doctor decision ‘unreasonable’. Australian Doctor available at www. australiandoctor.com.au 3 December 2013

An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia

PAGE 33 March 2014 Volume 21, No. 8.

Research Midwifery care is safer Pregnant women who see the same midwife during their pregnancy are more likely to experience fewer interventions during birth according to a study from the University of Sydney.

The research also showed reduced costs to the public hospital system when women saw the same midwife rather than receive standard shared antinatal care or private obstetric care.

The research examined three models of care at the Royal Hospital for Women for cost and outcomes of care. The models included caseload midwifery care, standard hospital care, or care provided by a private obstetrician in the public hospital.

Research lead Professor of Midwifery Sally Tracy said that first time low-risk mothers who received caseload midwifery care were more likely to have spontaneous onset of

labour and an unassisted vaginal birth.

“Caseload midwifery patients were also tentimes less likely to have an elective caesarean than women with private obstetric care.”

The study also found over one financial year there was an average saving of over $1,000 per woman for those who chose caseload midwifery care.

“The latest findings help to refute misconceptions that one-to-one midwifery care is expensive or unstainable to complex pregnancies,” Professor Tracy said.

and feel a stronger sense of satisfaction and personal control if they have the opportunity to get to know their midwife at the beginning of pregnancy.

According to Professor Tracy childbirth accounted for the highest number of occupied bed days for women, but the current structure of the maternity system made it challenging to deliver value for money.

“Caseload midwifery care works on the premise that women will labour more effectively, need to stay in hospital less time

Co-author Dr Donna Hartz said caseload midwifery care had been introduced at most hospitals as a token service with access to a small proportion of women. “It’s a very appealing model to women. If you review the few hospitals that provide caseload midwifery care you’ll find there is an enormous waitlist.”

Kids’ mental health screening checks deemed misleading Significant numbers of children screened for mental health problems in future years could be falsely identified, a study has found.

The Adelaide University study aimed testing the accuracy of potential screening measures, which encompassed parent reports, to identify children ‘at risk’ of developing school-related mental health problems in the future.

Research lead Dr Alyssa Sawyer said while there was a proposal to extend the Healthy Kids Check in Australia to include screening

for early signs of mental health problems it had caused some controversy both within the academic circles and in the general community. “The difficulty of accurately identifying young children at risk for future mental health problems poses a major challenge, especially for the implementation of effective, targeted intervention programs.”

Dr Sawyer said approximately 25% of the children with high levels of teacher reported problems at age 6-7 could be correctly identified on the basis of parent reports at age 4-5 years. “However approximately 75% of the children identified as ‘at risk’ at age 4-5 years

did not go on to experience high levels of problems at age 6-7 years. This speaks to the difficulty of screening being able to clearly identify individual children who will experience a high level of problems two years later when they are in their first years of school.

“These findings suggest that we could potentially reduce the number of children experiencing mental health problems at age 6-7 years by 25%. However, if treatments are stigmatising and expensive then 75% of the children at age 4-5 years who were falsely identified would be put at risk of receiving interventions that they may not need.”

Coping styles after a natural disaster A study, which looks at how people cope during times of natural disasters, has been undertaken to improve psychological intervention programs for people traumatised by such events.

The collaborative study, involving the University of Canterbury and the University of the Sunshine Coast (USC), surveyed participants who had been through the 2011 Christchurch earthquakes or the earlier Queensland floods.

PAGE 34

According to Study Lead Chelle Whitburn, different types of coping styles that people used after a traumatic event were identified, which resulted in mental health outcomes.

The study showed people who used problemsolving and help-seeking coping methods had significantly better mental health outcomes than those who used an avoidant coping style, which led to poor mental health.

Ms Whitburn said she had hypothesised that people who had experienced unrelated trauma or multiple traumas, such as childhood

abuse, would have higher levels of depression, anxiety and stress after a natural disaster. “But we found the only factors that had a significant correlation to mental health outcomes after the disaster were individual coping styles.

“This is encouraging because it means people can seek psychological assistance following any trauma to learn positive coping techniques that will improve their long-term mental health. It also has implications for the development of psychological interventions to assist people following the experience of trauma.”

Research Perspective Theresa Snijders

Building the bridge between the classroom and clinical practice: research into health care associated urinary tract infections.

The use of a urinary catheter is, when required, a necessary health care intervention but one which carries a significant risk of infection.

Catheter associated urinary tract infections (CAUTIs) are one of the most common health care associated infections, accounting for 80% of health care associated urinary tract infections (HAUTIs) (Lockwood et al 2004, p 273). For the catheterised patient who develops a CAUTI, there is an increase in morbidity, the risk of infective complications and discomfort and for the acutely ill, there is an increased risk of mortality (Moola et al 2010, p 697).

Catheter acquired urinary tract infections also result in prolonged hospital stays and increased treatment costs (Moola et al 2010, p 697), that can be averted through infection prevention and control measures such as better catheter care and management.

A recent protocol paper on HAUTIs has been published by researchers at Australian Catholic University (Mitchell et al 2013).

The study found a lack of documentation in relation to periurethral/meatal solutions used prior to catheter insertion (Gardner et al 2014). Given the importance of meatal colonisation in the pathogenesis of CAUTIs (Elvy et al 2009, p 36) and the findings from the previous study, the focus of this current research project is on determining the efficacy of periurethral/meatal care regimens in the prevention of CAUTIs. My role as an undergraduate nursing student working as a vacation scholar on this project was to assist in the preliminary stages of the research project by conducting extensive literature searches, managing the search results, appraising the quality of the evidence and selecting literature that complied with the inclusion criteria for review. The results of the searches were compiled into a literature list, tabling the authors, detailing research design and the outcomes of each study.

Interestingly, despite nurses being responsible for catheter care and management, there were only a small number of research articles that were nurse initiated. This is reflected in comments by Moola et al (2010, p 698), who argues that nursing knowledge of current research regarding the management of catheters is inadequate. Another study made the observation that nursing research on this subject is in the initial stages only (Ercole et al 2013, p 464).

Nurses are in a unique position to generate the research that will inform the evidencebase required to implement better nursing practice in the clinical setting so as to improve patient outcomes. A successful nurse driven initiative to reduce CAUTIs in a hospital setting using best evidence shows that nurses can instigate and drive change (Patrizzi et al 2009, p 539).

Undertaking the vacation scholarship as a nursing student has assisted me in developing the skills needed to participate in research, and has expanded my understanding of the generation of evidence and the importance it has in clinical practice. These skills will also translate into my future clinical practice as a registered nurse, allowing me to recognise best-evidence and advocate for its implementation in the clinical setting.

References

Elvy, J., & Colville, A. 2009. Catheter associated urinary tract infection: what is it, what causes it and how can we prevent it? Journal of Infection Prevention, 10(2):36-40.

Mitchell, B., Gardner, A., Beckingham, W., & Fasugba, O. 2013. Healthcare associated urinary tract infections: a protocol for a national point prevalence study. Healthcare Infection, http:// dx.doi.org/10.1071/HI13037 Moola, S., & Konno, R. 2010. A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections. JBI Library of Systematic Reviews, 8(17):695-729.

Patrizzi, K., Fasnacht, A., 7 Manno, M. 2009.

A collaborative, nurse-driven initiative to reduce hospital-acquired urinary tract infections. Journal of Emergency Nursing, 35(6):536-539.

Theresa Snijders is an undergraduate Bachelor of Nursing (Practice Leadership) student at the Australian Catholic University in Canberra. She received a 2013-2014 Undergraduate Vacation Scholarship from the Faculty of Health Sciences.

Ercole, F.F., Macieira, T.G.R., Wenceslau, L.C.C., Martins, A.R., Campos, C.C., & Chianca, T.C.M. 2013. Integrative review: Evidences on the practice of intermittent/indwelling urinary catheterization. Revista Latino-Americana De Enfermagem, 21(1):459-68.

Gardner, A., Mitchell, B., Beckingham, W., Fasugba, O. 2014. A point prevalence study of health care associated urinary tract infections in 6 Australian hospitals (manuscript under review).

Lockwood, C., Page, T., Conroy-Hiller, T., & Florence, Z. 2004. Management of short-term indwelling urethral catheters to prevent urinary tract infections. JBI Reports, 2:271-291.

PAGE 35 March 2014 Volume 21, No. 8.

Wellbeing Carefully does it: Tips to prevent injury at work The lifting and pushing that nurses and health care professionals do every day can lead to serious neck and back pain. In fact, Australian Bureau of Statistics figures show almost one quarter of women injured at work are health care or social assistance workers.

Australian Physiotherapy Association President Marcus Dripps warns manual handling injuries are often caused by unexpected circumstances rather than routine work tasks, particularly when assisting patients who have impaired balance due to their underlying condition or because of medications. “When you have circumstances where there’s patient handling involved and the degree to which the patients will assist during the transfer or during toileting, or bathing, or generally just moving around the setting of care, which can make things a little more risky for the staff.”

Be active Marcus stresses the most important aspect of injury prevention overall is people’s underlying physical condition and whether they do recreational exercise. “It’s a real challenge particularly where there is an ageing workforce, particularly in rural and regional areas where you can find that the nursing workforce is ageing. So when you’ve got the effects of age, which might be decreased fitness, decreased strength, decreased flexibility, this can affect your risk of injury.”

sustained periods of static postures to more active duties where we need to be aware [of the risk of injury], so when people get up from doing a period of desk based duties.”

If you’ve been sitting down for a period of time Marcus recommends doing some simple ‘transition’ stretches when you get up. “It’s really around assuming the postures that are the opposite of what you’ve just been doing if coming out of a static piece of work. So if you’ve been sitting there at a computer your lower back has probably been bent forward, you might be sticking your chin out for some time with rounded shoulders.”

High tech help Smart phone apps are also a great tool for finding simple stretches that you can do to help ease or avoid muscle pain. There is everything from yoga for backs, to finding your own acupressure points to relieve pain.

Marcus recommends downloading an app designed to get you moving. “One of the features that I really like and often get patients to use is something that gives a little pop up reminder every now and then to do some movement, because one of the emerging bodies of evidence is around the harmful effects of sedentary behaviours whether at work or at home. Basically if you spend your recreational time sitting and you’ve got a large sitting component at work, then every now and then when you have something that requires some more force or more agility, you’re not really prepared.”

Get moving

Marcus recommends doing these quick and easy stretches whenever you are transitioning from desk work to something more active.

1. Standing lumbar extension

Stand with your feet shoulder width apart.

Put your hands on the back of your hips. Arch your back backwards and hold for 3 seconds.

2. Neck rotation

Gently turn your head toward the left as though you are looking back over your shoulder. Hold for 5 seconds. Repeat on the other side.

Leading an active life, regardless of age, is one of the keys to avoiding injury. But that doesn’t mean you have to hit the gym or embark on a hard-core fitness regime. “Having regular periods of exercise through the week, so having a walk at morning tea or lunchtime, those sorts of things have enormous health benefits and I think they’re often overlooked as the simple tools that we can use to keep ourselves active,” Marcus advises.

Stretch after sitting It may feel like you are on your feet for a whole shift, however Marcus warns that time spent sitting at a computer or writing case notes adds up. “It’s the transition from PAGE 36

3. Neck side bend

Tilt your head toward your right shoulder.

Place your right hand on the top of your head and gently pull it toward your right shoulder. Hold for 10 seconds. Repeat on the other side.

Reflections Carmel Hurst

Honouring nurses On the day that the Australia Day Honours list was published in The Age, there was an article considering the disparity between awards presented to men and those presented to women.

Over 900 submissions were made, but only 30% of them were for women. Several reasons were offered for this, the most persuasive of them being that men tend to promote themselves and women do not. Some men ask others to submit an application on their behalf. I believe that most women would not even think of doing such a thing.

Nursing is a profession followed mostly by women and there are a lot of us. But how many nurses do you know with a gong? I can think of many nurses over a long career who have performed great things for this country and for their profession.

We should be more like the men, at least in recognising the worth of our colleagues and ensuring they are recognised officially. Put in a submission for a great nurse you know.

My occasion for thinking these thoughts and writing this paper is that I received a gong on that day. A nurse colleague submitted my name; I have been lucky in my colleagues and friends.

I was awarded an Order of Australia Medal.

This was a big event for me and for nursing. It was awarded for my involvement in the Homeshare program. It is a program that I think should interest nurses.

Homeshare history Homeshare is a fairly new concept and it is very new to Australia. I was first exposed to the idea when attending an international conference of the Australian Association of Gerontology in Adelaide in 1997 and was immediately interested. My interest came from the knowledge that I had designed something like this for my mother, but here it was – an international movement.

My mother, at 86, was gradually becoming unable to stay safely at home alone. She was legally blind and subject to attacks of severe angina. Because I lived hundreds of kilometres away I was very anxious about her and had the idea of getting someone to live with her. We eventually found a delightful young Chinese student from Hong Kong who came to stay at our house in Brisbane. He became

a family friend who gave her support, companionship and a new interest in life.

Importantly, he slept in the house at night.

And this is Homeshare. When I returned from the conference on Homeshare, I talked to colleagues involved in aged care, suggesting that we could do something of the same in Australia. From there we have been working towards setting up Homeshare in Australia ever since, and we have been incredibly successful.

What is homeshare?

A Homeshare program helps older, at risk householders or householders with a disability to stay in their homes while helping others find affordable housing. The program offers a comprehensive screening and matching service, making sure the needs of both parties are met.

Homeshare is a great option for seniors or people with a disability who would like to share their home in exchange for companionship and practical help and support. Arrangements vary according to the need, time and commitment of the people involved.

How homeshare works Householders and the homesharers complete detailed application forms. All applicants are interviewed and carefully assessed.

Introductions, follow up meetings and trials are arranged. If both parties decide the match is compatible the homesharer moves in.

Homeshare draws up an agreement detailing the arrangements for living together including specific tasks, sharing or managing living costs – electricity/gas, food, use of telephone. Every agreement will be different and designed to suit the circumstances of the match.

The program coordinators provide ongoing contact and support to both parties.

The homesharers Homesharers come from many different backgrounds and walks of life. There are no specific qualifications for homesharing. Homesharers need to be caring and responsible; willing to spend a regular portion of each week helping an older or disabled person with every-day domestic duties and provide security in the evenings and overnight.

Photographer Sarah Matray

Students, especially mature-aged and post graduate students are well suited to homesharing as it provides a secure and quiet environment.

Homeshare today The enthusiasm for Homeshare is great amongst those who are aware of the needs of older or disabled people. It is cost effective, it has cultural and community strengths and it means that both parties to the match have something to give. It also provides families like mine with the comfort of knowing that someone is looking out for their loved one.

A program has been running in Melbourne now for 12 years without much trouble and with spectacular successes.

Homeshare has spread. There are now organisations in most states either running programs or attempting to acquire funding to do so. There are Homeshare programs in Victoria, Adelaide, Perth, Canberra, Queensland and Tasmania.

If there is any interested nurse or health professional in New South Wales willing to give Homeshare a go, please contact us. We have all the wherewithal needed to get you started.

Enquiries can be made to HANZA - Homeshare Australia and New Zealand Alliance: (03) 9523 9418, (03) 9534 3229, Mobile: 0417 514 35, www.homeshare.org.au http://en.wikipedia.org/wiki/Homeshare PAGE 37 March 2014 Volume 21, No. 8.

Clinical View Jayr Teng, LLB, BN, BAppSci, GDLP, GC Mgmt, ATI RN

Consent – basic concepts for clinical nursing practice The issue of consent is often confusing even for the most experienced registered nurse. It is confusing because it requires consideration of issues which are often interlinked and hard to separate in practice, for example, pre-existing mental illness.

Registered nurses are in a difficult position when they are considering the issue of consent as at times it may feel like there are time sensitive decisions which are required to be made.

What should be remembered is that in the majority of situations registered nurses work as part of a multi-disciplinary team and often the practical solution is to work closely with medical practitioners to confirm that the issues related to consent have been dealt with appropriately. This article will consider basic issues related to consent, consent forms and detail the hierarchy of substitute decision makers applicable in Victoria.

Consent basics Broadly, consent in the clinical setting can be seen as a shield, meaning if it is given in the correct form, acts which would otherwise be illegal (such as a battery or assault) are lawful and any action in negligence by a patient claiming they were not warned of the risks related to the procedure would fail.

For consent to be valid it should satisfy the following elements: (a) the patient in the opinion of the medical practitioner is capable of understanding the proposed treatment; (b) full information related to the risks, benefits, alternatives related to the medical procedure are provided to the patient; (c) consent is specific to the procedure; (d) the consent is freely given having regard to the information provided by the medical practitioner; (e) t he patient has a right to withdraw consent at any time.

Further, consent may be implied, verbal or in writing. The type of consent required will depend on the treatment or procedure being proposed. For example, a patient may PAGE 38

give implied consent for an injection to be administered if they stretch out their arm prior to the administration of the injection.

Implied consent would not, however, be suitable for more complicated medical procedures such as an endoscopic ultrasound.

The registered nurse’s role in the consent process should be to support the patient and assist with raising any pertinent issues with the relevant medical practitioner.

This is because ultimately, it is the medical practitioner who is responsible for giving the requisite information to the patient and obtaining the patient’s consent.

Consent forms The use of a consent form is not definitive proof that consent in relation to a medical procedure has been obtained. It does however provide written evidence of the matters discussed as part of the consent process, therefore, it should disclose all risks and other issues discussed.

Registered nurses may be asked to check a consent form. It should be remembered that the review of the consent form should be focused on identifying potential gaps on the consent form, rather than verifying definitively whether legal consent has been actually given. Ultimately, whether or not the elements of consent have been satisfied is a determination made by a court based on all available facts and information, rather than solely what has been completed on a particular consent form.

In circumstances where parts of the relevant consent form have been clearly missed, such as the wrong identification wrist band, name of the patient, signature, name of the procedure, these matters should be brought to the attention of the treating medical practitioner and rectified prior to the medical procedure. This is done to ensure that contemporaneous evidence is kept about the communication process that occurred with the patient in relation to the consent process.

Person responsible - Guardianship and Administration Act Where a person lacks the capacity to understand and consent to medical treatment, the law allows for a substitute decision maker to make medical decisions on the person’s behalf. In Victoria section 37(1) of the Guardianship and Administration Act 1986 (Vic) sets out the persons, in the following order, who are eligible to make such decisions. The hierarchy of decision makers is as follows: (i) a medical agent; (ii) a person appointed by VCAT to make medical decisions; (iii) a person appointed under a guardianship order; (iv) an enduring guardian; (v) a person appointed in writing by the patient with authority to make decisions about the proposed treatment; (vi) a person’s spouse or domestic partner; (vii) the patient’s primary carer; (viii) the patient’s nearest relative.

It is important to ensure that in situations where a substitute decision maker is used that they are the appropriate person to make the decision. For example, a primary carer should not make decisions and be used as the substitute decision maker where the person’s spouse is available and willing to make decisions on the person’s behalf.

Conclusion Consent is a vexed and complicated issue which necessitates strong interdisciplinary communication between nurses and medical practitioners. The aim of obtaining consent is to ensure that the patient is aware of all matters relevant to their treatment so that they are able to make informed choices, including, the decision to refuse treatment.

Issues Renee Fiolet and Leah East

Gender equity: what the COAG report means for Australian nurses and midwives The Council of Australian Governments (COAG) Reform Council’s recent report revealed that although women are living longer, some women are still experiencing health disparities compared to men.

The report, Tracking equity: comparing outcomes for women and girls across Australia, examined whether Australian women and girls are benefiting from national reforms aimed at improving the lives of Australians and to track gender equity in the Australian context (COAG Reform Council, 2013). Key findings in the report highlighted several significant issues in which nurses and midwives need to consider in contemporary practice. Three pertinent issues that need to be addressed urgently are: • Over one third of women with a disability report they need more health services that address their needs. There are as many as two million women who experience disability in Australia, which signifies a significant number of these women are not receiving the care required to promote health and their positive wellbeing (COAG Reform Council, 2013).

• Domestic/family violence significantly contributes to poor outcomes for women and is the most commonly cited reason for homelessness among women.

However, due to the lack of national data and domestic violence often not being routinely assessed in health care settings, statistics may be grossly underestimated meaning that many women may still be suffering in silence, which equates to adverse health outcomes for these women (COAG Reform Council, 2013).

• Women identify the cost of health care, remoteness and extended waiting times as significant barriers to service accessibility, which is another contributing factor to poor health outcomes for women (COAG Reform Council, 2013).

So how can nurses and midwives working within Australia address these key issues that significantly impact the health outcomes for the country’s women and girls? We suggest that by drawing on our national competency standards (Nursing and Midwifery Board

of Australia 2006a; Nursing and Midwifery Board 2006b) particularly those relating to being informed, completing comprehensive assessments, utilising resources effectively, patient advocacy and working within interdisciplinary teams we can aim to address these health disparities.

It is imperative for nurses and midwives to recognise the current issues facing Australian women in order to provide therapeutic care. It is the duty of the nurse/midwife to be aware of the social and environmental conditions that may be impacting the health of a woman (and all clients). In order to stay abreast of current issues professional development opportunities can be utilised. Professional growth is easier today than it has ever been with online and hardcopy access to journals such as the ANMJ as well as online education, webinars and online forums that are often freely available and can be utilised during breaks, handover or from home.

Comprehensively assessing clients involves a holistic approach which includes recognition of the social and environmental context in which they live as well as acknowledging their ongoing needs. Through comprehensive assessment nurses and midwives are able to identify individual needs, suitable resources and if required referral for clients (Luxford 2012).

To be able to recognise and refer clients to suitable services and associated resources, nurses and midwives need to know what is available for individuals within the local community. This requires consciously familiarising oneself with other health care professionals, services and organisations available within the neighbourhood and also through telephone networks and the internet. Additionally, prioritising and taking advantage of opportunities to be educated about local services can assist with gaining this knowledge which in turn can assist with promoting health outcomes for clients. One of the most important roles for nurses and midwives is patient advocacy (McPherson and Stakenberg 2012). By being active patient advocates, nurses and midwives can take a leading role in bringing women’s health issues and disparities to the forefront of both the public and political arenas in order to help address these issues and improve health outcomes for women. Furthermore,

by working within the interdisciplinary team health outcomes for clients can be improved (McPherson and Stakenberg 2012). Interdisciplinary team work requires effective communication skills and dedication to the sharing of knowledge. This begins with the ability to recognise the unique contribution other team members can make towards client care and validating the role of the client in the process of care coordination, which in turn promotes therapeutic care and positive wellbeing among clients (Nursing and Midwifery Board of Australia 2006a; Nursing and Midwifery Board of Australia 2006b).

Nurses and midwives are in a prime position to promote wellbeing, provide therapeutic care and help minimise health disparities faced by some women. In taking an active stance to being informed, working within the interdisciplinary team, patient advocacy and conducting individual comprehensive assessments, we as a health care discipline can assist in reducing pertinent health issues faced by Australian women.

References:

Council of Australian Governments Reform Council. 2013. Tracking equity: Comparing outcomes for women and girls across Australia. Australia. www. coagreformcouncil.gov.au/reports/gender-equity/ tracking-equity-comparing-outcomes-women-andgirls-across-australia Accessed 1 December, 2013.

Luxford, Y in Berman et al. 2012. Kozier and Erb’s Fundamentals of Nursing: Assessing. 2nd Edition. Australia: Pearson.

McPherson, C and Stakenberg, S in Berman et al.

2012. Kozier and Erb’s Fundamentals of Nursing: Values, ethics and advocacy. 2nd Edition. Australia: Pearson.

Nursing and Midwifery Board of Australia. 2006a.

Registered nurse competency standards – rebranded. Australia. www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Codes-Guidelines.aspx# competencystandards Accessed 3 December, 2013.

Nursing and Midwifery Board of Australia. 2006b.

Midwifery competency standards – rebranded.

Australia. www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Codes-Guidelines.aspx# competencystandards Accessed 3 December, 2013.

Renee Fiolet RN, BN (Hons), GCHE, PhD Candidate and Lecturer in Nursing & Midwifery, Deakin University Dr Leah East RN BN (Hons) PhD, Senior Lecturer in Nursing & Midwifery, Deakin University PAGE 39 March 2014 Volume 21, No. 8.

PAGE 40

Midwifery & Maternal Health The Milky Way Midwives’ decision-making in

By Shahla Meedya 2nd stage labour-report on an The Milky Way is an innovative intervention to increase the rate of breastinterpretive study feeding until six months postpartum.

Health professionals including midwives, family and child health nurses and lactation consultants encourage women to breastfeed. However, many women, particularly first time mothers, stop breastfeeding in the first few weeks after birth.

By Dr Elaine Jefford

decision” (Jefford, 2012). The final act of the clinical reasoning process is decisionmaking which is defined as an “act of choosing a preferred option or course of action from a set of alternatives. It precedes and underpins almost all deliberate or voluntary behaviour (Calhoun, 2002).”

My concern is that midwives may not have been well prepared for independent clinical reasoning.

To address the issue an intervention was designed, based on theory and current best evidence, called the Milky Way. The study was a two-group, pre-intervention/post intervention design. Two hundred and twenty five women were assigned to the standard care group and 205 to the Milky Way intervention. Baseline data was collected antenatally. The intervention involved three antenatal breastfeeding classes and two postnatal follow up phone consultations for women who were breastfeeding. Postnatal data collection for both groups was by phone at one, four and six months postpartum or until the woman stopped breastfeeding.

Baseline data between groups did not differ.

The Milky Way group had higher rates of breastfeeding (compared with the standard care group) at one (83.7% vs. 61.3%, p<.001), four (64.5% vs. 37.1%, p<.001) and six months (54.7% vs. 31.4% p<.001).

After extra statistical analysis, the likelihood of any breastfeeding was nine times more in the Milky Way group at one month (OR= 9.02, CI 4.03-20.16), four times more at four months (OR= 4.13, CI 2.48-6.89) and three times more at six months (OR= 3.01, CI 1.86-4.86).

The Milky Way intervention was effective in increasing breastfeeding rates up to six months. It is a feasible intervention, which can be delivered by midwives and other health professionals. It is recommended that a multi-phased breastfeeding program, like the Milky Way, be considered as part of standard care for women who want to breastfeed for the first time.

Shahla Meedya is as a Lecturer at the University of Wollongong in NSW.

The subordination of midwifery to medicine and nursing has institutionalised midwives and curtailed their decision-making autonomy (Fahy and Parratt, 2006).

In the past decade, midwives have achieved increased levels of autonomy within professional guidelines, but are they ready for decisional autonomy? (Australian College of Midwives, Guidelines, 2013). Decisions can be made either analytically or nonanalytically; the first way is slow, open to consensual validation and more likely to be accurate. The other way of making a decision is much more commonly used because it is quick and often correct.

Clinical reason is an analytical way of making clinical decisions. Clinical reason is defined as “drawing upon an accurate knowledge base to systematically analyse assessment cues, whilst taking in to consideration ‘intuitive awareness’ in order to decide and act upon an evidence-informed

Clinical reasoning as a way to make decisions have the benefit of being analytical and transparent, but medical models of clinical reasoning exclude emotion and the patient from decision-making. They are not women-centred and do not resonate with the philosophical stance of midwifery. As midwifery has moved away from medically dominated models of maternity care they no longer have to refer to a doctor for much of their clinical decision-making. Midwifery decision-making models, embrace the inclusion of emotions and the woman in decision-making but lack detailed and specific steps for how to effectively engage in clinical reasoning; particularly the midwife’s responsibility to assess, plan, implement and evaluate safe, effective, evidenceinformed care (Jefford, 2012). Further, it is

“Clinical reasoning as a way to make decisions have the benefit of being analytical and transparent, but medical models of clinical reasoning exclude emotion and the patient from decision-making. They are not women-centred and do not resonate with the philosophical stance of midwifery.” not always possible that the woman be the decision-maker in care. Birth, for example, is a time where rapid decisions are required in a complex, fast changing situation where the woman may be in an altered state of consciousness and is counting on the midwife’s professional skill and judgement.

PAGE 41 February 2014 Volume 21, No. 7.

Focus I conducted a study using the question: To what extent do midwives engage in a clinical reasoning during second stage labour? Twenty-six practising midwives were interviewed.

A key finding from this study was nine of the interviewed midwives did not use analytical reasoning processes. This lack of clinical reasoning also occurred when they described what they thought to be good decision-making stories.

To optimise the safety and quality of midwifery care to women, it is imperative midwives use clinical reasoning processes to make critical decisions. In addition, in order to fulfil his/her obligations of professional accountability, the midwife must be able to explain and justify her clinical decision-making, not just to the woman, but to other maternity care providers (ANMC, 2008), (NMBA, 2008).

Clinical reasoning should be taught and assessed within midwifery curricula and enacted within the clinical environment.

References

Fahy, K. and J. Parratt, Birth territory: A theory for midwifery practice. Women and Birth, 2006.

19(2): p. 45-50.

Australian College of Midwives, National Midwifery Guidelines for Consultation and Referral, K.-C.A.P. Limited, Editor 2013, Australian College of Midwives: Australia. p. 1-92.

Jefford, E., Optimal Midwifery Decision-Making during 2nd Stage Labour: The intregration of Clinical Reasoning into Practice, in School of Nursing and Midwifery 2012, Southern Cross University: New South Wales. p. 257.

Dictionary of the Social Sciences, in Oxford Reference Online., C. Calhoun, Editor 2002, Oxford University Press: Oxford.

Australia, N.a.M.B.o., Code of Ethics for Midwives. 2008, Canberra: Australian Nursing and Midwifery Council.

Nursing and Midwifery Board of Australia, Code of Professional Conduct for Midwives in Australia, 2008, Australian Nursing and Midwifery Council,: Canberra. p. 1-10.

Dr Elaine Jefford is Assistant Head of School in the School of Nursing, Midwifery and Paramedicine (Signadou Campus) at Australian Catholic University and is Honorary Senior Fellow in the Faculty of Health & Social Care at Hull University UK

PAGE 42

Enhancing learning in the midwifery continuity of care experiences

By Linda Sweet With the introduction of the three year Bachelor of Midwifery program in Australia in 2002, a pedagogical innovation called the Continuity of Care Experience (COCE) was commenced.

The COCE affords an ongoing relationship for student learning between a midwifery student and a childbearing woman, from initial contact in the early antenatal period, through pregnancy, birth and postnatal period. It is intended as a way to give midwifery students the opportunity to provide continuity of care in partnership with women through their pregnancy and childbirth, thus imitating a midwifery model of continuity of care and continuity of carer.

Students were initially required to undertake a minimum of 30 COCEs over the three year Bachelor of Midwifery program, which has since been reduced to 20. Although the inclusion of COCE in Australia’s midwifery curriculum standards was mandated by the accrediting bodies, there was a lack of guidance on how to embed these within curricula to optimise student learning (Glover 2003). This change of clinical experience model whereby the students are partnered with women, rather than the more traditional model of the student being partnered with a clinician, has resulted in changed relationships and practices with childbearing women, clinical supervisors, health services and universities (Sweet and Glover 2013).

Following a study based at Flinders University Sweet and Glover (2011) have highlighted opportunities to improve the teaching and learning within the COCE, with a focus on supporting student learning before, during and after COCEs. They posit that access to authentic supported learning, formative feedback and clinical reasoning and reflection skills would enhance student learning. Moreover, they recommend better student preparation, enhanced awareness of learning outcomes and a restructuring of learning affordances for the COCEs (Billett, Sweet et al. 2013).

Sweet and Glover (2011) argue that such improvements will require the midwifery clinicians and academics to work together to enact the midwifery curricula and, in particular, improve supervision practices.

Furthermore, recent data collected by Sweet and Glover suggest that clinicians are keen to work with universities to better understand their role in clinical supervision of students engaged in COCE. During COCEs midwifery students align with childbearing women, not clinicians, directly impacting the supervisory relationship. This results in more unplanned supervision and brief and intermittent episodes of supervision that impact on the student and clinician’s ability to develop an effective learning relationship. This supervisory role is the next focus of this program of research.

References

Billett, S., L. Sweet and P. Glover (2013).

“The Curriculum and Pedagogic Properties of Practice-based Experiences: The Case of Midwifery Students.” Vocations and Learning 6(2): 237-257.

Glover, P. (2003). “Follow through experiences as midwifery curriculum.” Australian Midwifery Journal (June): 5-6.

Sweet, L. and P. Glover (2011). Optimizing the follow through experience for midwifery learning. Promoting Professional Learning. S. Billett and A. Henderson. Dordrecht, The Netherlands, Springer: 83-100.

Sweet, L. and P. Glover (2013). “An exploration of the midwifery continuity of care program at one Australian University as a symbiotic clinical education model.” Nurse Education Today 33(3): 262-267.

Linda Sweet is an Associate Professor at Flinders University School of Nursing and Midwifery in South Australia

Midwifery & Maternal Health WA’s new Fiona Stanley Hospital delivers maternity services

By Rebecca Tapp

Aerial view of the new $2 billion Fiona Stanley Hospital

Maternity services are now being provided at Western Australia’s new $2 billion Fiona Stanley Hospital (FSH).

As part of a transformation of health services in Perth’s south metropolitan area, Kaleeya Hospital has closed and all obstetrics, gynaecology and neonatal services are now being delivered at FSH’s state-of-theart facilities.

FSH’s maternity facilities includes 36 brand new maternity beds, eight labour rooms and 18 neonatal cots, including those able to support high-risk births.

The change has ensured the delivery of first class health care that meets the needs of the growing population, and a full

range of birthing options will be provided at FSH to meet community expectations.

Collaborative teams of midwives, junior medical staff and specialist obstetricians provide care for medium and high-risk women at FSH, with the most complex cases continuing to be referred to King Edward Memorial Hospital.

Along with FSH, high quality maternity services in the south metropolitan area will continue to be provided at Rockingham General Hospital, Bentley Hospital, Peel Health Campus and Armadale Kelmscott Memorial Hospital.

FSH ranks among the best hospitals in Australia and will be a leader in clinical care, research and education. It offers comprehensive health care services to communities south of Perth and across the state, and highly specialised services

including the 140-bed state rehabilitation service, a 30-bed purpose-built mental health unit, paediatrics and the state burns service.

The new hospital is the largest building project ever undertaken by the WA State Government and the first tertiary health facility to be built in WA in 50 years. FSH has been opening in a four-phased sequence that prioritises patient safety and care, beginning with the state rehabilitation service which opened in October 2013.

More information on FSH and career opportunities for nurses can be found at www.fsh.health.wa.gov.au Rebecca Tapp is the Senior Project Officer (media) at Fiona Stanley Hospital in Murdoch, WA PAGE 43 March 2014 Volume 21, No. 8.

Focus Mental health - whatâ&#x20AC;&#x2122;s that got to do with midwives?

By Jenny Johnson and Sarah Galal As midwives working as perinatal mental health clinicians we would answer that mental health and midwifery are inextricably linked. Most women with severe mental illness are mothers (Dolman et al., 2013), the perinatal period presents the highest risk for women to experience a new-onset or recurrence of psychiatric illness (Austin et al., 2013) and maternal suicide is one of the leading causes of perinatal mortality (Austin et al., 2007).

We would argue that midwives are highly skilled in developing relationships with childbearing women and their families and that this privileged position affords

a unique opportunity to support those women with mental health challenges.

An Australian study identified pregnant women, including those experiencing severe mental illness, are more likely to engage with a midwife than a mental health nurse (McCauley-Elsom et al., 2009).

Despite this, Australian midwives report they lack the required knowledge, skill, competence or confidence to deal with maternal emotional distress or mental illness (Jones et al., 2012; McCauley et al., 2011). Midwifery philosophy highlights the importance of holistic, woman-centred care (Australian College of Midwives, 2011), but how can midwives provide truly holistic care if they feel ill-equipped to talk to the woman about her emotional and mental health state? Midwives are required to rec-

ognise and respond to emergencies such as amniotic embolus and postpartum haemorrhage, but are they equally confident and competent to identify a postpartum psychosis, which may be life-threatening for both mother and infant?

Since June 2012, through National Perinatal Depression Initiative funding, we have worked within a multidisciplinary Parent & Infant Mental Health team. The philosophy of midwifery has remained intrinsic to our practice with our goal now extending from a healthy mother and newborn to a healthy mother and infant relationship. Our interventions, aimed to promote secure attachments, often begin in the antenatal period. The early relationships infants develop provide a foundation for their social, emotional and cognitive

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Midwifery & Maternal Health “The philosophy of midwifery has remained intrinsic to our practice with our goal now extending from a healthy mother and newborn to a healthy mother and infant relationship.” development and can influence their risk for mental health problems as well as the trajectory into adulthood with potential intergenerational consequences.

We have identified the importance of skilling up midwives in mental health and one of our aims for 2014 is to collaborate with Bachelor of Midwifery educators to deliver a mental health component geared directly to midwifery students. We are also collaborating with an obstetric research program which will examine the relationship between maternal mental health and adverse obstetric outcomes.

References

Austin, M-P., Kildea, S. and Sullivan, E. 2007.

Maternal mortality and psychiatric morbidity in the perinatal period; challenges and opportunities for prevention in the Australian setting.

Medical Journal of Australia. 186(7):364-366.

Austin, M-P. V., Middleton, P., Reilly, N.M., Highet, N.j. 2013. Detection and management of mood disorders in the maternity setting: The Australian Clinical Practice Guidelines. Women and Birth. 26:2-9.

The Australian College of Midwives. 2011 ACM Philosophy for Midwifery. Available at www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ ccms.r?pageid=10019; accessed 19/12/13.

Dolman, C., Jones, I. and Howard, L. 2013.

Pre-conception to parenting: a systematic review and meta-synthesis of the qualitative literature on motherhood for women with severe mental illness.

Archives of Women’s Mental Health. 16:173-196.

perinatal mental health. Journal of Psychiatric and Mental Health Nursing. 18:786-795.

McCauley-Elsom, K., Elsom, S., Gurvich, C., Cross, W. And wwKulkarni, J. 2009. Monograph 6 – Expert opinion on the need for a perinatal mental health nurse practitioner, in O’Connor, M., Griffiths, D., Ives, G., Newton, J. and Tan, H. (eds).

From birth to death: Clinical nursing and midwifery across the lifespan. Melbourne: Monash University.

Jenny Johnson is Clinical Nurse Specialist, Parent & Infant Mental Health Service, Hunter New England Local Health District(HNELHD) Child and Adolescent Mental Health Services (CAMHS) and is a Credentialed Mental Health Nurse.

Sarah Galal is Clinical Nurse Specialist, Parent & Infant Mental Health Service, HNELHD CAMHS

Jones, C.J., Creedy, D.K. and Gamble, J.A. 2012. Australian midwives’ attitudes towards care for women with emotional distress. Midwifery. 28:216-221.

McCauley, K., Elsom, S., Muir-Cochrane, E. And Lyneham, J. 2011. Midwives and assessment of

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Midwifery & Maternal Health Perinatal mental health education for midwives in Victoria

By Kay McCauley, Maureen Miles, Cheryle Moss, Wendy Cross, Dr Rosalind Lau, Jakqui Barnfield and Louise Newman Perinatal mental health issues affect women and their families worldwide. Midwives can make a difference to women and families lives with early and prompt detection of perinatal mental health issues.

To achieve improvements in the delivery of perinatal mental health care, training for midwives working in maternity setting was identified as critical. The Department of Health Victoria funded the development of perinatal mental health education programs for midwives. These comprised of

education”. The e-learning perinatal mental health education program is available via: perinatal.med.monash.edu.au The advanced perinatal mental health education program consisted of pre-learning materials, six half-day modules and workshops, and optional post-learning activities. The six modules were offered across

“Launched in May 2013 it has currently been accessed by 270 midwives in three different states and internationally, with positive feedback.”

1. a n introductory e-learning perinatal education package, and 2. a more in-depth face to face advanced perinatal mental health education program.

consecutive days, and these were repeated on five occasions around Victoria during 2012-13. Modules covered in the advanced perinatal mental health program included:

The online e-learning program is available for all midwives across the country.

Launched in May 2013 it has currently been accessed by 270 midwives in three different states and internationally, with positive feedback received. In the words of one midwife who has completed the program: “It needs to be a mandatory topic in midwifery

• role and function of perinatal service system elements; • perinatal mental health conditions; • managing women with a history of mental illness; • medication for mental health conditions during the perinatal period; • advanced communication skills;

• mentoring and reflective practice.

Midwives who completed the modules have reported increased confidence, knowledge and skills.

Kay McCauley, Maureen Miles; Cheryle Moss; Wendy Cross; Dr Rosalind Lau are all located in the School of Nursing and Midwifery at Monash University, Victoria Jakqui Barnfield is located at Monash Health and the School of Nursing and Midwifery at Monash University, Victoria Louise Newman is located in the Centre for Developmental Psychiatry & Psychology at Monash University, Victoria

Male semen crucial in shaping health of offspring University of Adelaide researchers have discovered seminal fluid particularly affects the developmental stages of sons, which in turn affects the chances of developing obesity, diabetes and other metabolic health conditions.

While seminal fluid is critical in determining whether or not a couple is able to conceive a child, researchers have now discovered that the fluid itself, not just the sperm, influences a range of developmental stages of the offspring.

“We’ve discovered that it’s not just the sperm but the entire composition of the seminal fluid which has an important role to play in establishing the offspring’s future health, and this is most notably seen in male offspring. If the seminal fluid is of poor quality it affects the female’s capacity to support an embryo. If the embryo manages to survive despite the poor quality seminal fluid, the metabolism of the resulting foetus will be permanently altered, making it more likely to develop a syndrome of metabolic disorders including

obesity, high blood pressure and glucose intolerance after birth,” said research lead Professor Sarah Robertson.

Professor Robertson said this new understanding of the role of seminal fluid could lead to better advice and new options for infertile couples. “It’s clear to us now that the seminal fluid produces signals to the embryo absolutely needs for the best possible start to life. Assisted reproductive techniques, as good as they are today, cannot currently replicate such complexity. Therefore, it’s helpful if we can find ways to encourage couples to take care of their reproductive health, including men as well as women.”

PAGE 47 March 2014 Volume 21, No. 8.

Birth notification – the vital link

By Karen Wilshier and Narelle Everard Victorian midwives have a responsibility to abide by Victorian State Government legislation and regulations which guide their practice and maintain the safety and wellbeing of the babies and families they care for.

The birth notification is the key to ensuring appropriate care post hospitalisation and is the all-important trigger for the commencement of that care by the maternal and child health (MCH) sector early in the neonatal period. It has the potential to ensure that women, babies and families receive the support and care necessary for following care plans initiated by the hospital and also receive the encouragement and support that can assist with building confidence and encourage bonding with the new family member.

The birth notification, however, is a document that is sometimes poorly completed.

For example, in one local government area1 the error rate for birth notification received from the midwifery services varies

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“It has the potential to ensure that women, babies and families receive the support and care necessary for following care plans initiated by the hospital and also receive the encouragement and support that can assist with building confidence and encourage bonding with the new family member.” from 0% - 100% depending upon the service. This means that MCH nurses often waste valuable time chasing up accurate information and parents and babies are denied the timely and responsive services they deserve.

Some midwives appear to be unaware of the importance of the birth notification, which not only has service implications, but also legal implications. Midwives are one of the defined “responsible person[s]” under the Births, Deaths and Marriages Registration Act 1996 (Vic) and must notify the appropriate Local Government Area

(LGA) of any birth they attend in accordance with Part 7 of the Child Wellbeing and Safety Act 2005 (Vic). Failure to provide valid information exposes the errant midwife to a potential fine of $144.36, is a breach of competency standards and is reportable to the Nursing and Midwifery Board of Australia.

The implications are however, even more serious for mothers and babies, as the result is all too often avoidable delay in service provision. Where the LGA is left ignorant that a particular baby has arrived, service is not commenced until someone, often the parent, contact the LGA wondering why they haven’t heard from the MCH services.

It is therefore possible that some vulnerable or transient families fall through the cracks and never receive a service at all.

Common mistakes include: • incorrect address (may have actually moved out of LGA), • incorrect contact phone numbers for the parents, • incorrect sex of the baby (may have implications in registering the birth with Birth Deaths and Marriages), • incorrect date of birth.

Attention to these details not only ensures compliance with the legislation, but also has the capacity to increase efficiency, reduce costs and improve service provision to Victorian families as they transit from hospital to home at a potentially vulnerable time.

So next time you are completing the Birth Notification, please ensure that you comply with the legislation, check the details with the parents before it is sent off and let’s see if we can move to 100% accuracy for every maternity service across Victoria, for everyone’s wellbeing.

Reference 1. Cardinia Shire Council Jan–Sept 2013

Karen Wilshier RN, Midwife, Master of Child and Family Health is a home visiting liaison midwife at the Cardinia Shire Council.

Narelle Everard RN, PG Dip in Health Promotion, Bachelor of Law works at Pearl Care

Midwifery & Maternal Health Establishing a mental health (MH) consultation liaison service within a maternity department in a general hospital setting

By Kimberly Adey, Robyn Rigby, Eleri Griffiths and Monica Taylor

By providing mental health screening, mental health psychiatric and social assessment, planning and implementing treatment in the antenatal period, we aim to avert a range of negative lifelong consequences, such as poor attachment, learning and behavioural issues, and interpersonal relationship problems reducing the trajectory of a new life towards mental ill health. By establishing linkages to affordable and accessible local primary care

“A trial pilot position was launched in October 2010 based primarily in the midwives antenatal clinic to demonstrate the need for a mental health consultation liaison service within maternity services and to identify and address the unmet need.”

In 2010 Armadale Kelmscott Memorial Hospital an outer metropolitan hospital in Perth, Western Australia proposed the concept of initiating a MH Consultation Liaison Service within its maternity department.

With the expansion of new services within the antenatal clinics and maternity wards it was recognised there was an increased need to access mental health services for review of identified patients, and to provide specialist mental health support and education for midwives. A trial pilot position was launched in October 2010 based primarily in the midwives antenatal clinic to demonstrate the need for a mental health consultation liaison service within maternity services and to identify and address the unmet need.

The clinical nurse specialist MH consultation maternity position coordinates services for women and their families who are experiencing symptoms of mental illness in the antenatal and postnatal period. The women referred

range in age groups, from varying socioeconomic and cultural backgrounds and live in both the local and rural areas. The service is provided to many diverse populations in the areas, many of whom have complex psychosocial situations and are socially isolated.

A consumer and a general practitioner survey was conducted in April 2011. The feedback was overwhelmingly positive, there was a higher than average return rate of over 32% and 30% respectively.

The challenges in setting up the position within the midwives antenatal clinic, included some confusion amongst staff in regards to the role ie consultation versus case management.

It has been identified that the role does have limitations in that often patients assessed and referred on may not follow up on the management plan devised or attend appointments arranged.

services, families are more likely to engage with a general practitioner in the longer term, and feel confident in addressing all health issues earlier, preventing complex comorbid presentations in the future. It also streamlines appropriate referrals to acute mental health services and improves accessibility to all services for consumers. Empowering women to take control of their mental health leads to improved self-esteem, and role models ‘help seeking’ behaviours for all the family.

The pilot position reported on the provision of service delivery, assessment protocols and the service evaluation prior to the establishment of a permanent 0.6 FTE position in 2013.

Kimberly Adey is a Clinical Nurse Specialist Mental Health Consultation-Maternity; Robyn Rigby is Clinical Nurse Consultant – Maternity; Eleri Griffiths is the Manager Surgical & Obstetrics Services and Monica Taylor is the Nurse Director – Mental Health. All work at the Armadale Health Service in Western Australia

Perceived benefits on the part of midwives when a woman presented in crisis was ‘relief’.

PAGE 49 March 2014 Volume 21, No. 8.

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Midwifery & Maternal Health Early years outreach clinic defeating barriers to perinatal mental health care in rural Australia

By Fiona Little and Anne Galloway Access to perinatal mental health services in regional and rural locations is an area of concern identified in the beyondblue Perinatal Clinical Practice Guidelines (2011).

Fewer options for specialist mental health care are available for rural women experiencing symptoms of anxiety and depression during pregnancy and after delivery. This poses difficulties to midwives and nurses providing care to these women as they have mandatory requirements to screen for symptoms of depression and anxiety. Options for referral in rural areas are traditionally limited to public mental health services that often have limited capacity to provide specialised perinatal mental health care.

In an attempt to address these issues, a rural perinatal mental service was developed in northern NSW called the Early Years Outreach Clinic (EYOC). The EYOC was developed within the primary health care setting to be interprofessional in nature with therapeutic interventions provided by credentialed mental health nurses, psychologists, social workers and occupational therapists.

The EYOC mental health professionals recognised very early the need to work collaboratively with nurses and midwives based within the public health system. This further developed into building networks with other community organisations further integrating services. One of the key benefits identified by all health professionals involved with the EYOC was the way in which the mental health professionals and midwifery services learnt from each other interprofessionally. Stronger relationships were formed leading to higher levels of liaison and collaboration.

The EYOC had a strong role in delivering professional development activities including clinical supervision to the local midwifery services. To date 22 group clinical supervision

sessions have been provided to 135 health professionals, predominantly midwives.

Outcomes from the last 18 months evaluation show that over 150 families have been referred to the service with wait time to access intervention consistently low with 75%

“The EYOC was developed within the primary health care setting to be interprofessional in nature with therapeutic interventions provided by credentialed mental health nurses, psychologists, social workers and occupational therapists.” of referrals seen within two weeks. Although general practitioners are the primary referrers to the service (69%), midwives and child and family nurses have made 20% of the total referrals reflecting the integration of mental health and midwifery services.

The EYOC is an innovative service that is an example of the system change required in rural areas to improve collaboration of care and interprofessional practice between all sectors of health relating to perinatal mental health.

Reference

beyondblue (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative.

Fiona Little is a credentialed mental health nurse and Anne Galloway is a clinical services coordinator and a credentialed mental health nurse in NSW

Role in prevention of infant and child sexual abuse

By Yvette Florence Strawbridge I am a RN, RM, CHN and CMHN who works as a clinical counsellor, psychotherapist and credentialed mental health nurse. Currently, I also work as a family dispute resolution practitioner (FDRP) and mediator in both the public sector and in private practice.

In this “expanded role” of the nurse, one of my responsibilities as a FDRP is to conduct pre mediation assessments with separated parents. These comprehensive assessments include an assessment of each parent’s mental health status to determine whether mediation is in fact suitable or unsuitable. Another mandatory component of my role is to assess the safety, wellbeing and best interests of the child/children during and currently in the separated parental relationship. Also, I assess the level of current parental conflict between the parents.

These child/children range in age from in-utero upwards to young teenagers.

As a midwife and child health nurse with many decades of experience, I have always carried in my mind and in my practice both the physiological and psychological needs of babies and young children. Currently focusing on the emotional and psychological needs of children is a mandatory component of my work as a FDRP. These needs of infants and small children have been acknowledged by multiple authors and writers for decades.

Bradshaw expressed the needs of children and then in the book “Healing the Shame that Binds You” (Bradshaw, 1988) published the needs of children. He wrote that children are dependent and needy and have needs that depend on others for fulfilment.

Children need to be held and touched and for a face to mirror and affirm their feelings, needs and drives. Children also need a PAGE 51 March 2014 Volume 21, No. 8.

Focus structure with limits and a sense of predictability. Another need of children is to know there is someone they can trust or count on and who will provide space and allow them to be different. Another important need of children is their parent’s time, attention and direction in the form of problem solving - techniques and strategies. These needs remain as important as ever now for children in both intact and separated parent families.

In the light and knowledge of the current Royal Commission into Institutional Child Sexual Abuse (CSA) I believe it is now important for all professionals involved with infants and young children, however particularly midwives and child health nurses to focus on the needs of children with parents they interact with. I am also the mother of an eldest son who without my knowledge, experienced chronic child sexual abuse over many years and then as a young adult, committed suicide 20 years ago, still without me being aware of his CSA experiences as a young child, until two years ago.

According to Cicchini (2012) “The emotional and social development of children are dependent on the quality of care and protection they receive. Long-term problems in wellbeing and adjustment develop when those important needs are not fulfilled by the care of the infant, child or adolescent, or if those needs are threatened by others.” Children who suffer emotionally in their developing years are more prone to emotional upsets such as anxiety, depression or antisocial behaviours. They then carry these burdens of emotional pain into their future lives.

As early as the 1930’s psychologists who were studying adults found that bad childhood experiences were the precursors of neurotic

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.

patterns of suffering and distress which were then carried into and observable in adulthood. The unmet needs of children and the impact of this in respect to child sexual abuse is commented on by Cicchini (2012) “Clinical work with sex and other offenders shows the same pattern: pain and upset associated with unmet psychological needs in childhood carry forward as seeds for internal suffering of an enduring kind, such as loneliness, low self-esteem, anxiety and depression or the expression of antisocial behaviours.”

such deprived children are abused or engage in sexual activity whilst immature, they are at greater risk of perpetuating the abuse through their confusion of affection and sexuality, which springs from their combined affectional neglect and sexual experiences.”

“If we wish to embrace our role more fully in assisting in the prevention of child sexual abuse, we need to perhaps refocus more broadly in the education of parents on the importance of meeting the emotional and psychological needs of their newborn children.”

Bradshaw, J. (1988). Healing the Shame that Binds You. Health Communications Inc: Florida.

So what is the significance of all this for midwives and child health nurses? If we wish to embrace our role more fully in assisting in the prevention of child sexual abuse, we need to perhaps refocus more broadly in the education of parents on the importance of meeting the emotional and psychological needs of their newborn children.

Cicchini (2012) proposes several interventions with regard to the question, “How can we prevent abuse? One suggestion is, “by inoculating our children through an infusion of care, love and supervision. Boys and girls neglected of love, physical touch, care and attention are at greater risk of attracting the attention of potential abusers who will try to manipulate or seduce them for their own benefit. Particularly in the case of boys, if

References

Cicchini, M. (2012). Preventing Child Sexual Abuse. A Guide for Health Professionals & Members of the Community. Mercurio Cicchini: Kelmscott, WA. ISBN: 978-0-9806833-3-2.

Cicchini, M. (2013). Submission in response to Issue Paper 4: Preventing Sexual Abuse in and out of Home Care, Are there interventions or strategies, based on psychological knowledge, which can be applied to reduce the risk and incidence of children being sexually abused by adults whilst in and out of home care? Royal Commission into Institutional Responses to Child Sexual Abuse. www.preventingchildsexualabuse.org/ on 22 December 2013. www.childabuseroyalcommission.gov.au/ to view public submissions The printed booklet “Preventing Child Sexual Abuse. A Guide for Health Professionals & Members of the Community” can be purchased, or downloaded as a PDF (free of charge), from the web: www.PreventingChildSexualAbuse.org

Yvette Strawbridge is a clinical counsellor, psychotherapist and credentialed mental health nurse and also works as a family dispute resolution practitioner (FDRP) and mediator in both the public sector and in private practice

Month

Focus Topic

Due date

May

Palliative care

March

June

Mental health

April

July

Women’s health

May

Aug

Oncology nursing

June

Sep

Infection control

July

Oct

Emergency nursing

Aug

Nov

Men’s health

Sep

Dec

Remote and rural health care

Oct

w PAGE 52

So in conclusion, we as communities and as a society need to infuse all infants and young children with care, love and supervision to assist in the prevention of child sexual abuse.

Calendar MARCH

APNA Continuing Education Workshops for Nurses in General Practice

MAY

Lung Health Promotion Centre at The Alfred

21–22 March 2014, Pullman Melbourne Albert Park, Victoria.

World Congress of Cardiology

4 March, Educating & Presenting With Confidence 5–7 March, Asthma Educator’s Course 20–21 March, Managing COPD 27–28 March, Smoking Cessation Course

For more information and to register go to www.apna.asn.au/nigp

4–7 May, Melbourne Victoria

Health–e–Nation Leadership Summit

www.world–heart–federation.org/congress– and-events/world–congress–of–cardiology– scientific-sessions-2014/

Lung Health Promotion Centre at The Alfred

Powerful health connections

Lung Health Promotion Centre at The Alfred

Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au

25–27 March, Shangri-La Hotel, Sydney NSW. Leaders from health care, government and IT take the opportunities the one day Summit and associated meetings provide to shape next steps and connect across the health industry. Health is powered by information and relationships – with people, concepts & organisations. All are in plentiful supply at Health–e–Nation. In a time of unprecedented change Health–e–Nation stays true to its focus – taking care of business, the business of health in all its guises – while looking after the individual – you.

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

http://www.health–e–nation.com.au/ehome/ index.php?eventid=66856&

APNA’s sixth exciting national conference will provide extensive opportunities to network with your nursing colleagues from around Australia, and a fantastic program to enhance clinical expertise and add to your personal and professional development.

Nurses-Healing.com Nursing Hands Healing – Hands Healing Nurses 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.

13 March, Intro to Massage in Nursing (Leading aged care services) Glenelg SA Boutique Training in Luxury Surroundings 24 March, Massage in Nursing - An Intro 25 March, Massage for Palliative Care and/or Relaxation 26 March, Baby Massage (Afternoon Session) 27 March, Massage in Midwifery Care (Women and Babies) An Intro 28 March, Reflexology for Health 29 March, Skin Care, Facials and other Pampering 30 March, Spa and Wellbeing Day (relax, re energise, re balance in this whole day spa experience for you) 31 March, Quantum Touch and Kinesiology Cost $145 per day. Contact Angeline von Doussa – RN, RM, Dip Massage Therapies, Spa Therapies, Nurse Educator.

Mobile: 0431 994 618 Email: angeline@nurses–healing.com http://nurses-healing.com

3rd Annual Electronic Medication Management Conference 25–26 March, Sydney Harbour Marriott, NSW. This event will act as an interactive meeting place for clinicians, pharmacists, vendors, LHDs and policy makers to allow for open discussion and knowledge sharing on how eMM can be best implemented, managed, maintained and further integrated into the health care setting. www.healthcareconferences.com.au/emedicationmgmt14

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

Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au 6th APNA National Conference Thriving through change 29–31 May, Hilton Sydney, NSW

http://apnaconference.asn.au/

JUNE 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

Network LISTER HOUSE – WHAT ARE YOUR MEMORIES? From 1950 to 1989, Lister House at 37 Rowan St, Bendigo was home to the Northern District School of Nursing (NDSN). The NDSN Graduates Association is compiling a history of the NDSN in order to publish a book. This is an opportunity for you to contribute anecdotes, photographs and experiences of your time at Lister House.

Please contact Jenny on 03) 54427857 or

kayjay@netcon.net. au or Fay on 03) 5443 8280 or flyawayfay@ gmail.com or Joan on (03) 5443 6850 or joan.o@bigpond.com or mail to PO Box 509, Bendigo 3552 Austin 74 1 A&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 wen-

dybrack@gmail.com or 0427 154 505

PANCH 50-year reunion

Geelong Hospital Nurses League 80th annual reunion and AGM

5 April 2014. To confirm interest and receive more details contact Yvonne Shallard (nee Fleming) Mobile: 0418 589 582 Margaret Mudford (nee Hanley) Mobile: 0410 549 908

15 March 2014. If you have a connection to the Geelong Hospital (Barwon Health), are a past trainee or current employee and are interested in attending this reunion please contact Bev Lodge Ph: (03) 5243 7794 or email: terrylodge@ bigpond.com

Royal Children’s Hospital past trainees and RCH Grads reunion 17 May 2014 at RACV Club, Melbourne. Contact Chris Fautley Email:

chrisfau@netspace. net.au Ph: (03) 9347 3546 or Sue Scott Email: sue.scott@rch. org.au John Fawkner Private Hospital / Sacred Heart Hospital celebrates its 75th anniversary October 2014. 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 2014 in Adelaide, at a venue to be announced. Please contact Julia Curley for further details Email: juliacurley@ hotmail.com

PAGE 53 March 2014 Volume 21, No. 8.

Mail Euthanasia and professional conduct I would like to respond to the latest article (Feb ANMJ) by Professor Megan-Jane Johnstone on the media representation of voluntary euthanasia legislation.

Professor Johnstone asks: “What are nurses to make of the quest to have them acquiesce to highly politicised catalysts to support the legislation of euthanasia?”

I ask: “What are nurses to make of the quest for nursing leaders such as Professor Johnstone to have them acquiesce to highly politicised responses on voluntary euthanasia legislation?”

The media reports anything that they deem will be newsworthy, whether it be newsworthy for entertainment, interest, or speculation about future scenarios.

Each person responds to the media portrayal of these items in their own individual way, which is shaped by their moral and ethical values.

The ethics of the individual nurse will determine their individual response to any referendum or policy they are asked to vote upon including supporting legislation for voluntary euthanasia.

So, why does Professor Johnstone feel that we should not respond to this issue as individuals?

Little importance placed on euthanasia disappointing I was interested to read Professor Johnstone’s article in February’s ANMJ. I was disappointed to read Professor Johnstone seems to think that the small number of people affected by euthanasia means it is of little importance.

Presumably the author does not think that murder is of little importance politically, even though it too affects a limited number of people. I do not understand how the number of people affected changes the ethics of a proposal.

Further, her use of the emotional term “death policy” in an article discussing media manipulation is surely an example of manipulation of the reader’s emotions.

Is this the intention of the good professor?

As to the idea that an “individual preference” cannot lead to a change in legislation. Who decides whether an issue is an individual preference or an idea worthy of being enshrined in legislation? Or is it an individual preference because the author does not agree with the proposition?

John McCormick RN, Victoria

PAGE 54

As nurses, we conduct our practice by professional codes of conduct and ethics, not media – or so we should. The Australian Nursing & Midwifery Federation’s position statement on Voluntary Euthanasia is quite clear about how nurses should behave on this issue.

Yet this article represents the fourth media article in a series by Professor Johnstone about public opinion, media and the ethics of voluntary euthanasia legislation with no clear advice offered other than for nurses to observe neutrality in this discussion.

People die and before they die, many suffer. These are facts substantiated by reports conducted by the Australian Institute of Health and Welfare (AIHW Palliative Care in Australia 2012) and the WHO (Global Atlas on Palliative Care 2014) on the number of people who die without palliative care.

When people suffer, many say they have had enough and want to die.

It is at this point that nurses need to be able to inform, educate and advocate for their patients for appropriate end-of-life care.

Where the patient’s preferred method of end-of-life care is not legally sanctioned, then nurses do not have to aid, abet, or provide assistance for this. However, the question becomes, do they inform?

Ethically, nurses should not hesitate to enter into a discussion with the patient about what they are asking for and why they are asking for it since it provides the opportunity to offer other treatment and care that may make the patient’s dying process easier.

Those of us who engage in end-of-life care know that many people just want the knowledge without actually taking any action – this provides them with comfort and knowledge that they can control the dying process.

It’s pretty simple really – individual nurse’s private ethics have nothing to do with patient care. Patient care is guided by professional codes of conduct and ethics that encourage nurses to inform, educate and advocate for their patients, even on topics as distasteful to some as legislation of voluntary euthanasia.

Sandra L Bradley, RN, FACN, PhD Candidate, Flinders University, South Australia

Mail Nurses to remain non-partisan bystanders in euthanasia debate?

I am writing in response to Megan-Jane Johnstone article ‘Media manipulation and the euthanasia debate’ in February’s ANMJ. In this article Johnstone insists the media is “generating public opinion polls” with the purpose of “priming” the “average person” as well as the nursing profession and “decision makers” to support the legalisation of euthanasia.

While it is hard to believe euthanasia advocates would have the power and moral scruples of media moguls, it is even more absurd to think nurses should remain nonpartisan bystanders.

Johnstone accuses euthanasia supporters of being driven more by personal opinion than by ethics, and by conjecture rather than empirical fact. The question of how to face death is probably the most profound question anyone could face. It is the ultimate conjecture, the brink of life and death. Personal opinion hardly expresses that, and what do “empirical facts” have to do with it?

For Johnstone, personal opinion is second to empirical facts, as well as majority vs minority status, international commentators, professionals and decision makers. It’s rather ironic, given that the essence of nursing is helping others live their life, which tends to involve their personal opinion.

The facts may lie in Johnstone’s argument that euthanasia is a “minority issue”.

Presumably if it is a minority issue, then it is not important. I must admit I laughed aloud when I read why she sees it as a minority issue, which she states is because the actual practice of euthanasia affects only a small percentage of people. In an ideal world, I suppose everyone would have the luxury of deciding when to die.

Aside from sound reasoning and minority status, there are also unnamed “International commentators” who universally agree that euthanasia is not a universal question. Their authority must far outweigh that of the church, or tradition as these authorities are not appealed to.

Johnstone further discredits euthanasia by labelling it a ‘want’. This label reduces it to a consumerist plane of choosing between wants and needs. The suffering, the hard choice and the courage to say ‘enough!’

Letter of the month Concern over euthanasia viewpoint

I am writing to comment on the article: “Media Manipulation and the euthanasia debate” Professor Megan-Jane Johnstone ANMJ 21(7): 32.

At university I saw ethics as an interesting distraction from the skills I needed to master to work as a nurse. I suspect many other students felt the same. Later, those skills and the tasks we do become more routine, and the ethics behind what we do, to whom, when and how, become more important. So I read Professor Johnstone’s regular contributions to ANMJ with interest.

I appreciate that Professor Johnstone is warning us, as nurses, to ensure that we carefully consider evidence in any area of our work, and use it, combined with sound reasoning, especially in areas which relate to complex moral issues. The clarification of the process of considering a referendum is also valuable. The media’s web polls are surely empirically flawed and are possibly drawn from a self-selected audience, therefore deserving close scrutiny. But three of the four sources in the article are written by her - surely this is not a good start for providing balanced insight into an issue?

While the “actual practice of euthanasia” may “only affect a small percentage”,

the issue of death and the manner of dying concerns us all, and the issue of euthanasia is very relevant to nurses. To conclude that the ABC web poll is a political act surprises me, and yet again, I can’t see where the logic came from. Is Professor Johnstone saying that there is an ongoing media conspiracy?

I am not an academic, or an ethicist, and I don’t know Professor Johnstone. But reading and re-reading of the article made me wonder whether Professor Johnstone wrote from a position of opposition to euthanasia.

I have worked in many areas of nursing, and euthanasia in some form has been discussed in all of them. I am disappointed that an opportunity to sort through the ethical issues of media manipulation, or else the ethical issues of the euthanasia debate, has been lost. I know that in only one page it is probably hard to go into depth, but in this case perhaps limiting the discussion to media manipulation would have reduced the information load.

If articles on ethics are intended to be thought provoking, and to elicit a response from readers, I suppose this one could be considered a success. But I would prefer to read an article which inspires thoughtful, ethical practice, rather than one that annoys me enough to make me write to the editor of ANMJ. Or perhaps it is just me, and I have missed the point altogether.

Leanne Mason, RN, Victoria

The winner of the ANMJ best letter competition receives a $50 Coles Myer voucher.

If you would like to submit a letter to the ANMJ email anmj@anmf.org.au Letters may be edited for clarity and space is shunted aside. Illogically, despite having declared it to be a minor problem, Johnstone is concerned its legalisation would constitute a major change in public policy.

their initial viewpoints”. As it is research, then it must be true. In which case why worry about what the media are up to in the first place?

Johnstone declares that right and wrong can only be decided by sound reasoning, rather than public opinion. This assumes simplistically there is only one answer. Is life and death just an on/off switch?

The article ends ignominiously by dismissing the euthanasia debate as “a political stunt aimed at dragging a non-partisan party into an unwanted dispute”. But I suppose nobody wants euthanasia; no one can dispute that. However the stunts in this article are entirely Johnstone’s.

These arguments are annulled, as Johnstone declares research has shown “decision makers… only accept information that reaffirms

Niko Leka EN, NSW PAGE 55 March 2014 Volume 21, No. 8.

Coral Coral Levett ANMF Federal President

Vaccination and union membership – benefits all • Parent and provider incentives such as cash payments to those parents who provide evidence of immunising their children • The Australian Childhood Immunisation Register (ACIR) - a national register to record the uptake of immunisation programs and activities • The National Centre for Immunisation Research and Surveillance (NCIRS) • General Practice Incentive Programs - where GPs (or their practice) are paid if they reach determined targets of immunisation.

These initiatives and continued progress in this field of health promotion are truly remarkable, and thousands of unnecessary Australian deaths have been prevented as a result.

Since 1945, when vaccines first came into widespread use in Australia, we have seen a significant and steady decline in vaccine preventable disease across all populations.

Vaccines available until the late 1960s mainly included tetanus, diphtheria, pertussis and polio. The 70s and 80s added measles, mumps, rubella and hepatitis B to the mix, and eventually in the last twenty years we have seen the widespread use of Haemophilus influenzae type b (Hib), hepatitis A, influenza, varicella, pneumococcal, meningococcal, human papillomavirus and rotavirus vaccines throughout Australia. The evidence that Australia has one of the highest rates of immunisation is well reported in the literature. A better understanding of disease processes, the human immune system, and the spread of disease has focused Australian efforts towards a number of specific initiatives that have led to improvements in immunisation rates, particularly over the last 10-15 years. Many vaccines are provided free through the Immunise Australia program to certain members of the community, especially infants and children, and those with special health needs such as the elderly and Aboriginal and Torres Strait Islander peoples. Immunise Australia is a Commonwealth Government funded program that is also responsible for: PAGE 56

In my reading about vaccination and immunity in recent times, I have come to the realisation that my interest in this field probably lies with its similarities with unionism. Now I know some of you will think this link is a bit of a stretch, but let me tell you why I think the link exists. For those that are not currently working in an immunisation context, you may remember the concept of ‘herd immunity’ from your training days. It occurs when a significant portion of individuals within a population are protected against a disease through immunisation. It offers indirect protection for people who are still susceptible to the disease, by making it less likely that they will come into contact with it. It also benefits a small number of people who fail to respond to vaccines or who cannot be vaccinated for medical reasons.

So, the more people that are vaccinated (or have immunity by another means) in a given group, the more protection is afforded to the whole group. Similarly, we know in our industry that where more nurses and midwives are union members, they tend to be better off in terms of pay, work conditions and patient ratios. Although there are always exceptions to this rule, it is particularly well demonstrated in nursing and midwifery when you compare these outcomes in the public sector (highest level of union membership), the private sector (lower level of union membership) and the aged care sector (lowest level of union membership).

The concept of ‘herd immunity’ is a key determinant of the success or otherwise of vaccination programs in Australia. Until we achieve vaccination rates of 100%, we will continue to have the potential for disease outbreaks. The closer we are to achieving

that 100% figure, the better the situation for those unable to be vaccinated (for health reasons) and those who despite vaccination do not seroconvert. The same can be said for union membership. If all nurses and midwives were members of the Australian Nursing & Midwifery Federation (and their relevant state union), our potential for best outcomes in pay, conditions and ratios is far higher. Conversely, low and non-unionised workplaces will continue to bear the brunt of unscrupulous employers who will always take advantage of this fact.

Further information: Australian Government Department of Health, Immunise Australia Program, Available at: www.health.gov.au/internet/ immunise/publishing.nsf/Content/aefi.htm, Accessed February 2014 Australian Technical Advisory Group on Immunisation (ATAGI) 2013, The Australian Immunisation Handbook, 10th edn, Department of Health and Ageing, Canberra. Available: www.immunise.health.gov.au/internet/ immunise/publishing.nsf/Content/Handbook10-home, Accessed February 2014

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