ANMJ May 2014

Australian Nursing & Midwifery Journal Volume 21, No. 10.

May 2014

Spotlight on forensic nursing www.anmf.org.au

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

Editorial Lee Thomas, Federal Secretary As nurses and midwives how often do we acknowledge the work that we do to better the lives of our patients? How often do we commend our colleagues for the commitment and passion they bring to the professions?

If you are anything like me it’s easy to get caught up in life without taking stock of the amazing job we actually do.

Two special days this month pay homage to all nurses and midwives across the world - International Day of the Midwife on 5 May and International Nurses’ Day on 12 May. It is on these days we proudly acknowledge our professions and reflect on our individual and collective achievements.

‘The World Needs Midwives Today More Than Ever’ is the theme for International Day of the Midwife and the sub theme is ‘Midwives changing the world one family at a time’. The theme, set by the International Confederation of Midwives (ICM), provides a strong message that through midwives’ involvement in the lives of mothers and babies, they are providing care which changes families, communities and the world.

The theme of International Nurses’ Day 2014, set by the International Council of Nurses (ICN), is ‘Nurses: A Force for Change – A vital resource for health’.

Under this theme’s umbrella the ICN stresses nurses, and also midwives, have a great responsibility in improving health outcomes across the world, but in order to do so investment must be made in educating and retaining nurses in health and aged care workplaces. This is the ethos that as union members we stand by and strive for every day.

celebrations at your workplaces or in your communities to mark your achievements because you deserve it.

More on the international days can be read on pages six and 18.

May is also the month that nurses and midwives renew their annual general or nonpractising registration under the National Registration and Accreditation Scheme.

The due date for all registrations is 31 May. As you are all aware part of the process of registration is to ensure a minimum number of continuing professional development (CPD) hours directly relevant to the context of your practice is achieved. This can range from a minimum of 20 hours to 40 hours, depending on your qualifications.

As we reported to you last year the board has commenced randomly auditing nurses and midwives to ensure they have completed their hours. If you are audited you will need to show evidence that you have completed the requirements for the 12 month period and provide a copy of your CPD plan. There is a variety of ways to build up your CPD hours; one of them is to read the ANMJ! You can also access ANMF’s online professional development training rooms as well as best practice information in a number of specialised areas of practice.

Page 16 has a sample of ANMF’s online professional development or go to http://anmf.org.au/pages/online-education-programs for more information.

So I congratulate and commend you all not only for providing crucial care to all Australians and citizens of the world but wanting to improve standards and conditions in care. I hope that you join in PAGE 1 May 2014 Volume 21, No. 10.

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

Assistant Federal Secretary Annie Butler

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 96,450

Source: BCA verified audit, March 2014

Contents Volume 21, No. 10.

News 5 World 15 Education 16 Professional 18 Annie 19

News

Page 5

Short changing care?

News

Page 7

Feature 20 Issues 25 Reflections 27

Time to celebrate you

View Point

28

Research

29

Wellbeing 30 Legal 31 Clinical Update

32

Focus 36

Reflections

Page 27

Importance of appropriate interpreters

Focus

Page 36

46

Mail 47 Coral 48

Palliative care

Feature: Spotlight on forensic nursing

Calendar

Page 20

PAGE 3 May 2014 Volume 21, No. 10.

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PAGE 4

News Short changing care The Australian Nursing & Midwifery Federation (ANMF) has slammed a new report that recommends increasing the number of nurse assistants to replace nurses so as to save health dollars.

The Grattan Institute study, Unlocking Hospital Skills: better jobs, more care, suggests nursing assistants should comprise 15% of the nursing workforce in order to help save up to $390 million a year.

ANMF Federal Secretary Lee Thomas said the conclusions of the report was based on unsophisticated analysis and a simplistic approach to nursing care. “Whilst nursing assistants are a valuable addition to the nursing family, recommending their roles be expanded ignores the complexity of care provided in hospitals today.”

Grattan Institute’s Health Program Director Dr Stephen Duckett said that government budgets were under pressure. “Hospitals have to get more efficient, or much tougher decisions about who should miss out on care will become inevitable.”

Ms Thomas said the ANMF accepted better workforce planning was essential, but the Grattan report failed to acknowledge the importance of the right skill mix in hospitals, which could lead to adverse outcomes for patients. “From long experience, ANMF members know that in a pressure environment, scopes of practice expand to meet the needs of patients but not always in line with safety or quality.”

Additionally, Ms Thomas said the report drew on a naïve conclusion that massive increases in the number of nursing assistants would not have a negative impact on the employment of registered and enrolled nurses. “Notwithstanding this issue the report also ignores the fact that large numbers of graduates are unable to find work.”

Ms Thomas said public safety must always outweigh budget containment.

“Unfortunately, very few, if any nurses

New education opportunities in rural WA A new simulation training and education centre in rural Western Australia will help nursing students practice their clinical skills in a rural environment, while also encouraging them to consider a rural career in the future.

The $3.7 million simulation training and education (EdSIM) centre is an expansion of the Western Australia Centre for Rural Health at Geraldton.

The centre, which aims to improve rural health practices in Western Australia, consists

and certainly no frontline nurses were consulted in this report, which indicates the only people who had input were hospital administrators and bureaucrats.

That’s a fundamental and potentially fatal oversight in the report alone and must call into question some of the recommendations.”

of two demonstration bays, five consultation rooms, staff offices and student areas, along with integrated audio visual and IT systems.

The EdSIM will provide education to undergraduate health care students in all disciplines.

Assistant Minister for Health Senator Fiona Nash said the facility would allow health students completing placements in regional sites to access support and better training experiences.

“This technology allows students in Geraldton to interact on face-to-face level with health professionals, universities and supervisors anywhere in the country, providing educational opportunities previously inaccessible in rural WA.

“In time the simulation training on offer at this facility will also allow for better training of health workers in rare and complex procedures such as treating cardiac arrest and the management of chronic conditions, ultimately improving care and safety for patients.”

Senator Nash said providing education training and support for students and rural health professionals was vital for providing better health care outcomes for Australians living in rural and remote areas. “Providing top quality education to undergraduate students in a rural and remote setting is an important step in attracting and keeping more health professionals in WA.” PAGE 5 May 2014 Volume 21, No. 10.

News Time to celebrate you

of being with a woman, being there when they meet their baby for the first time. The overwhelming feeling of accomplishment from the woman is a very positive thing.”

By Kara Douglas

Sharron works in an all-risk model of caseload midwifery where the midwife works individually with a certain number of pregnant women and also within a team.

“The women are cared for by a primary midwife through their pregnancy and we are to be available as a team for when they go into labour, and we also look after them for two weeks postnatally.”

With ever increasing workloads and demands, it is easy to get caught up in the daily grind and lose sight of why you became a nurse or midwife in the first place.

What better time to stop and reflect on both the challenges and satisfaction the professions deliver than International Day of the Midwife on 5 May and International Nurses’ Day on 12 May.

One of the differences between caseload midwifery and core midwifery is that families do get a bit more involved, said Sharron.

“I get to know the whole family because I might look after the woman for three or four pregnancies and that really includes everyone. The children come into the antenatal appointments and they know that I was there when they were born and that’s a really positive side of it.”

Australian Nursing & Midwifery (ANMF) Federal Secretary Lee Thomas said the International days of recognition rightly acknowledged the crucial role nurses and midwives play in delivering quality care across the full spectrum of the health system both in Australia and around the world. “So it’s time to celebrate you. As nurses and midwives we are the backbone of the health care system worldwide.”

Ms Thomas said in honour of the days she hoped nurses and midwives across the country would take time out from their busy days to attend breakfasts, morning teas and other events, coinciding with celebrations attended by nurses all across the world.

However caseload midwifery also puts additional stresses on a midwife.

“I do enjoy the job immensely however I don’t get a lot of sleep and I do feel extra responsibility when things may not go according to plan.”

Visit your local state or territory ANMF branch website to see how you can celebrate and take part in International Nurses’ and Midwives’ Day 2014.

International Day of the Midwife The theme for International Day of the Midwife - Midwives: changing the world one family at a time - is one that resonates with registered midwife Sharron Millard.

“I really wanted to become a midwife because I love that personal experience of becoming involved with a woman and her family from the start of their family.”

Sharron has been practising as a midwife at a Victorian hospital for 12 years.

“From nursing I went into midwifery because I really enjoyed the personal aspects PAGE 6

There is also a high staff turnover rate because of the extra demands. “We are on call a lot of the time and the remuneration is probably not as high as it should be for what we are doing and the responsibility that we are carrying,” Sharron said.

Sharron expects there will be some changes to midwifery models of care over the next few years. “Whether case load models continue or not will depend on if we can be effective financially and that pressure is on us all the time. You have the responsibility where you don’t feel you can take sick leave when you need it because you worry about women who you know are in labour when you are rostered off.”

But for all the challenges midwifery presents, Sharron said there is no other career that she would choose. “To be there for a woman and her family when their baby is born is probably one of the most fulfilling things you can actually do and one of the most positive things you can ever do.”

News International Nurses’ Day

Photo courtesy of Francis Andrijich/bauersyndication.com.au

The theme for International Nurses’ Day - Nurses: A Force for Change reflects a growing recognition that sufficient, adequately trained and motivated health workers are essential for the world’s population.

International Council of Nurses (ICN) president Judith Shamian said equitable access to necessary health services of good quality cannot be achieved without an adequate number of appropriately prepared nurses. “As the largest group of health professionals, who are the closest and often the only available health workers to the population, nurses have a great responsibility to improve the health of the population.”

One nurse who is doing just that is 2013 Nurse of the Year award winner, Sara Lohmeyer. A registered nurse and midwife, Sara has been working as a child

health nurse in the High Wycombe area in Western Australia for the past ten years. She was recognised for her work to improve the health and mental wellbeing of new mothers by setting up early morning walking groups for local mums.

“It was on a voluntary basis where I was doing it out of working hours. Taking the mums for an early morning walk with their babies was really wonderful practice in terms of them being able to access me and also get early morning light and exercise that would help for good mental health.”

The walking groups have now been running for eight years, said Sara. “It generated a couple of leaders within the community to start up walking groups of their own as their children got older and started school, which I wasn’t involved in, but I thought was quite an exciting process that you start something off and it grows from small roots.”

So popular were the walking groups that one of the mothers set up a Facebook page called Sara’s Mums. “I couldn’t believe it. It is an enormous compliment but it shows appreciation that I am making a difference in their own personal world.

It was really astonishing,” Sara said.

The Facebook group now has over 500 local mothers as members. It has proven so popular that fathers and grandparents also want to join, so the group’s name will soon be changed to Sara’s Families.

Sara said that knowing she has been a force for change within her community is one of the things she will be reflecting on this year for International Nurses’ Day. “You form connections in a community.

I’m only one person, a connection in the hub, but what a difference it can make in these mothers groups that can be lifelong in friendship and support.”

PAGE 7 May 2014 Volume 21, No. 10.

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News Pregnancy and return to work discrimination One in two women in Australia report experiencing discrimination in the workplace during their pregnancy, parental leave or on return to work, a national review has found.

The review, Supporting Working Parents: Pregnancy and Return to Work National Review, surveyed women’s perceived experiences in relation to discrimination at the workplace as a result of pregnancy, requesting or taking parental leave, and their return to work following parental leave.

negative attitudes and comments through to dismissal. “Commonly reported types of discrimination women experienced during pregnancy, or when on parental leave, included reductions in salary, missing out on training, professional development and promotional opportunities. The most common types of discrimination women reported experiencing on returning to work after parental leave included negative comments about breastfeeding or working part-time or flexibility and being denied requests to work flexibly.”

Sex Discrimination Commissioner Elizabeth Broderick said the major conclusion drawn from the data was that discrimination has a cost to women, their families, businesses and to the Australian economy and society as a whole.

As a consequence of discrimination 84% of mothers reported a negative impact related to mental health, physical health, career and job opportunities, financial stability and their families, said Commissioner Broderick.

While discrimination was prevalent at all stages, the review showed it was more commonly reported as occurring upon return to work (35%) followed by when requesting or on parental leave (32%), and during pregnancy (27%).

Additionally, the review found discrimination had a negative impact on women’s workforce participation with high numbers of women having to leave the workforce or change their employer.

Commissioner Broderick said discrimination took on many different forms ranging from

ACTU Secretary Dave Oliver said the ACTU called for the inquiry because unions were getting increased rates of complaints from

members. “This survey reinforces just how big a problem employer attitudes are for families who want to stay in the workforce and have a family.”

Mr Oliver said it was a national disgrace that one in two women experience discrimination and that one third don’t return to work because of employer attitudes.

“We need urgent amendments to the Fair Work Act so that employers are legally obliged to seriously consider an employee’s requests for flexible arrangements. Employees should have the right to appeal the Fair Work Commission if an employer unreasonably refuses a request.”

More people in rural SA accessing chemotherapy services units in country South Australia, more country residents are now able to receive treatment close to home.”

Minister Snelling said in the past 12 months 10 new chemotherapy sites had been opened in rural communities while two others were currently being built and three other services had been extended.

More people are having chemotherapy treatment at country South Australian health sites than ever, according to state government reports released last month.

SA Health Minister Jack Snelling said there had been a 46% increase in the number of chemotherapy treatment at regional chemotherapy units in 2013 compared to 2012. “Through establishing new chemotherapy units and enhancing some existing

Regional Development Minister Geoff Brock said this had helped make what could be a difficult and stressful time easier for country patients and their families.

“We are continuing to see the number of people treated locally in rural areas increase and we expect this upward trend to continue as patients become more aware of their local chemotherapy services.”

PAGE 9 May 2014 Volume 21, No. 10.

News Australians: fat but socially advanced?

Australia finished behind top performer New Zealand and other countries including Canada and Norway, but ranked ahead of Germany, the United States and France.

Published by US based non-profit organisation, the Social Progress Imperative, the index is designed to complement economic indicators, such as GDP, by measuring a country’s social progress.

“Australia’s ranking as the 10th most socially progressive nation on earth is testament to factors like the exceptional personal rights and freedoms citizens enjoy,” said the organisation’s Michael Green.

Australia is the world’s 10th most socially advanced nation according to a new global index of 132 countries.

“On ‘Health and Wellness’, ‘Personal Rights’, and ‘Basic Medical Care’ Australia ranks higher than the United States despite America enjoying the world’s second highest per capita GDP,” he said.

While Australia ranked 5th for health and wellness, one in four Australians are classified as obese, giving the nation a 111th ranking in terms of obesity.

Australia’s biggest weakness was in terms of ‘Shelter’, with the lack of affordable housing (44th globally) and quality of electricity supply (21st globally) leading to an overall ranking of 18th.

“Australia also performs relatively well compared to the United States, which finishes 16th in the index ranking,” said Mr Green.

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News Promoting women in unions collar union campaign for maternity leave award provisions and initiated campaigns against sexual harassment as an industrial issue.

At a time when women made up one third of the workforce but were poorly paid, lacked job security, flexibility and skills recognition, many women gained strength and confidence from Anna’s example of combining motherhood and a career.

If you have ever taken maternity leave, or plan to, you can thank Anna Stewart for fighting to ensure you have that right.

During Commission hearings, Anna would either breastfeed her young son or seek adjournments to do so, exposing the Commission, employers and the union to the needs of women workers.

A former journalist and active Victorian union official from 1974 to 1983, Anna successfully spear-headed the first blue

By setting these precedents, she secured many conditions for the members she represented and indirectly for all working women.

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The project aims to increase women’s involvement in the union movement by placing women union members with their own, and sometimes with another union, for two weeks.

They experience the full range of union work, including mass meetings, enterprise bargaining negotiations and hearings at Fair Work Australia. There are also group training sessions at the Victorian Trades Hall Council to discuss women, work and union issues.

If you are interested, contact Jennifer O’Donnell-Pirisi at the Victorian Trades Hall Council: jodonnellpirisi@vthc.org.au or (03) 9659 3511.

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PAGE 11 May 2014 Volume 21, No. 10.

Your career in safe hands CRICOS provider: Monash University 00008C

School of Nursing and Midwifery The School of Nursing and Midwifery offers high quality degrees in a vibrant and supportive learning environment to prepare students for a rewarding career in healthcare.

One of the largest schools for the education of nurses and midwives in Australia, the school offers undergraduate, a range of research and coursework postgraduate courses and professional development programs.

All courses and professional development activities are created in collaboration with the School’s professional partners to be responsive to the contemporary needs of the healthcare industry and are designed to be engaging for prospective students. for more information on all our programs visit www.med.monash.edu/nursing

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SOCIETY OF NEUROMUSCULAR SCIENCES INC. 40TH ANNUAL CONFERENCE IN THREDBO

The S.O.N.S (Society of Neuromuscular Sciences) 40th Annual Conference in Thredbo is to be held at the Thredbo Alpine Hotel from Monday 11th to Friday 15th August 2014 and boasts a very good lecture and social programme.

A variety of topics from all areas of Medicine will be presented and these will appeal to Specialists, Registrars, RMO’s, General Practitioners and Allied Health Professionals.

PAGE 12

New members are welcome and the registration fee is quite modest with special discounted rates for Registrars and RMO’s.

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News Positive outcomes through research explored

onstrate and to understand how research informs service delivery to close the gap in Aboriginal and Torres Strait Islander health.

Photo courtesy of James Henry Photography, The Lowitja Institute

By Robyn Coulthard, Federal Professional Officer The many successes of Aboriginal and Torres Strait islander controlled health services were celebrated at the Lowitja Biennial Congress, held in Melbourne last month.

The Lowitja Institute for Aboriginal and Torres Strait Islander Health Research ensures research is developed with Aboriginal and Torres Strait Islander people. The institute also makes sure Aboriginal and Torres Strait Islander people set the agenda for research, inform activities and own research processes and outcomes. Dr Lowitja O’Donoghue is the Institute’s proud patron.

The purpose of Congress was to give researchers and policy makers, community and individuals the opportunity to dem-

Congress Lowitja 2014 covered diverse topics with key themes emerging. One such theme was the many successes community controlled health sector has on Aboriginal and Torres Strait Islander health. Community controlled health started from humble beginnings in Redfern 40 years ago. The movement has become the model for significant and sustained improvements in health care delivery, while enhancing access to culturally safe and high quality health care for Aboriginal and Torres Strait Islander peoples.

Congress Young Orator, Shannon Dodson, who works for Recognise, the people’s movement to gain recognition of Aboriginal and Torres Strait Islander peoples in our Constitution, powerfully illustrated how identity and belonging build confidence, strength and capacity.

She said identity was individual, personal and powerful, bound in community and experience.

Ms Dodson spoke of the significance of the Recognise campaign to promote acknowledgement of Aboriginal Australians by updating the Constitution. She said Identity, respect, dignity and hope were essential to realising full health.

racism underminded individuals’ freedom, assurance, and sense of safety and confidence. At the civic level, racism diminishes the social cohesion and harmony of the nation, and goes to the question of civic health.

Racism affects individual’s quality of life by limiting their willingness to contribute. It also reduces the quality of civic life by limiting full participation by all citizens.

Dr Soutphommasane outlined three levels where racism must be addressed. Firstly, recognition of Aboriginal Australians in the Australian Constitution, where they would be acknowledged as the first people, which would provide a platform to formally acknowledge their standing.

Secondly at the legislative level, the Race Discrimination Act protects citizens from attack based on race, while providing for freedom of speech. Proposed amendments to this act would undermine those legal protections.

The third level is in our everyday interactions.

It is our responsibility to stand up to racist behaviour. The worst thing we can do is remain silent in the face of a racist attack, as it sends a message of complicity with the attacker.

Other issues discussed included how racism significantly causes poor physical and emotional wellbeing. Research has consistently shown that racism diminishes the targets of racism, those who behave in a racist manner and our society’s civic life.

The conference finished with confidence in the strength and ability of Aboriginal and Torres Strait Islander people to achieve and excel, to lead and to guide Aboriginal health research and organisations in a knowledgeable, confident and inclusive manner. We non-Indigenous people have much to learn from them.

Race Discrimination Commissioner, Dr Tim Soutphommasane (pictured), who spoke at Congress, said that at the individual level,

More information about the work of the Lowitja Institute and Dr Lowitja O’Donoghue can be found at www.lowitja.org.au/

Primary health care spending increased Federal government spending in Australian primary health care has risen while the share directed towards hospital has fallen in the past decade, according to a recent Australian Institute of Health and Welfare (AIHW) report.

According to AIHW spokesperson Dr Adrian Webster, during 2001-2004 for every dollar the Australian Government spent on hospitals, it spent on average 97 cents in primary care. “In 2011-12 the Australian Government spent around $1.16 on primary health care for every dollar it provided for hospitals.”

The report, Health expenditure Australia 2011-12: analysis by sector, showed that over the decade from 2001-12, expenditure increased in all areas of health, but some grew faster than others.

However in contrast state and territory governments in total increased the proportion of their recurrent expenditure allocated to hospitals and reduced the proportion allocated to primary health care.

Between 2001-12 the total growth in state and territory government funding for hospitals ($11.5 billion) was almost double (1.8 times) Australian Government funding growth for hospitals and 2.4 times nongovernment expenditure growth.

Western Australia had the largest growth in state government funding for hospitals, more than doubling (2.16 times) its spending between 2001-12 with an annual average growth rate of 8.0%.

PAGE 13 May 2014 Volume 21, No. 10.

News New global panel to promote nursing leaders Professor Daly said GAPSON will look at ways and means to develop more nurse experts in health policy work. “They need to be active and they need to contribute from the bedside to the board room – that’s quite a broad remit. So what [we need to look at is how] can we assist people to become well skilled, well educated, well prepared to get more involved in the senior levels in the decision making forums within health where policy is determined.”

Members of the Global Advisory Panel on the Future of Nursing

A new international panel of nurse leaders has been set up to provide a global voice and vision for nursing that will advance global health.

of debate around areas we should be addressing and getting some agreement about, and what we could do to advance nursing in those particular areas,” he said.

The Global Advisory Panel on the Future of Nursing (GAPSON) identified a number of key issues at its first meeting in Switzerland earlier this year, including the need for reform, advocacy and innovation in leadership, policy, practice and work environments.

GAPSON has been established by Sigma Theta Tau International, a non-profit organisation that supports learning and professional development of nurses.

Professor of Nursing John Daly from the University of Technology Sydney is the only Australian on the 18 member panel.

“There was a lot discussion around what the global issues are in nursing and a lot

One particular area the panel will focus on is nurse leadership, said Professor Daly.

“Capacity building for leadership moving forward is very important. Nurses are still under represented in many important forums where decisions are being made about really critical things like health policy.”

Professor Daly said there is no intention for GAPSON to work in isolation. The panel plans to hold regional consultations with key nursing groups, he said. “It’s also important that we work with the other health professions, with medicine and with allied health, and with experts in primary health care, with the World Health Organization and so on.”

While it is early days for the panel, Professor Daly believes it has great potential. “It’s an effort to garner some level of consensus and some level of collective voice and agreement to a work plan that we might be able to tackle over the next two to five years.”

GAPSON will meet again in October where it will set an agenda and work plan to address the issues it can tackle as a group, said Professor Daly.

“Part of it is raising awareness, part of it is working as a collective with other organisations then building some strategies together whereby we can offer opportunities to nurses around the world to get the kind of leadership experience that will assist them in moving their careers forward.”

Mental health programs reassured Mental health has received a funding boost to ensure 150 programs already running will continue through 2014-15.

Minister for Health Peter Dutton said the funding was essential to ensure continuity for mental health services, suicide prevention and postvention programs while the National Mental Health Commission undertakes its review of all existing services.

“Early notification of the continuation of PAGE 14

funding will enable service providers to effectively plan service delivery through 2014-15 financial year.”

Mr Dutton said the National Mental Health review was important to ensure services were being properly targeted and that funding was going to programs that have proven effective.

SANE Australia’s CEO Jack Heath said the decision for continued funding was a huge relief to Australians affected by mental

illness, their families, and those who work to support them.

The national mental health charity especially welcomed the certainty of suicide funding until 2015 while the Mental Health Commission’s Enquiry into Mental Health Services is completed. “The Enquiry is a welcome opportunity to reinvigorate suicide prevention as well as mental health services more generally,” Mr Heath said.

World Air pollution killing millions

The World Health Organization (WHO) estimates one in eight people around the world died as a result of air pollution in 2012.

Not a single maternity hospital or unit in Ireland has the internationally recommended midwife to birth ratio.

The WHO estimates the seven million deaths recorded more than doubles previous estimates, confirming air pollution as the world’s largest single environmental health risk.

A recent midwifery staffing survey by the, Irish Nurses and Midwives Organisation (INMO), showed a critical shortage of midwives in all of Ireland’s 19 maternity hospitals/units.

The new data reveals a stronger link between both indoor and outdoor air pollution exposure and cardiovascular diseases, such as strokes and ischaemic heart disease, as well as cancer.

Outdoor air pollution-caused deaths: • 40% - ischaemic heart disease • 40% - stroke • 11% - chronic obstructive pulmonary disease (COPD) • 6% - lung cancer • 3% - acute lower respiratory infections in children Indoor air pollution-caused deaths: • 34% - stroke • 26% - ischaemic heart disease • 22% - COPD • 12% - acute lower respiratory infections in children • 6% - lung cancer “Cleaning up the air we breathe prevents noncommunicable diseases and reduces disease risk among women and vulnerable groups, including children and the elderly,” said Dr Flavia Bustero from the WHO. “Poor women and children pay a heavy price from indoor air pollution since they spend more

Under attack

Health workers suffered more than 1,800 violent incidents during 2013, with hospitals and health centres bombed, shot at or looted in the majority of cases.

Health Care in Danger, a new report by the International Committee of the Red Cross (ICRC) highlights attacks on health facilities as well as lesser-known types of incidents, such as armed personnel disrupting hospital services by forcing their way in, or sexual violence against health personnel.

Ireland in midwifery staffing crisis

The union’s survey found the national average midwife to birth ratio in Ireland was 1:40, compared to the internationally recommended ratio of 1:29.5, which is accepted by authorities including the Royal College of Midwives and the NHS in the United Kingdom.

time at home breathing in smoke and soot from leaky coal and wood cook stoves.”

Low and middle-income countries in the South East Asia and Western Pacific regions had the largest air pollution related burden in 2012, with 3.3 million deaths linked to indoor air pollution and 2.6 million deaths related to outdoor air pollution.

Dr Carlos Dora from the WHO said excessive air pollution is often a by-product of unsustainable policies in sectors such as transport, energy, waste management and industry. “In most cases, healthier strategies will also be more economical in the long term due to health care cost savings as well as climate gains.”

“This is the first time that a report of this kind has been based on such a large number of incidents,” said Pierre Gentile from the ICRC. “It clearly shows that the situation is not improving. All too frequently health facilities are still being targeted and patients are being mishandled or even killed.”

The report is based on information collected during 2012 and 2013 on 1,809 incidents in 23 countries, in which violence was used against patients, health care personnel, ambulances or medical facilities.

INMO general secretary Liam Doran said the survey confirmed that Ireland needed over 620 more midwives to deliver safe, better and high quality care to mothers and babies. “Births in this country continue to be at a very high level, relative to the EU, and have increased by over 16% in the last decade while midwifery staffing numbers have been cut.”

Around 5,200 nursing and midwifery jobs have been lost in Ireland over the past five years, as a result of a ban on recruitment as part of austerity measures introduced in response to the global financial crisis.

The nursing union is fighting to have the ban lifted by Ireland’s Labour Relations Commission.

“Media reports only highlight violence affecting health services in just a few conflict-stricken countries, such as Syria,” said Mr Gentile. “However, the ICRC report shows that the violence occurs in other countries too. It is therefore urgent that governments, armed forces and the health care community step up their efforts to make health care delivery safer all over the world.”

PAGE 15 May 2014 Volume 21, No. 10.

Education Palliative care The following is an excerpt from the palliative care tutorial available on the ANMF Continuing Professional Education (CPE) website.

The goal of palliative care is to improve quality of life for individuals, their families and care givers by providing care that addresses the many needs patients, families and care givers have; physical (including treatment of pain and other symptoms), emotional, social, cultural and spiritual.

No one professional can deliver all of the elements of care. Palliative care requires the cooperation and participation of a range of health care providers.

The individual receiving palliative care is an important partner in the planning of their care and managing their illness.

When people are well informed, participate in treatment decisions and communicate openly with their doctors, nurses and other health professionals, they help make their

care as effective as possible. Care planning is an important process in ensuring the individual’s wishes, in relation to their care are met. Palliative care is active care. It anticipates problems that might arise, and aims to minimise the impact of the progressing illness so that the person can live life to the fullest.

The underlying philosophy of a palliative approach is a positive and open attitude towards death and dying.

The promotion of a more open approach to discussions of death and dying between the care team, the client and their families ensures identification of their wishes regarding end-of-life care.

Are you

ready

for a

It is vital to be aware of and understand the individual’s cultural and spiritual beliefs in order to address their needs in an appropriate and acceptable manner.

A palliative approach is not confined to the end stages of an illness. It provides a focus on active comfort care and a positive approach to easing an individual’s symptoms and distress.

In most western societies, discussion of death and dying creates discomfort. This distancing response to death and dying is reflected in poor communication about the topic, limited resources directed to this specialty area, and minimal education about how to provide supportive end-of-life care.

The decision to implement a palliative approach should not be based on the individual’s clinical stage or diagnosis; rather, it should be offered according to the needs of the individual.

CPD audit Aged Care Training Room

When you renew your registration by 31 May will you be able to declare that you have met the CPD requirements set out in the registration standards? Remember the NMBA also undertakes retrospective random audits throughout the year to ensure these standards are adhered to.

To assist you in meeting your CPD requirements the ANMF offers three online professional development training rooms, providing best practice information on a wide range of topics applicable to all areas of practice. Each of the training rooms also assist you in maintaining compliant CPD records.

If you are an ANMF, NSWNMA or QNU member you can access the online training at affordable reduced rates, there are even some FREE topics available. Non members can also access the online training.

Get ready today!

http://anmf.org.au/pages/online-education-programs Contact the ANMF Federal Education Team via email education@anmf.org.au or phone 02 6232 6533

ANMJ - Rego renewal 2014.indd 1

PAGE 16

7/04/2014 11:07:18 AM

Education In the presence of incurable illness there may be tension between the desire to pursue a cure and the need to control the individual’s symptoms. This tension may exist within the individual, between the individual and their family or carer’s, between health care providers, and occasionally between the individual and the health care providers. The level and complexity of an individual’s needs, as well as strengths and limitations of the individual, their care giver/s and family will determine the level of care required.

Palliative Care Australia has developed a framework which describes the interwoven roles of primary health care and specialist palliative care services defined by the level of resources available to them and by their expected capabilities. The Standards have been developed for use in a number of ways to support and enhance quality care for individuals with a life limiting illness.

Each of the 13 Standards has criteria for primary care services and three levels of criteria for specialist palliative care services.

Each option is equally appropriate according to the needs of the client and their family.

Palliative care nurses are employed in a variety of settings – domiciliary nursing services, hospice inpatient and outreach services, and public hospitals. They are usually accessed in one of two situations: 1. E arly in the course of an illness in order to establish a relationship and facilitate planning prior to major symptom control problems being evident. Referral at this stage is preferred.

2. W hen the illness starts to require frequent or complex nursing interventions.

There are three forms of palliative care; a palliative approach, specialised palliative care provision and end-of-life (terminal) care.

A palliative approach • When the client’s condition is not amenable to cure and the symptoms of the disease require effective symptom management, a palliative approach is appropriate; • Providing active treatment for the person’s disease may also still be important and may be provided concurrently with a palliative approach;

• However, the primary goal of a palliative approach is to improve the person’s level of comfort and function, and to address their psychological, spiritual and social needs.

direct access to palliative care doctors, nurses and specialists in pain and symptom control with some hospitals having a specialised palliative care unit.

Specialised palliative service provision

A hospice has hospital facilities with a homelike setting and staff that specialise in palliative care. It can be used for short periods of time to help control pain and symptoms, or to provide respite for the carer/s. An added benefit is that a hospice has a less structured routine in a comfortable environment with more privacy than a hospital.

• This form of palliative care involves referral to a specialised palliative care team or health care practitioners; • However, this does not replace a palliative approach but rather augments it with focused, intermittent, specific input as required.

The goals are: • Assessing and treating complex symptoms experienced by the individual; and • Providing information and advice on complex issues (eg. ethical dilemmas, family issues or psychological or existential distress) to the individual, their family and their care team.

End-of-life (terminal) care • This form of palliative care is appropriate when the individual is in the final days or weeks of life and care decisions may need to be reviewed more frequently.

Goals are more sharply focused on the person’s physical, emotional and spiritual comfort, and support for their family.

Palliative care is flexible and can be provided at home with the support of community based palliative care services or in a hospital or hospice. Each option is equally appropriate according to the needs of the client and their family.

Ideally, palliative care services should be provided wherever patients/clients reside.

Patients/clients should be able to move freely between institutions and home, depending only on their needs and the needs of the carer/s. Adequate transfer of information between carer/s and agencies is essential to provide high quality, continuous service.

The complete tutorial, which has details on matters such as ethics, advance care planning, physical symptom assessment and management, cultural and spiritual issues, caring for a dying patient, to name but a few sub topics, is available at: http:// anmf.org.au/pages/cpe Log in as an ANMF, NSWNMA or QNU member. Nonmembers also have access to this best practice learning. The ANMF palliative care tutorial offers you 5 hours of CPD toward your annual registration requirement.

For further information contact the ANMF education team at: education@anmf. org.au or phone Jodie or Rebecca on 02 6232 6533.

Professional help and support can be provided by a community based palliative care team in the persons home with many people preferring to have their last days at home because it is familiar and more comfortable. It allows for a comfortable, private, informal setting for carers, family members and friends in which to interact, share memories and express their feelings.

It also provides the carer with the convenience of not having to spend time travelling to be with the ill person.

Hospital based care may provide a sense of security to the person requiring palliative care. Some hospitals may be able to provide PAGE 17 May 2014 Volume 21, No. 10.

Professional Julianne Bryce & Elizabeth Foley, Federal Professional Officers

Celebrating nurses and midwives

Nurses and midwives make a significant contribution to the health and wellbeing of all Australians.

Largely, however, their outstanding work appears to go unnoticed by the broader community. Even within our professions we often don’t celebrate the achievements of nurses and midwives enough, and certainly not to the extent that our colleagues in the US do.

So it’s great to have two major events occurring in May which give us the opportunity to join with our global colleagues to give due recognition to the vital role played by the nursing and midwifery professions. The events we refer to are:

workplaces. The ICN says “It is clear that while there is a nursing shortage in many countries, just adding more nurses is not the solution and improving the work environment is a key aspect of improving patient safety and the quality of health care”.

International Day of the Midwife on 5 May and International Nurses’ Day on 12 May

Access the resource kits produced by ICM and ICN to read further about the themes chosen to this year’s celebrations: ICM website: www.internationalmidwives. org; ICN website: www.icn.org

May 5 is the internationally recognised day for highlighting the work of midwives. The International Confederation of Midwives (ICM) established the idea of the ‘International Day of the Midwife’ following suggestions and discussion among midwives associations in the late 1980s, then launched the initiative formally in 1992. On this day each year ICM asks the world to focus on the role of midwives and midwifery, and provides a campaign theme to champion the work of midwives. Reflecting the WHO call for midwives, ICM has been using an overarching theme ‘The World Needs Midwives Today More Than Ever’ in an attempt to progress the midwifery related Millennium Development Goals (MDGs 4 and 5). ICM has declared the subtheme for 2014 to be: ‘Midwives changing the world one family at a time’. This aims to send a strong message that through midwives involvement in the lives of mothers and babies, they are providing care which changes families, communities and the world. We urge our members to join with global colleagues in celebrating International Midwives Day and thereby support the case that adequately educated and resourced professional midwives are crucial to achieving MDGs 4 and 5.

International Nurses’ Day is celebrated around the world every 12 May, the anniversary of Florence Nightingale’s birth.

The International Council of Nurses (ICN) initiated this day of celebration in 1965, and each year commemorates this important day with the production and distribution of an International Nurses’ Day (IND) Kit. The IND theme for 2014 is: ‘Nurses: A Force for Change – A vital resource for health’.

As with the midwives, ICN recognises that, ‘nurses have a great responsibility to improve the health of the population as well as to contribute towards the achievement of the Millennium Development Goals’. Investment must therefore be made in educating and retaining nurses in health and aged care

PAGE 18

We encourage you to join in locally run celebrations on 5 May and 12 May, or, if you can’t see anything that has been organised, then ask your health service or aged care facility to host an event - this could be a morning or afternoon tea or a BBQ for staff to say thank you to their nurses and/or midwives.

The policy work of ANMF attests to the broad reach into our community that nurses and midwives have as they seek to make a difference in people’s lives - literally from ‘the cradle to the grave’. The Federation, like ICM and ICN, advocates that investing in nurses and midwives makes economic sense. Our publication Ensuring quality, safety and positive patient outcomes: Why investing in nursing makes $ense (2009)* remains relevant in demonstrating the value and contributions nurses make to positive patient outcomes. We argue there is a tangible economic and human benefit associated with access to quality nursing and midwifery care.

Visit the ANMF website to discover the range of issues covered by our policies, position statements and submissions to government and health and aged care bodies. All of these promote and celebrate the essential work of nurses and midwives in improving the health of our community.

Likewise, access policies from the ICM and ICN, which also provide guidance for nurses and midwives in daily practice, contributing to global health and wellbeing.

Join with us, during May, in giving special recognition to nurses and midwives: their intervention saves lives. That’s worth celebrating! *To access the report: http://anmf.org.au/pages/anf-reports

Annie Annie Butler, Assistant Federal Secretary

Moving from a state view to a national perspective It is with pleasure that I’m writing my first article as the new Assistant Federal Secretary for the ANMJ.

Following a decade or so working as a registered nurse in hospital and community settings as well as in research and education, I’ve spent the last 11 years working for the NSW Nurses and Midwives’ Association.

At the Association, for many years I worked with members on professional issues, such as registration, nursing practice and education. More recently, and up until my move to the ANMF federal office, I’ve been working with nurses and midwives on state and national campaigns and the issues, both industrial and professional, that were affecting their specific workplaces – from major city hospitals to tiny multipurpose services in rural and remote NSW.

Now moving to the national role of Assistant Federal Secretary, I’m finding that not only are these issues shared across small and large facilities but they are common across state and territory borders as well.

The broad issues that were the union’s focus in NSW – ensuring mandated safe staffing arrangements and preserving current conditions, particularly penalty rates; protecting public services; and maintaining universal access to safe, quality health care for all Australians are issues that are affecting nurses and midwives across the country.

Now nurses and midwives across the country are faced with the additional pressure of trying to provide best possible care in an environment where the federal government wants to take away more and more from nurses and midwives and their patients.

What’s been interesting to me is despite the differences in those environments and the obvious challenges different health care environments have, nurses and midwives shared many common issues. These issues often centered on workloads, appropriate skills mix for the specific environments and ensuring the needs of the community could be met.

And that’s not just about money.

Almost always with the overlay of the continuous pressure of constantly being asked to do more with less.

But the legitimacy of these activities is being questioned and the integrity of the union and its members is being challenged by the

Many of the gains achieved by nursing and midwifery and for the community have been through their collective activities as union members. The union’s actions both at state and national levels have achieved improved wages and conditions for nurses and midwives, significant professional developments and ultimately, improved health care for Australians.

government’s royal commission into unions which is seeking to discredit the union movement and undermine the capacity of ANMF members to improve their working lives.

So while I find myself coming to the role of assistant federal secretary in a particularly challenging time, my twenty plus years in the health system and union movement has shown me that nurses and midwives will never give up and will never back away from challenging times but will always fight to win a better life for the community.

It is an honour to have been appointed as the new Assistant Federal Secretary for the Australian Nursing & Midwifery Federation and to have the opportunity to continue work for improvements for nursing and midwifery across the country.

Outstanding nurse, outstanding future.

If you’re just as motivated about patient care as you are about health reform, then postgraduate nursing at QUT is the best way to an outstanding career.

You can be confident that you’ll learn from influential leaders in Australian nursing, and that our courses are informed by QUT nursing research which is independently ranked as above world standard.

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Send your career skywards with postgrad study at QUT. Find out more at www.qut.edu.au/postgraduate-nursing CRICOS No.00213J © QUT 2014 HLT-14-1220 20334

PAGE 19 May 2014 Volume 21, No. 10.

Feature

Forensic nurse examiners are the first line of defence for some of the most vulnerable people in society. The evidence they collect during a forensic examination of a victim of crime could be what puts their violent attacker or rapist behind bars. It is confronting, challenging and the burnout rate in this emerging discipline is high. But for the 20 or so forensic nurses currently practising in Australia - it’s not just a job, it’s a calling.

Kara Douglas examines forensic nursing in Australia.

Spotlight nursing PAGE 20

Feature

on forensic PAGE 21 May 2014 Volume 21, No. 10.

Feature

Margaret Stark

What would you do if you were a forensic nurse called into a police station to treat the hand injuries of a suspect arrested for a serious assault who police are waiting to question, when you ask him how he got the injuries he replies, ‘I punched him because he raped me.’

Making a difference

Is the man a suspect or a victim? What is a nurse’s duty of care in this situation? These are the sort of ethical dilemmas a forensic nurse examiner has to face.

“Forensic nurse examiners are essentially the first people who could have such a significant impact on whether the police are going to investigate, whether they’re going to prosecute, whether a person is going to get sentenced and whether that sentence is going to be significant,” says president of the Australian Forensic Nurses Association Linda Starr.

This real life scenario was put to the attendees of the second annual National Forensic Nursing Conference in Sydney earlier this year by the Director of Clinical Forensic Medicine Unit for NSW Police, Dr Margaret Stark. “Police would say - but he’s a suspect, lets treat him as a suspect - and yes he is a suspect but he’s also a victim or an alleged victim and we need to look after that.”

Dr Stark says all forensic practitioners, which includes forensic nurses, doctors and other allied health examiners, also have to consider legal ramifications. “Because if we have a suspect for a really serious offence and we don’t do things properly, ethically, morally and legally, then maybe if he is guilty down the line the case could get thrown out of court.

“So whether he’s guilty or not, if we treat him as a victim he ought to go and have the forensic examination and we’ll be able, with his consent, to collect any samples and document any injuries. It’s just that police don’t like anybody moved from their particular environment, so you’ve just got to discuss that with them and explain it.”

Reconciling the perspective police have of a person as a suspect, rather than a patient, is another challenge for forensic nurses, says Dr Stark. “It’s very easy to say I’m the medical practitioner and we’re going to do this and for the police to say we’re the police and we’re going to do that - you definitely want to avoid that if at all possible.”

Dr Stark says the forensic practitioner is there in an advisory capacity and often doesn’t have as much information as the police. “If we’re talking about a terrorist prisoner or a very serious offence there may be loads of information that the police won’t or can’t share, so all we can do is say we think this person is really sick, they’ve got severe abdominal pain and we’re really worried.”

Dr Stark says demanding that a sick or injured suspect be taken to hospital is not how to manage the situation. “Whereas if you say look I’m really concerned about this patient, I think he needs to go to hospital for further investigations, they know they don’t want to have a death in custody or an incident, so usually they will do it.

It’s about being able to have the confidence to go and say to them what you think without getting into any sort of confrontation.”

PAGE 22

Being able to make a difference in the medicolegal outcome of a person’s criminal case – whether victim or suspect – is what sets forensic nursing apart from other nursing disciplines.

“At the very beginning they’re the ones that have the opportunity to identify evidence and collect it. If they disregard it or don’t know it’s there, it’s lost for good and that could be the end of the individual’s case. So I think what’s significant about forensic nursing is the difference that they can make in the legal outcomes for a victim of crime.”

It has been around ten years since the first Australian nurses were trained to collect evidence and perform forensic examinations, but despite that passage of time there are only about 20 forensic nurse examiners practising Australia-wide.

Associate Professor Starr says the system has struggled to move from being totally medically dominated to multidisciplinary, including nursing. “We get the political support when it’s a funding issue and governments think yes we need forensic examiners and nurses are cheaper but then that’s where it ends. The nurses don’t get supported and leave, then it’s a fait accompli – the government or health department thinks we put that money into forensic nurses and it didn’t work.”

This lack of support led to the group resignation of five forensic nurse examiners in Alice Springs last year, says Associate Professor Starr. “The health department in the Northern Territory recognised there was a need for nurses to be trained to do forensic examinations… but once that happened they decided that they no longer needed a doctor or nurses there, so the forensic nurse examiners were left there in isolation.”

While the nurses were properly trained, working with victims of sexual assault and other crimes is extremely challenging on many levels, says Associate Professor Starr. “You do need support in this kind of stuff and especially when you are beginning and are a novice in this area, but it got to the point where they felt it was an untenable position and they couldn’t do it anymore and they resigned.”

This meant that people living in the Alice Springs area who needed a forensic examination had to get a commercial flight to Darwin or Adelaide, creating an issue with the timeframe in which DNA evidence needs to be collected and adding to the person’s stress.

Feature

“

Forensic nurse examiners are essentially the first people who could have such a significant impact on whether the police are going to investigate, whether they’re going to prosecute, whether a person is going to get sentenced and whether that sentence is going to be significant

”

Associate Professor Starr said it was a disappointing outcome for everyone. “We had the beginning of a service up there that was going to be really beneficial to the community.”

There has been a similarly disappointing start in NSW where only seven of the original 27 sexual assault nurse examiners (now called forensic nurse examiners) are still practising after their initial training in 2005. Without ongoing training, support and mentoring, burn-out takes its toll and nurses leave.

Associate Professor Linda Starr says this experience is also reflected elsewhere around the country. “I understand they’ve had a similar thing in Victoria. Queensland is doing a lot to support their nurses but they’re finding their nurses are also leaving as soon as they start for similar reasons, so they’re really trying to put in the infrastructure to keep their nurses in place. Tasmania seems to be going along ok for the time, but they’re also putting in a lot of energy into supporting the nurses and that seems to be the key.”

While there are these hurdles to overcome, the push to establish forensic nursing as a discipline in Australia is getting support from most doctors working in the forensic area, says Associate Professor Starr. “They are really supportive of forensic nurses and they see them as an asset and would like to see it grow as well but there are no positions and no paid positions.”

The lack of paid positions and varying pay rates is another issue facing the fledgling discipline. “For example, in NSW they’ve had varying pay. You could be doing the same job in a different suburb and be getting paid a quarter of what your counterpart is. On call pay is also different, there is just the lack of recognition industrially for what it is they do,” says Associate Professor Starr.

Achieving this recognition and establishing forensic nursing as a discipline in its own right is what led to the formation of the Australian Forensic Nurses Association two years ago, says Associate Professor Starr. “Because we have so many nurses now across all jurisdictions, our association wants to look at how we can develop standards across the country as well as a scope of practice so that these nurses won’t be challenged and that we can get a normalisation. And with that we hope to work with the police, the crime laboratories as well as the medical forensic staff and incorporate what they’ve already established for themselves but put it into a nursing context.”

The association was recently accepted as a member of the Coalition of National Nursing Organisations (CoNNO), which Associate Professor Starr says is another important step for establishing the discipline. “That’s a wonderful professional recognition of the worthiness of this area but I think we need to go a step further now and get it out to the Chief Nurses as well as the Commonwealth

Linda Starr

Chief Nurse to make sure these people are aware of what it is and what we do and hopefully we can get support that way as well.”

Australian Nursing & Midwifery Federation (ANMF) Federal Secretary Lee Thomas says it is exciting to see new disciplines develop within the nursing and midwifery professions. “Forensic nursing is another great example of how nurses can be utilised to deliver a whole different range of health care services and provide support to vulnerable patients.”

Ms Thomas says it is always challenging trying to get a new discipline established. “By joining CoNNO, the Australian Forensic Nurses Association will be able to draw on the experience and support of other organisations, including the ANMF.” Most importantly, forensic nurse examiners should be raising issues around classification and pay with their ANMF state branch, says Ms Thomas. “These are the sort of things that need to be raised during enterprise bargaining but in the interim a state branch could look at a nurse’s classification to make sure they are being paid correctly under their current EBA.”

PAGE 23 May 2014 Volume 21, No. 10.

Feature

Virginia Lynch

An international perspective While the discipline is still finding its feet in Australia, forensic nurse examiners have been practising in the United States for 40 years. Forensic Clinical Nurse Specialist and author of the first medico-legal text book for nurses, Virginia Lynch is recognised as a global pioneer of forensic nursing.

She says the challenges facing Australian forensic nurse examiners are similar to those she experienced in the early years of establishing the discipline in the United States. “We’ve had 40 years to work towards the standard and scope of practice that we’ve established today. We are a formal speciality in nursing, not a sub-speciality, but a specialty of nursing just like emergency nursing, psychiatric nursing, geriatric nursing, oncology nursing – forensic nursing is a unique discipline unto itself but it took us a long time to get there.”

A passionate human rights campaigner, particularly for the rights of women and children, Ms Lynch says a forensic nurse examiner is often the first line of defence when vulnerable patients come into an emergency department. “Most other health professionals haven’t been taught how to recognise those subtle signs and symptoms of human abuse and violence and the patients that we refer to as the silent victims, don’t identify themselves as crime victims. They are often women, children, the uneducated and the poor who are under the control of those who violate them.”

This is when a forensic nurse needs to take action, says Ms Lynch.

“Women come in complaining of injury but won’t tell us how they were injured because that man that brought them to the hospital is with her and she’s afraid, she’s humiliated and embarrassed and so she lies about how the injury occurred.”

Ms Lynch says it’s imperative to separate the woman from the man who caused her injuries and give her the time and space to explain what really happened, and to offer her the information about how she can break away from that abusive relationship. “If we don’t, if we fail them, [and they are only seen by health professionals] who are not educated in the forensic sciences who haven’t been taught the concepts, the philosophies of advocating for the vulnerable, that patient may not ever have another chance – next time they may bypass the emergency department and be admitted directly to the morgue.”

Ms Lynch firmly believes every nurse should have some training in forensic science. “It’s not something that you can mandate or require that every nurse be trained to do a rape examination, that every nurse be trained to do death scene investigations, or child abuse or elder abuse however, it should be mandated that every nurse is educated about the basics of understanding the application of forensic science to health care.”

For example, she says every nurses should be allowed to pronounce death. “Often police officers who aren’t as educated as nurses, who PAGE 24

have no medical training are allowed to pronounce death but oh no, nurses can’t do that, and yet it puts a burden on the physician when an unexpected death occurs in the hospital or a long term care facility, when a nurse knows perfectly well when someone is dead.”

Ms Lynch believes that developing standards and education programs will eventually lead to forensic nurse examiners practising in all major hospitals in the future. “One day we will see boards of health, ministers of health and government agencies requiring every hospital with trauma facilities at least, to have on staff an individual skilled in the identification of crime victims and the collection and preservation of evidence. It is a human right to have these types of standards that will protect our patients in a court of law. It protects the hospital from liability related issues and it promotes human rights.”

The way forward Australian Forensic Nurses Association president Linda Starr agrees that developing education programs is vital. Sexual assault services run internal courses to qualify medical officers to do forensic exams.

These courses were gradually opened up to nurses in remote areas and are now available to nurses who are interested in the area, but Associate Professor Starr says there is a need to formalise the training. “When doctors were doing it they would generally come with a comprehensive GP training and they would just be picking up the forensic skills, but putting nurses into the training program you realise there are other skills they need like immunisation qualifications and things like that.”

As a result of these gaps in training for nurses, Associate Professor Starr says the current training process is a bit ad hoc. “They are getting nurses to do this bit of one program at a cost, this bit of another program at a cost, and then their own internal training – so we’re just starting to get people to realise that we need people to get formal qualifications.”

Associate Professor Starr says that while a handful of Australian universities offer subjects in forensic nursing, there is no dedicated tertiary level course for forensic nurse examiners. “Ideally in the long term it would be great to see nurse practitioners, so nurses who are candidates for nurse practitioners, actually specialising in this area. They’re the ones that will provide the clinical leadership for nurses in the future, so if we could get a nurse practitioner forensic nurse that would be fantastic.”

In the meantime, it is up to the handful of dedicated forensic nurse examiners in Australia to continue advocating for their patients and carving out a place in the medical and legal world of forensics. As the international pioneer of forensic nursing, Virginia Lynch notes: “Not every nurse is interested in becoming a forensic nurse. It’s a calling. You are either drawn to it or are repelled by it and those who are drawn to it become committed and they don’t want to do anything else.”

Issues Steven Cowin

Not waving drowning- challenging the documentation arms race in nursing One of the challenges facing bedside nurses is dealing with the insidious rise in the volume of documentation required. Upon reflection it appears that the number of documents (charts, forms, other) has increased over the years and there is a paucity of research within an Australian context to support this idea.

International research has recognised a data or knowledge explosion (Hamric 2002) affecting nursing. It is widely acknowledged that there is a mind boggling amount of information to be absorbed and used in patient care. However so far there has been no acknowledgement from anyone in the nursing profession whether nurses are able to deal with such large volumes of information.

While the purpose of documentation is well understood (improve and formalise patient care) the author believes that the correlation between increasing documentation and better patient care is weak.

Two concepts appropriate in this situation are on load and information overload.

Communication load is a measure of the impact of organisational processes on individuals and indicates under which circumstances cognitive resources are likely to be stretched (Spencer, et al 2004). Specifically when an individual’s working memory is occupied with several items, an interruption may disrupt working memory, resulting in forgetting some items. While multitasking is an essential component of nursing and possibly suited to female brain function (Pease & Pease 2001), how often would a clinical nurse be able to sit quietly and complete documentation without interruptions?

Research proves the average number of variables a human can deal with simultaneously is four (Halford, et al 2005).

Alvin Tofler introduced the concept of information overload in the 1970s. While social scientists recognise this as a societal issue the author was only able to find one published article with a link to Nursing.

Information overload occurs when a person is exposed to more information than

the brain can process at one time (Palladino 2007). This can lead to poor work performance, especially in nursing where it is normal to have many tasks to attend, in short timeframes. Nursing documentation is often reviewed toward the end of a shift when time pressure may be present and may not allow appropriate time to process information and add value to patient care.

If the average nurse cares for four or more patients, how many documents and charts does one have to review process and complete, and then add value to patient care?

Is it acceptable to believe there is a limit to how much information a nurse can deal with in a work shift? Or is there an unrealistic assumption that nursing staff should have or develop a skill set to deal with large volumes of information generated by nursing documents.

Previous exposure to academia acquainted the author to the concept of critical thinking. This is defined as a purposeful outcome directed thinking that is based on a body of scientific knowledge derived from research and other sources of evidence (Ignatavicius 2001). Also the term ‘evidence based practice’ is accepted as an appropriate pathway for the nursing profession. A link to this concept is found on the Australian Nursing and Midwifery Council Competency standards for the registered nurse. The practising nurse is supposed to use analytical skills in accessing and evaluating health information and research evidence and compare it to current practice. As such the practice of developing further or other charts or documents to solve a clinical issue must be challenged. As the volume of paperwork rises, compliance with completion and usefulness falls. The paradox of this is that there is a societal assumption that more information is better, when this is clearly not the case. Minimising information maximises information transfer.

lenged. If nursing staff are operating way beyond levels of usable information patient care may not improve. There needs to be serious consideration given to limiting and or reducing the number of documents and charts affecting nursing practice. This area needs to be researched further, and should be identified as a priority by nursing leaders, academics and those who work on the frontline.

References

Halford,G.S., Baker,R., McCredden,J.E., & Bain,J.D., (2005), How many variables can humans process.

Psychological Science, January, 16(1), 70-76.

Hamric,A.B., (2002) Dealing with the knowledge explosion. Clinical Nurse Specialist, 16(2), 68-69. www.nursingmidwiferyboard.gov.au/documents Ignatavicius,D.,(2001), Six critical thinking skills at the bedside success. Dimensions of Critical Care Nursing, 20(2), 32-33.

Palladino,L.J., (2007). Find your focus zone, an effective new plan to defeat distraction and overload.

New York, Free Press.

Pease,A & Pease,B,. (2001) Why men don’t listen and women can’t read maps. Great Britain, Orion Press.

Spencer,R., Coiera., E., & Long., P., (2004), Variation in communication loads on clinical staff in the emergency department. Annals of Emergency Medicine, 44,(3) 268-277.

Steven Cowin is a Clinical nurse at the Coronary Care unit, Royal Perth Hospital.

The practice of chart and documentation intensification is not supported by evidence, cognitive science or critical thinking. As such the current practice of producing more charts and documents to guide nursing practice needs to be chalPAGE 25 May 2014 Volume 21, No. 10.

Issues ICN Chief Executive Officer David Benton and ICN Communication Officer Lindsey Williamson

Fake medicines are everybody’s business In 2010, an Australian truck driver was admitted to hospital with severe hypoglycaemia. It was soon discovered he had unwittingly taken a counterfeit version of Cialia, a sexual performance-enhancing drug (The Medical Journal of Australia 2010).

Unfortunately, this is not a unique case.

According to The Partnership for Safe Medicines (2013), Australian custom officials catch 24 packages of fake drugs every month. The World Health Organization (WHO) estimates that up to 1% of medicines available in the developed world are likely to be fake. This figure rises to 10% globally, but in some areas of Asia, Africa and Latin America fake medicines may account for up to 30% of medicines in circulation. In Africa, one-third of all malaria medicines are probably fake (Nayyar et al 2012). WHO (2006) also estimated that one medicine in two purchased on internet sites that hide their physical address is fake.

In 2009 in Nigeria at least 84 children died after taking a syrup for teething pain, that contained diethylene glycol, an industrial solvent and an ingredient in antifreeze and brake fluid (The Partnership for Safe Medicines.org, 2013). In 2011 nearly 3,000 Kenyans were affected by a falsified batch of their antiretroviral therapy (WHO 2006).

ICN believes that if we are all aware of the existence of fake medicines and the dangers they pose, we will be better at putting pressure on our governments, and all those involved in the manufacturing and distribution of medicines, to tackle this public health threat on a global level.

Fake medicines put patients and the general public at risk. They trick patients into believing they are receiving genuine treatment, when instead they are getting deceitful products that could cause further illness, disability or even death. Furthermore, fake medicines pose a public health danger as they can contribute to the development of treatment resistance.

By avoiding authorisation from regulatory authorities and by attempting to pass themselves off as something they are not, fake medicines pose a global public health risk, leading to resistance to treatment, illness, disability and even death. Fake medicines undermine patients’ trust in health systems, their governments, health care providers and manufacturers of genuine medicines.

Manufacturers of fake medicines do not PAGE 26

discriminate; they counterfeit both long established and recently marketed medicines, both branded and generic, and both domestically manufactured and imported.

In order to combat this threat, the International Council of Nurses (ICN) launched a counterfeit medicines campaign in 2005. The initiative aims to raise awareness among nurses, provide them with some tools for detecting counterfeit medicines and with strategies for informing colleagues and patients. In the first stage of the campaign, ICN joined forces with the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), the Pharmaceutical Security Institute (PSI) and the International Alliance of Patient Organizations (IAPO) to alert their respective members to the problem of fake medicines and to encourage them to work together on this issue.

The 2005 ICN toolkit for International Nurses’ Day addressed this topic, providing tools for nurses to identify possible fake medicines, information on how to report possible fake medicines and ways to raise public awareness.

In 2010, ICN and their partners at the World Health Professions Alliance (WHPA) launched the ‘Be Aware, Take Action’ campaign focusing on public health, patient safety issues and enhancing the role of health professionals and associations. WHPA has spoken out at the World Health Assembly, carried out workshops in various countries and issued a call for action and joint statement.

The campaign continues today. Last year, ICN joined Fight the Fakes, the multi-stakeholder campaign which aims to raise awareness about the dangers of fake medicine by giving a voice to those who have been personally impacted and sharing the stories of those working to put a stop to this threat to public health. It seeks to build a global movement of organisations and individuals who will shine a light on the negative impact fake medicines have on people around the globe and to reduce the negative consequences on individuals worldwide.

Fight the Fakes shares stories such as Victoria Amponsah’s who was diagnosed with malaria when she also learned that she was two months pregnant. She left the hospital with a prescription for an anti-malarial drug and, like patients anywhere else in the world, went to a local pharmacy, believing that the medicine she purchased would treat her condition. Victoria bought what she thought was a genuine, effective drug, but this was not the case. Her condition quickly worsened and within hours she was admitted to the hospital, learning later that she had been sold counterfeit pills.

Fortunately, Victoria and her baby survived the trauma and successfully fought off malaria, but this would not be her only personal encounter with fake medicine. In her seventh month of a healthy pregnancy, she was deceived by a fake version of a basic painkiller, disguised in an official-looking package. Within thirty minutes of taking the pill, Victoria started sweating, shaking, vomiting and bleeding. She was in the hospital for two days, nearly lost her baby and had to return to the hospital every week after the incident.

“I am hoping that globally people understand that our lives are more important than the little money they will make out of bringing a fake drug out,” said Victoria. “[I hope] people will understand that it’s not all about money. It’s about life. The smallest thing, like just a tiny drug which is bad can cause so much damage in one’s life.”

As the world’s single largest group of health care providers, nurses have an interest in safe, quality medicines. In places where the brand names of medicines as yet hold no meaning, people have long relied on the nurse who vaccinated their child, or cared for their elderly relative.

Nurses as frontline health care providers can become key players in increased vigilance for and reporting of possible counterfeit drugs.

This frontline role and presence in all care settings puts nurses in a unique position to detect differences in the appearance of a drug or its packaging, ineffective action, or very low price as indicators of fake products. As the health profession closest to the patient, they are often the first to recognise failure of treatment or intoxication from fake medicines.

In daily practice nurses can assist identifying counterfeit products through observation of people and products, particularly looking out for products that are not intact, that have been altered damaged or are unsealed.

Nurses can help educate patients encouraging them to speak up if they have any questions about medicines, to ask questions about the medicine, its effects and possible side effects and to report any lack of improvement in health.

Nurses should also be involved in national efforts to raise awareness and combat fake medicines including lobbying for appropriate legislation, drug regulation and law enforcement against fake drugs.

Fake medicines are everybody’s business, so make it your business and join the Fight the Fakes campaign at: http://fightthefakes.org References on request

Reflections Joseph Szwarc

Importance of appropriate interpreters It was after ordinary office hours and I was about to leave when my colleague ‘Anna’ asked if I could stay a while longer – we have a policy that staff should not be in the building on their own. Anna, a counsellor, was waiting for an ambulance to come and take a client ‘Ali’ who was experiencing serious mental health problems to hospital.

The next day Anna told me the ambulance officers had attempted to speak with Ali in ‘pidgin English’. This was despite Anna telling the officers Ali spoke very little English and that she had a phone interpreter on the line who could translate. Anna accompanied Ali to the hospital, a major inner Melbourne facility. The emergency department staff told Anna that Ali would have to remain overnight without assessment because there was not an interpreter on duty until the next morning. She told them he was so distressed he would probably leave.

Fortunately a doctor arrived who knew how to contact an interpreter by phone and arranged the call using his personal mobile phone, as there was not an appropriate phone instrument available. As a result Ali was assessed and then admitted.

This incident is not unique. Similar accounts of health practitioners and services not engaging properly qualified credentialed interpreters as a matter of course when required are commonly reported by staff of our agency and others. The lack of interpreter engagement occurs in a variety of health care settings and by an array of health professionals.

This issue is of considerable concern. Effective communication between a health practitioner and their client is essential for the practitioner to accurately understand the client’s health concerns and symptoms. It is also essential that the client understands diagnoses, can give informed consent to treatment to comply with prescribed care and advise the practitioner of any adverse effects.

Additionally, the practitioners’ failure to ensure effective communication may expose them to legal risks.

The Victorian Foundation for Survivors of Torture published a study about the barri-

ers to and facilitators of the engagement of interpreters in health settings. The barriers identified include health providers: • not being aware they can access interpreters without charge; • not having appropriate equipment for telephone interpreting; • incorrectly assessing that patients’ English skills are adequate.

There are also common circumstances where services actively want to engage interpreters but are unable due to funding constraints or simply because no interpreter in the required language is available at the right time.

Evidence suggests a number of facilitators of good practice, such as the development and implementation of systems, ensures circumstances where interpreters will be required are identified in a timely manner and that there is adequate knowledge of the processes to access interpreting services.

Victoria is the main focus of this report but the issues and a number of the solutions are clearly relevant on a national scope.

• adequate funding by the state and Commonwealth governments; • adjusting the national funding formula for hospitals to provide weighting for the engagement of interpreters when patients have low English proficiency; • encouraging health services and tertiary institutions to routinely provide training on working with interpreters in professional development and professional practice education.

The report also identifies the pressing need for a Commonwealth Government led review to ensure Australia has an interpreting workforce and industry to meet current and projected requirements for language services in health and other key areas of government responsibilities.

The report is available at: www.foundationhouse.org.au/resources/ publications_and_resources.htm Joseph Szwarc is a manager of research and policy at Foundation House, Victoria

The report provides a number of recommendations relating to matters such as: • strengthening legislation, organisational and professional guidelines and standards; PAGE 27 May 2014 Volume 21, No. 10.

View Point Jayne Gow, Evelyn Collins, Michelle Giles and Tony O’Brien

Developing a nurse-led clinic for patients with Parkinson’s disease Parkinson’s disease is a complex neurodegenerative disorder affecting more than 1,000 patients in the Hunter New England Local Health District (HNELHD).

Those affected require a specialised team of health professionals to coordinate their care. To ensure the best outcome for patients, it is imperative they have access to an experienced movement disorder specialist for assessment and treatment of their Parkinson’s disease. This should occur ideally within two to six weeks of referral (National Health Service 2006).

Registered Nurses are well placed to conduct a preliminary assessment and then review in consultation with the movement disorder medical specialist. Parkinson’s disease registered nurses (PDRN) can fast track and offset the barriers to accessing a movement disorder specialist, which includes long waiting lists and geographical location and isolation often with long travel time to appointments.

In an effort to overcome these barriers the role of the HNELHD PDRN has evolved and is assisting in bridging the gap between patients, movement disorder specialists, general practitioners (GPs) and community services (Department of Health, State of Western Australia 2008).

The role of Parkinson’s disease registered nurse The PDRN provides telephone and email support to patients and carers. This places the PDRN in a unique position to gain insight into the experience and quality of life of patients living with Parkinson’s disease, which is often not extensively discussed in medical clinic appointments.

This positioning of the nurse opens up an opportunity to conduct evaluative research to determine the intricacies of the extension in clinical practice. The role of the PDRN has developed into an autonomous highly specialised area, and according to Martin and Mills (2013), “has evolved to undertake activities once considered for doctors only”.

PAGE 28

There is now clear indication for the need and development of a nurse-led clinic for Parkinson’s patients in the HNELHD. A review of the literature which has identified the benefits of nurse-led clinics in the management of chronic diseases, including Parkinson’s disease, affirms this assumption. Benefits of nurse-led clinics in chronic disease management include, increased patient satisfaction, improved quality of life, improved clinical outcomes, increased understanding of chronic diseases and improved access to health professionals such as allied health referrals (Department of Health and Ageing 2007).

Potential outcomes It is expected these benefits would be similar in a formalised Parkinson’s nurse-led clinic, especially when nurses are instrumental in the coordination of care and in terms of the time they spend in homes visiting and in liaison with families and patients.

of the PDRN for patients with Parkinson’s disease and their carers can be evaluated and documented.

References

Australia. Department of Health and Ageing.

(2007). Nurse Led Clinics. Chronic Disease Management.Victoria. Whitehorse Division of General Practice.

Australia. Department of Health, State of Western Australia. (2008). Parkinson’s Disease Service Model of Care. Perth. Aged Care Network.

Martin, A. and Mills, J. 2013. Parkinson’s Disease Nurse Specialist and the King’s College model of care. British Journal of Neuroscience Nursing, 9(1):22-26.

Of importance to nursing practice is that the benefits of a Parkinson’s nurse-led clinic is not extensively documented in the literature; a surprising situation when these clinics have been running for some time in the United Kingdom.

This gap in the literature opens up the Parkinson’s nurse led clinic for exploration in regard to extending the scope of practice for PDRN.

United Kingdom. National Health Service. 2006a.

Parkinson’s disease: Diagnosis and management in primary and secondary care. London: National Institute for Health and Clinical Excellence.

In such a large often isolated health district, such as HNELHD a nurse-led clinic, offered through telehealth for example, is expected to make a difference to our patients. The literature available focuses on the role and impact of the PDRN rather than discussing the design and usefulness of nurse-led clinics.

United Kingdom. Parkinson’s Disease Society. n.d. Commissioning Parkinson’s Services: The clinical and financial value of Parkinson’s Disease Nurse Specialist, www.health.gov.au/internet/nhhrc/publishing.nsf/Content/143/$FILE/143%20Parkinson’s%20Australia%20Submission%20Attachment%20A.pdf (viewed, 6 January, 2014).

For example, reports suggest, “by managing outpatient follow-ups, PDRN’s are having a positive impact on waiting times, relieving the burden on consultants” (Parkinson’s Disease Society) and that “it is anticipated that regular access to specialist nursing will reduce the need for hospitalisation, outpatient appointments and GP attendances” (National Health Service 2006). These documented benefits of the nurse’s role could be utilised and enriched through the development of a nurse-led clinic in the HNELHD, where the benefits

United Kingdom. National Health Service.

2006b. Parkinson’s disease: Diagnosis and management in primary and secondary care, National Cost impact report. London: National Institute for Health and Clinical Excellence.

Jayne Gow is a Parkinson’s Clinical Studies Nurse. Evelyn Collins is a Parkinson’s Clinical Nurse Specialist both at the John Hunter Hospital, Neurology Unit, NSW. Michelle Giles is a CNC in research and knowledge management at HNE Nursing & Midwifery Research Centre Gate Cottage, James Fletcher Campus, NSW and Anthony O’Brien is an Associate Professor and Clinical Lead at the HNE Nursing and Midwifery Research Centre School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle

Research Neonatal nurses need more training to support parents “Parent support has become a core part of the nurses’ role, but many of them have not been trained for the level of mental health care or emotional support required.

They feel they need additional training to be able to assist families in a meaningful and consistent way.”

Also, Dr Turner said neonatal units often have junior staff working on placement.

Nurses working in neonatal intensive care feel poorly equipped to provide the intense emotional support needed by parents, and require more training and improved facilities to carry out their work effectively.

The findings by University of Adelaide researchers are published in the Journal of Clinical Nursing.

“Nurses working in neonatal intensive care have high emotional demands placed upon them, in addition to providing a high level of care to premature babies,” said lead author Dr Melanie Turner.

“These junior staff can find it difficult to support families who are experiencing an extremely emotional time in their lives.”

Figures show 20,700 or 8% of all Australian babies were born prematurely in 2008.

Dr Turner said many hospitals simply do not have the physical space to cope with such large numbers of premature babies.

Nurses also identified other issues including movements of staff from shift to shift leading to inconsistent communication with parents, language and cultural barriers, busy workloads and rapid patient turnover.

The long walk on the road to stroke recovery Stepping up walking practice is the only way to improve walking ability for stroke survivors, according to a new Australian study.

The University of South Australia trial found increasing physiotherapy sessions for stroke survivors receiving rehabilitation did not lead to a faster recovery time in terms of walking ability, co-investigator Dr Coralie English said.

“Our study looked at whether providing stroke survivors with weekend physiotherapy services, or providing group circuit class therapy during the week, would increase physiotherapy time and therefore improve people’s ability to walk.

“But when we compared those with increased physiotherapy to the control group, who received usual care physiotherapy, we

found that all participants achieved the same level of walking ability four weeks later.”

Dr English said the clear message from the study is that only increased walking practice will help stroke survivors get back on their feet. “When we looked at what was happening within physiotherapy sessions, there was very little difference in how much time people spent actually practising walking,” she says.

While therapy services can be increased, Dr English said that unless walking practice is increased there is no benefit in terms of recovery of walking ability. “That said, having extra physiotherapy time may have other benefits for people in rehabilitation - people can become bored and frustrated if they don’t have enough to do while in hospital.

So there are many other reasons why we might want to increase therapy time.”

Carrying extra weight could be healthier for older people Older people with a BMI (body mass index) in the overweight range live longer, according to a new Australian study.

Researchers at Deakin University looked at the relationship between BMI and risk of death in people aged 65 years and older.

They found that the lowest risk of death was among those with a BMI of around 27.5, which is considered overweight according to the World Health Organization (WHO) guidelines, while mortality was significantly increased in those with a BMI between 22 and 23, which is in the normal weight range.

The findings suggest that current BMI recommendations may not be suitable for older adults.

“It is time to reassess the healthy weight guidelines for older people,” said Deakin University’s professor of nutrition and ageing, Caryl Nowson.

“These findings indicate that, by current standards, being overweight is not associated with an increased risk of dying.”

Professor Nowson said it is those sitting at the lower end of the normal range that need to be monitored: “As older people with BMIs less than 23 are at increased risk of dying.”

Advice on ideal body weight should also take into account factors other than BMI, Professor Nowson said. “Factors such as chronic diseases and the ability to move around need to be considered as there is no real issue with being in the overweight range unless it is preventing people from moving around freely,” she said.

“Rather than focussing on weight loss, older people should put their efforts into having a balanced diet, eating when hungry and keeping active.

“Putting too much emphasis on dietary restrictions also increases the risk of malnutrition in this age group. Malnutrition in older people is not well recognised as this can occur even when BMI is in the overweight range.”

The study was published in The American Journal of Clinical Nutrition.

PAGE 29 May 2014 Volume 21, No. 10.

Wellbeing Kara Douglas

Surviving night shift Our bodies are naturally wired to be awake during the day and to sleep for approximately eight hours at night.

Working night shifts runs counter to the body’s sleep-wake cycle and can seriously affect your health – not to mention your family and social life.

The sleep-wake cycle is controlled by a part of the brain known as the ‘circadian clock’. It monitors the amount of light you see, moment by moment. When the light starts to wane in the evening, your clock notices and floods the brain with melatonin, which gives the body the signal to fall asleep.

During the day, other chemicals known as neurotransmitters (such as noradrenaline and acetylcholine) increase in the body and keep you awake. Many other functions of the body, including temperature, digestion, heart rate and blood pressure also fluctuate during the day in tune with the circadian clock.

Additionally, Professor Lushington says there is a general sense shift workers might potentially have a higher mortality rate than non-shift workers. “So as well as being a risk factor for cardiovascular and metabolic diseases in particular, it may in fact shorten your life.

“The other complication of working shift work is that if you’re not sleeping enough that’s going to affect other things like your mood, appetite and whether you feel like socialising, so there are psycho-social functions,” says Professor Lushington.

Shift workers get on average 2-3 hours less sleep than other workers, often due to having split sleep patterns instead of a continuous block of sleep.

Professor Lushington says sleeping for short periods at the end of one night shift and before the next one works well for some people, but it is not an easy schedule to keep particularly if you have other demands on you such as children.

This 24 hour cycle is known as the circadian rhythm. Working night shift or starting work before 6am runs counter to this natural cycle.

“For the majority of people it tends to be that one continuous sleep bout tends to work best, once they wake up there’s no chance that they can go back and have another sleep.”

University of South Australia’s Sleep Research Centre Professor Kurt Lushington says that as a result there is a higher risk for most medical complaints, such as gastrointestinal disorders. “There’s some evidence to show there is more cardiovascular risk and possibly some immune functioning risk.”

Short naps during the day can be beneficial but napping too close to the start of a shift could lead to sleep inertia. Also referred to as being ‘sleep drunk’ – it is the groggy feeling you can experience upon waking that leaves you not quite 100% on the ball.

“That might put you at risk when driving to and from work,” Professor Lushington says. “One of the other things that is very clear with shift work is that working these very odd hours means not only are you less attentive at work, you might be less attentive on the roads and it is known that shift workers are more prone to have car accidents.”

The health and social issues associated with night shift work is a serious workforce management issue. While some hospitals are looking at the best rotating shift patterns and lengths, Professor Lushington says it is essential that nurses who do need to work nights consider their own health and wellbeing, and maximise sleep during the day.

Tips to promote better sleep during the day Avoid stimulants, such as caffeine and nicotine before bedtime If you are working nights and need to sleep from morning until afternoon, try to avoid caffeine after midnight.

Create a restful environment Turn off or unplug your phone and hang room-darkening shades on the windows. Try wearing an eye mask and post a “Do not disturb” sign on your bedroom door and PAGE 30

even your front door as well. Schedule appointments and other activities outside of your sleep period, and train your family and friends to leave you alone while you sleep.

Stick to the routine Going to sleep and waking up at the same time every day helps promote good sleep. Be as consistent as possible, even on weekends and days off.

Make healthy lifestyle choices Eat a healthy diet and include physical activity in your daily routine. If exercise seems to energise you, work out after you wake up rather than before you go to sleep. Resist the temptation to use junk food or nicotine to stay awake or alcohol to get to sleep.

Legal Linda Starr

Limits of the law

Three cases making dramatic headlines in the Australian Doctor recently (online) demonstrate how practice can be scrutinised in a variety of venues - a civil court, the Health Care Complaints Commission and the Health Practitioners Tribunal that lead to different outcomes.

Fugitive midwife found using doctor’s name (24 March 2014) - refers to Patterson v Khalsa [2013] NSWSC 336 a case where a six year old boy through his guardian successfully sued a midwife and was awarded $6.6 million in damages. Khalsa was engaged by the parents as an independent midwife for antenatal care and attending a home birth. The plaintiff alleged the midwife was negligent in recommending a home birth and in the negligent performance of her midwifery duties. The plaintiff’s mother went into labour at 41 weeks gestation early in the morning progressing to strong labour around midday when the defendant arrived. Foetal observations indicated a heart rate of between 140 and 158 bpm. A complex and protracted labour followed with the baby’s head slowly descending from 2pm being delivered at 6pm – thick meconium was noted. There was considerable difficulty in delivering the plaintiff’s shoulders - delivery was not completed until 6.50pm. The baby was ‘flat’ and slow to breathe. He was transferred to hospital where it was determined he had suffered a hypoxic brain injury toward the end of labour and right Erb’s Palsy. The defendant indicated she would contest the claim against her, but ultimately failed to comply with Court directions. Subsequently Khalsa notified the Court she no longer intended to participate in the Court processes as she was unable to fund her defence. Consequently her defence was struck out and a default judgment in favour of the plaintiff was made. Seven months later a warrant was issued by police as Khalsa failed to comply with a Supreme Court order

to freeze her assets. Khalsa was arrested in February 2014 attempting to fly to New Zealand with tickets purchased in a doctor’s name. Although listed on the AHPRA’s register as having non-practising registration, on her own website she continued to advertise home birth services for between $2,500 and $3,500 outside of Australia. Despite her assertions that she had no assets, she was found to have a home in New Zealand where she had recently purchased a car, had just withdrawn $35,000 from a bank account in addition to a considerable amount of Japanese Yen found in her possession at the time of her arrest. Further enquiry revealed recent trips to New Zealand, India, Myanmar and Malaysia. Khalsa remains in custody pending a further hearing. Despite being awarded damages for what the court described as an extreme case of injury the plaintiff is unlikely to recover from an unregistered and uninsured practitioner.

Rogue nurse on run after botched injection (5 March 2014) - refers to an unregistered practitioner reportedly ‘on the run’ after she ‘botched a cosmetic [treatment]’ provided without any medical authorisation or supervision. In 2013 the Health Care Complaints Commission (HCCC) investigated a complaint by Mr A following cosmetic treatment provided by Tran who claimed she was a registered nurse with qualifications in laser therapy, beauty therapy and Botox administration. Tran convinced Mr A that he needed a cosmetic filler to fix his wrinkly forehead and subsequently injected a substance into his eyes and forehead causing immediate pain, swelling and discolouration. He was given 45 antihistamine tablets wrapped in a tissue to take over the next few days but became progressively unwell. He returned to the clinic where Tran gave him antibiotics from which he experienced serious side effects. Mr A then sought medical advice and was diagnosed with suspected vascular compromise and necrosis due to complications following a dermal filler injection. An investigation concluded that Tran was a risk to the health and safety of the public, having breached the Code of Conduct for Unregistered Health Practitioners in that she had provided treatment for which she was not competent to perform, practised outside her experience and training, supplied and/or administered S4 substances without authorisation, used her previous qualifications to mislead a client as to her ability and authorisation to

provide treatment and failed to provide treatment in a safe and ethical manner – importing drugs from Korea and Vietnam that were not registered under the TGA. Consequently a prohibition order was made that permanently prohibited Tran from providing any injectable cosmetic treatments, supplying any unregistered therapeutic goods or scheduled medicine, and from administering an unregistered therapeutic good or Schedule 4 medicine to any patient. This prohibition affords some public protection – in NSW (Statement of Decision for Jenny Tran NSW HCCC 2014).

Rogue midwife involved in six homebirth deaths (13 March 2014) - refers to the outcome of disciplinary proceedings against Lisa Barrett an unregistered midwife. The Nursing and Midwifery Board of Australia issued the complaint that Barrett’s conduct constituted professional misconduct and despite her voluntarily surrendering her registration in 2011, continued to practise as a midwife. The grounds for the complaint were that Barrett inappropriately planned and/or accepted the sole role in providing care before, during and after labour and demonstrated knowledge, skill and judgment that fell substantially below the standard expected of an equivalent trained and experienced midwife, when she attended a number of high risk home births where the infants tragically died. Having considered all the evidence the Tribunal concluded that Barrett’s conduct amounted to professional misconduct and issued a reprimand in the strongest terms, ordered her to pay a fine of $20,000 and permanently prohibited her from providing midwifery services (NMBA v Barrett [2014] SAHPT 1). This case led to the introduction of legislation in SA rendering it an offence for anyone to engage in midwifery practice without being a midwife, medical practitioner or student registered under the Health Practitioner Regulation National Law (SA), those who ignore this could face a penalty of $30,000 or 12 months imprisonment.

National Registration fortunately enables close monitoring of unregistered practitioners who attempt to seek re-registration in any Australian jurisdiction providing additional protection to the public.

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 31 May 2014 Volume 21, No. 10.

Clinical Update Sally Hayes

Using motivational interviewing to encourage women with gestational diabetes mellitus to breastfeed as a method of reducing their risk of type 2 diabetes mellitus The incidence of Gestational diabetes mellitus (GDM) is increasing each year with up to 60% of these women subsequently developing type 2 diabetes mellitus (T2DM) (Australian Institute of Health and Welfare AIHW 2013).

Clausen et al (2007) found 20% of offspring born to mothers with (GDM) developed T2DM or pre diabetes by the age of 27.

Breastfeeding reduces the risk of T2DM in mothers and their offspring (Lui et al 2010).

Telling women this information can be an ineffective mechanism for encouraging breastfeeding (Kim 2007). However, motivational interviewing (MI) is a communication method that can be used to engage women and address ambivalence about breastfeeding (Wilhem et al 2006). This clinical update includes a description of diabetes and associated risks, breastfeeding effect on the mother with GDM and her infant. A description of MI, key MI communication skills, questions for the health professional and a hypothetical example of a motivational interview MI to encourage women with GDM to breastfeed is also included.

What is GDM? GDM is defined as higher than normal glucose levels in pregnancy that results in glucose intolerance and insulin resistance (Diabetes Australia 2012).

The prevalence of GDM GDM occurs in 3 to 8% of women diagnosed in week 24 to 28 of pregnancy (Diabetes Australia 2012). The rate of GDM in Australia has risen from 3.6% in 2000-2001 to 4.4% in 2009-2010 and is expected to increase further (AIHW 2013).

Risk factors for GDM are obesity, low socioeconomic background, ethnicity, Aboriginal descent, age and multiparity (Vibeke et al 2008). Some of these risk factors are preventable, but this requires support and counselling (Diabetes Australia 2012).

Risks of developing T2DM after GDM Women with GDM have a 50 to 60% chance of developing T2DM postnatally (Kim et al 2002). T2DM can lead to heart disease, stroke, eye disease, peripheral vascular disease, neuropathy and renal dysfunction reducing quality of life and life expectancy (AIHW 2013).

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Breastfeeding to reduce the risk of T2DM in mothers and their babies Women with GDM who breastfeed, subsequently reduce their risk of developing T2DM. Recent studies found regardless of GDM status a 14% risk reduction of T2DM with one year of breastfeeding (Lui et al 2010). This negates an earlier study failing to demonstrate a reduction in T2DM in breastfeeding women with GDM (Stuebe et al 2005). Futhermore, evidence from a study of women from birth to 19 years with GDM (Zeigler et al 2012) found a 40% long-term risk reduction of T2DM with at least three months of breastfeeding. This has been further demonstrated in a study over 20 years in women with GDM, on the breastfeeding effect on metabolic syndrome, a precursor to T2DM, which indicated a six-fold lower incidence of metabolic syndrome greatly reducing the risk of T2DM (Gunderson et al 2010). This is a strong argument for breastfeeding to reduce T2DM. In addition to the impact on mothers, offspring born to women with GDM have increased insulin resistance and have a 2021% risk of T2DM by the age of 27 (Boerschmann et al 2010). Pettitt and Forman (1997) found two months of exclusive breastfeeding decreased the rate of T2DM by up to 50%. More recent research by Young et al (2002), found 12 months or more breastfeeding reduced the risk of T2DM by 24%. Additionally, recommending breastfeeding for women also protects their offspring.

Background on MI to encourage women with GDM to breastfeed Miller and Rollnick (2012) developed MI as a method of communication to facilitate the resolution of ambivalence and encourage positive behaviour change. Ambivalence is affected by the intrinsic or extrinsic motivation of the mother. Intrinsically motivated mothers will breastfeed for their

Clinical Update own and infant’s health and are open to knowledge (Racine et al 2009). Extrinsically motivated mothers will breastfeed due to the influence from others and are less likely to initiate or maintain breastfeeding (Racine et al 2012). Thus while MI is applicable to all women, it is particularly pertinent to extrinsically motivated women ambivalent about breastfeeding.

Table 1 Communication skills for motivational interviewing (adaptation from Miller 2012)

Traditional methods of information giving provide fewer opportunities to resolve ambivalence. Kim et al (2007) state that telling women breastfeeding information in terms of risks and directive actions is minimally constructive and that it is insufficient to recall advice and change breastfeeding behaviour. Some women with GDM often feel judged by health professionals telling them what to do and this becomes a barrier to change (Nicklas et al 2011). Women exposed to these traditional methods may not undertake the changes if they perceive the personal cost is too great, the result can be resistance and ambivalence to change (Hauck and Irurita 2003).

Resolving ambivalence through open sharing conversation, exploring the woman’s motivation, strengths and resources is the key to embracing change and the focus of communication in MI (Miller and Rollnick 2012). Swan et al (2007) and Nicklas et al (2011) felt the communication style of MI would be helpful to resolve ambivalence about positive behaviour change. Wihelem et al (2006) found longer duration of breastfeeding was achieved with MI on day two and day four postnatal, although this was not statistically significant, the authors stated MI would be more effective antenatally and at six weeks postpartum.

Antenatal use of MI for breastfeeding initiation has been suggested as women are more receptive at this time (Racine 2009, Kim et al 2007) and is particularly pertinent to the pregnant diabetic mother.

Antenatal intention to breastfeed at 32 weeks was a stronger predictor of initiation and duration of breastfeeding than in the postnatal time (Donath et al 2003). Most tests for GDM occur at 28 weeks. This is an ideal time to commence MI addressing breastfeeding intention and breastfeeding issues. Whilst MI is most effective when the woman is pregnant, MI should continue to be used with any postnatal support.

Asking open ended questions

Allows the exploration of ideas.

Affirming

Finding the woman’s strengths, capabilities, efforts and positive attitudes.

Reflective listening

Encourages the conversation to develop into ideas and thoughts about change. Understanding the meaning of what the woman is saying and voice this for reaffirmation.

Summarising

Gathering reflections to confirm you are listening and understand each other.

Informing and advising

As information is requested, offering advice rather than imposing.

Helping the woman to understand the usefulness of the information and support.

How do I apply MI to practice?

Focusing

Reflective listening is the key communication skill in MI (Miller and Rollnick 2012).

This is achieved through reinforcing our understanding of the conversation and the direction of motivation. This enables the woman to find her own values, beliefs and target behaviour change that will motivate and inspire confidence (Miller and Rollnick 2012). See Table 1 for key communication skills for MI.

The woman is encouraged to explore the pros and cons of change, identifying gaps and any ambivalence in attitude to change.

Swan et al (2007) and Nicklas et al (2011) found women with GDM were concerned about a moderate to high chance of developing T2DM. Swan et al (2007) found women with GDM were ambivalent about changing to healthy behaviours, as one third of women were unsure this would actually change their chance of getting diabetes, so there was little incentive to change.

In addition to these communication skills, there are four main factors and stages of MI: engaging, focusing, evoking and planning. (Miller and Rollnick 2012).

Engaging This involves using empathy to allow the exploration of thoughts and motivations.

The woman is encouraged to find her own motivation, values and beliefs and their conflict with her current behaviour. This becomes the trigger for change. Motivation is high when it is important to the person to change and they feel confident (Miller and Rollnick 2012).

Evoking Encouraging the woman to reflect on her own motivation to breastfeed. Affirming her active participation and attitude to change. Using open ended questions to facilitate the woman’s reflection

When a woman is diagnosed with GDM she is in a high state of motivation as the health of herself and her child are at risk (Kim et al 2007). Swan et al (2007) found pregnant women with GDM, were able to maintain a healthy lifestyle, so the health of the baby was not at risk. However the maintenance of healthy choices and behaviours were difficult postnatally (Swan et al 2007).

PAGE 33 May 2014 Volume 21, No. 10.

Clinical Update Planning Here the motivation reaches a stage for organisation of how to undertake change and develop self-efficacy. Self-efficacy is the degree of confidence the mother has to breastfeed her baby and is developed by valuing the mother as a resource to solutions for problems and change (Dennis and Faux 1999).

Nicklas et al (2011) found that women would be happy to adopt healthy behaviours if there was adequate support and access to programs. Swan et al (2007) found the partner and immediate social network were a strong influence on women adopting positive behaviour.

To ensure the aspects of MI are followed, Table 2 is an adaptation of questions for the health professional from Miller and Rollnick (2012) The following is an adaptation of a MI with a cardiac patient from Miller and Rollnick (2012); to a scenario of a woman with GDM. The focus is to reinforce understanding and direct conversation towards motivating factors and ways to resolve ambivalence and achieve change through building self-efficacy.

PAGE 34

Table 2 Questions for the health professional during MI Engaging

Is the woman comfortable talking and/or feeling supported?

Is the relationship non-judgemental, understanding, comfortable, collaborative?

Focusing

Is my perspective and attitude different, can I see her goals and values, is there direction and are we moving together to achieve them or is there resistance?

Evoking

Is the woman’s focus for change reluctance due to confidence or degree of importance? Is there any change talk happening? Are we still moving together or am I trying to use the righting reflex, imposing my views to correct her behaviour?

Planning

What steps can be made to achieve change that is achievable and woman centred? The plan needs to be collaborated not imposed, advice given with permission.

Example of MI and reflective listening Interviewer: How have you been feeling since your diabetes diagnosis?

Woman: I was feeling pretty awful I am feeling better now.

Interviewer: You could have ended up quite sick.

Woman: Yes I am lucky they found out in a way, they said my baby could be at risk.

Interviewer: I know your baby is important to you.

Woman: Yes I am worried about my health affecting my baby I just want to see her healthy in my arms.

Interviewer: You have a lot of reasons to keep healthy.

Woman: I am trying now but I am not sure how I will go once I have the baby and I’m breastfeeding.

Interviewer: That’s good you have thought about breastfeeding.

Woman: Yes I want to breastfeed I know it’s good for the baby.

Interviewer: That’s right it’s good for the baby and did you know of any benefits to you?

Woman: I have heard you can lose weight but is there anything else?

Interviewer: Yes, you can reduce you and your babies’ risk of T2DM by breastfeeding.

Woman: That sounds good it’s worth the effort but I don’t know how well I will do it (breastfeeding).

Interviewer: That sounds like you are not sure about some things about breastfeeding.

Woman: I hear so many bad stories cracked nipples, no milk I am not sure how to avoid them.

Interviewer: It sounds like you have heard some of the difficulties of breastfeeding, have you heard any positive stories.

Woman: Yes I have, my sister breastfed her two children for over a year.

Interviewer: That’s great, did you spend time with her when she was breastfeeding?

Woman: Yes I did, she had some sore nipples at first but she seemed to get over it.

Interviewer: That does sound positive, do you know how she managed?

Woman: Yes, she went to some breastfeeding place for help.

Interviewer: That’s good she sought help, have you heard of any places to get help with breastfeeding?

Woman: I am not sure where she got help, I should ask her, I would like to know.

Interviewer: I think that would be great to spend time with her and find out. How would you like some handouts or information on breastfeeding?

Woman: That would be very helpful.

Clinical Update Conclusion As GDM and the risk of T2DM are increasing, health professionals are in a position to improve maternal and infant outcomes through breastfeeding. Traditional models of telling women information and imposing change can result in ambivalence and poor breastfeeding outcomes. MI is a style of communication to resolve ambivalence by encouraging women to find their own personal motivation for breastfeeding and gain self-efficacy to manage longer breastfeeding durations. As midwives and nurses, using our communication skills, adapting our knowledge of reflection and planning, we can facilitate change rather than telling and enforcing change. As reviewed, there is ample evidence that this will provide positive outcomes to reduce risks of T2DM post GDM for the woman and her offspring.

References:

Australia; Australian Institute of Health and Welfare. (2013). Incidence of diabetes. edited

by Australian Institute of Health and Welfare.

Boerschmann, H., Pflüger, M., Henneberger, Zeigler, A., Hummel, S. (2010). Prevalence and predictors of overweight and insulin resistance in offspring of mothers with gestational diabetes mellitus. Diabetes Care no. 33 (8):1845-1849.

Clausen, T., Mathiesen, E., Hansen, T., Pedersen, O., Jensen, D., Lauenborg, J., Damm, P. (2007). High prevalence of type 2 diabetes and pre-diabetes in adult offspring of women with gestational diabetes mellitus or type 1 diabetes the role of intrauterine hyperglycemia. Diabetes Care no. 31 (2):340-346.

Dennis, C., Faux, S. (1999). Development and Psychometric Testing of the Breastfeeding SelfEfficacy Scale. Research in Nursing & Health no.

22:399-409.

Diabetes Australia. (2012). Gestational Diabetes. edited by Diabetes Australia.

Donath, S., Amir, L., The ALSPAC Study Team.

(2003). Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study. Acta Peadiactrica no. 92 (3):352-356.

Gunderson, E., Jacobs, D., Chiang, V., Lewis, C., Feng, J., Quensenberry, C., Sidney, S. (2010).

Duration of Lactation and Incidence of the Metabolic Syndrome in Women of Reproductive Age According to Gestational Diabetes Mellitus Status: A 20-Year Prospective Study in CARDIA (Coronary Artery Risk Development in Young Adults). Diabetes no. 59 (2):495-504. doi: 10.2337/db09-1197.

Kim, C., McEwen, L., Kerr, E., Peitte, J., Chames, M., Ferrara, A., Herman, W. (2007). Preventive counseling among women with histories of

Gestational Diabetes Mellitus. Diabetes Care no.

30 (10):2491-2495.

Hauck, Y., Irurita, V. (2003). Incompatible expectations: the dilemma of breastfeeding mothers.

Health Care for Women International no. 24:62-78.

Sally Hayes is a registered midwife and lactation consultant (IBCLC) at the Royal Hobart Hospital. She completed her Masters of Clinical Midwifery in 2013

Lui, B., Jorm, L., Banks, E. (2010). Parity, breastfeeding, and the subsequent risk of maternal Type 2 Diabetes. Diabetes Care no. 33 (6):12391241. doi: 10.2337/dc10-0347.

Miller, W., Rollnick, S. (2012). Motivational Interviewing: helping people change. Guilford Press (E Book accessed 23/9/2013).

Nicklas, J., Zera, C., Seely, E., Abdul-Rahim, Z., Rudloff, N., Levkoff, S. (2011). Assessment of readiness to prevent type 2 diabetes in a population of rural women with a history of gestational diabetes. BMC Pregnancy and Childbirth no. 11 (23).

Pettitt, D., Forman, M. 1997. “Breastfeeding and incidence of non-insulin-dependent diabetes mellitus in Pima Indians.” Lancet no. 350 (9072):166.

Racine, E., Frick, K., Strobino, D., Carpenter, L., Milligan, R., Pugh, L. 2009. How motivation influences breastfeeding duration among lowincome women. Journal of Human Lactation no.

25 (173):173-181.

Stuebe, A., Rich-Edwards, J., Willett, W., Manson, J., Michels, K. (2005). Duration of Lactation and Incidence of Type 2 Diabetes. JAMA no.

294 (20):2601-10.

Swan, W., Kilmartin, G., Liaw, S-T. 2007. “Assessment of readiness to prevent type 2 diabetes in a population of rural women with a history of gestational diabetes.” Rural and Remote Health no. 7 (802).

Vibeke, A., Hidde, P., Cheung, N., Huxley, R., Bauman, A. ( 2008). Sociodemographic Correlates of the Increasing Trend in Prevalence of Gestational Diabetes Mellitus in a Large Population of Women Between 1995 and 2005.

Diabetes Care no. 31 (12):2288-2293.

Wihelem, S., Stephans, M., Hertzog, M., Callahan, Rodehorst, T., Gardner, P. (2006).

Motivational Interviewing to promote sustained breastfeeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing no. 35 (3):340-348.

Young, T., Martens, P., Taback, S., Sellers, E., Dean, H., Cheang, M., Flett, B. (2002). Type 2 diabetes mellitus in children prenatal and early infancy risk factors among native Canadians JAMA no. 156 (7):651-655.

Ziegler, A., Walker, M., Kaiser, I., Rossbauer, M., Harsunen, M. et al. (2012). Long-Term Protective Effect of Lactation on the Development of Type 2 Diabetes in Women With Recent Gestational Diabetes Mellitus. Diabetes no. 61 (2):3167-3171.

PAGE 35 May 2014 Volume 21, No. 10.

Leanne Davey

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Palliative Care The nurse who is there when life’s Easing the clock is five minutes to midnight transition to

By Leanne Davey palliative care Recently RDNS welcomed 23 new nursing graduates. After their initial weeks of induction they were rostered to their allocated RDNS sites around Melbourne and I found myself wondering whether any of them would journey down the privileged path of palliative care.

It’s something I consciously did about 17 years ago and today as a nurse practitioner in palliative care, I have not one regret.

Indeed caring for people in their final days is an amazingly humbling experience.

The holistic nature and often complex interweaving of physical, emotional, psychosocial and spiritual symptoms of caring for people with a life limiting illness can require the care of several services and disciplines.

RDNS works collaboratively with specialist palliative care services throughout Melbourne within varying models of care.

These models may range from RDNS providing the majority or all of the client’s care, through to shared care, or even providing the clinical component of care with the specialist service as the lead agency.

Clocks and time take on a different meaning when we talk about palliative care.

The need for care is ever present, regardless of the hour of day. RDNS provides after hours visits as required for some of the specialist palliative care services, including clients who are not current RDNS clients.

Specialist support is required within RDNS to enable the delivery of high quality, evidence based and holistic care and to continually support and educate staff and enhance collaborative relationships with specialist services.

By Heather Broadbent

To provide such support RDNS has a specialist structure including palliative care nurses at specific sites, regional Palliative Care Clinical Nurse Consultants and, since October 2005, a Nurse Practitioner (NP) in palliative care.

The advanced and extended role of the NP, including the ability to write prescriptions and authorisations for administering medications specific to palliative care, can enable prompt symptom management and often prevent admission to hospital.

“The need for care is ever present, regardless of the hour of day. RDNS provides after hours visits as required for some of the specialist palliative care services, including clients who are not current RDNS clients.”

RDNS also has a Palliative Care Clinical Leadership Group that meets monthly to review any identified issues, conduct literature reviews where appropriate and develop plans for improvement.

Providing care to palliative care clients and their families can be very complex, confronting and challenging, but it can also be extremely rewarding and a great privilege.

The prospect of meeting the palliative care team for the first time may at best be reassuring for people, but at worst deeply confronting.

The Southern Adelaide Palliative Service (SAPS) in Adelaide, South Australia is adopting a new nurseled approach to the early introduction of palliative care services.

Night staff may be called out to provide support and symptom management to clients and carers who can be understandably anxious in stressful situations. Occasionally we will also be called to verify death or provide support after a client has died.

In fact, if I were to liken nursing to a giant jigsaw, I would say quite confidently that the palliative care piece is the one that truly completes the picture. I do hope that new nurses starting out today will try to fit that piece into their professional experience.

For many people, the subject of death is an uncomfortable one, probably because the majority of us love life so much! We tend to dodge and weave around death talk until we actually come face to face with it and then discomfort can bring anxiety, uncertainty and even fright.

Florence Nightingale said: “Live life while you have it. Life is a splendid gift. There is nothing small about it.” She was so right.

A palliative care nurse can be a splendid gift for someone whose life clock is five minutes to midnight.

The construction of the GP Plus clinics at Marion and Noarlunga in 2011 and 2012 provided a unique opportunity for the development of a multi-disciplinary palliative care introductory clinic. The clinic shares space with multiple other communitybased health services and significantly is not located in a hospital and is separate from the person’s home. People attending the clinic represent a broad range of advanced illness, from metastatic cancer to end-stage lung, heart or kidney failure.

This is precisely where the Palliative Care Nurse Practitioner (Palliative) can make a difference.

Leanne Davey is a Nurse Practitioner Palliative Care with RDNS in Melbourne

Referrals to SAPS are triaged and an appointment at the clinic is offered if PAGE 37 May 2014 Volume 21, No. 10.

Focus Building palliative care capacity in rural health: a collaborative approach the person is sufficiently clinically stable, ambulant and able to attend. A letter of invitation is mailed to the person and a request that they attend with their significant caregiver. Key to the role of the clinic is the opportunity for a ‘one stop shop’ with a comprehensive and holistic assessment by palliative care health providers with varied skills including: • Nurse Practitioner to undertake an initial assessment of symptoms; • Community Social Worker to discuss any social, financial or issues related to care planning; • Psychosocial Nurse to discuss any concerns regarding personal coping and adjustment; • Caregiver Facilitator to meet with the caregiver and explore any needs in relation to providing care.

Following review a letter of summary is forwarded to the referrer, the person’s general practitioner and to other relevant health professionals.

While there are multiple entry points to palliative services, the clinic focuses on improving the experience for people diagnosed with a life limiting illness and in delivering a truly community based approach. At a time of change and ongoing adjustment such as a transition to palliative care the importance of timely assessment, identifying preferences about end of life care and providing a point of contact are crucial.

This clinic is a new concept for palliative care services and acceptability of the model has been evaluated with high levels of satisfaction reported by patients and their family caregiver. Further evaluation which explores the impact of separating the patient from their caregiver within the clinic setting for private focused attention is underway and we look forward to disseminating results of the study at a future time.

Heather Broadbent is a Nurse Practitioner at the Southern Adelaide Palliative Service in South Australia PAGE 38

By Katrina Recoche, Susan Lee, Margaret O’Connor, Mary Ross-Heazlewood, Vicki Doherty and Kerry Hood The provision of palliative care is an essential component of health care, as all health care providers come into contact with clients at various points along their trajectory of dying.

The core attitudes, values and knowledge of a ‘palliative approach’ equip health care professionals to provide person-centred care to some of the most vulnerable and fragile clients.

The Australian government advocates a needs-based approach to palliative care, whereby people with life limiting illness are able to access palliative care appropriate to their needs and wishes in any in-patient or community setting (Department of Health, 2013). A ‘palliative approach’ describes the key skills and attitudes required of any health care professional who is caring for a person at the end of life in any setting – symptom management, communication skills, meeting the holistic needs of the person and being respectful of their needs and wishes.

“A ‘palliative approach’ describes the key skills and attitudes required of any health care professional who is caring for a person at the end of life in any setting – symptom management, communication skills, meeting the holistic needs of the person and being respectful of their needs and wishes.”

Since 2009, Monash University School of Nursing & Midwifery, in partnership with the Gippsland Region Palliative Care Consortium (GRPCC), has delivered education in the Gippsland region aimed at building the capacity of non-specialist health care professionals to provide a quality palliative approach for clients. The program is tailored to local needs to ensure context and relevance, and is delivered by a team of leading academic and clinical palliative care experts.

The twelve week course uses a blended learning approach, and includes webbased materials (PCC4U, 2012), online discussions, readings, four intensive workshops, online quizzes and critical reflective tasks. The program is underpinned by mentor support and guided development within their workplace, or for some, an option to observe specialist palliative care.

The primary aim of this program is to improve the experience of people requiring palliative care, by building workforce capacity in acute care, community and aged care settings. The collaboration between academic, clinical and local experts has achieved this primary goal, with enhanced workforce capacity demonstrated by improved knowledge skills and attitudes. Past participants report increased confidence in working with clients, families and other staff. Analysis of pre and post course evaluations has revealed statistically significant improvements in participants’ views, attitudes, and knowledge of the palliative approach.

References

Department of Health, (2013) Australian Government Department of Health: Palliative Care www.health.gov.au/palliativecare Palliative Care for Curriculum for Undergraduates (PCC4U) Project Team. (2012) Palliative Care: A learning resource for health care students. Canberra: Commonwealth of Australia.

Katrina Recoche is a Lecturer; Dr Susan Lee is a Senior Lecturer; Professor Margaret O’Connor is Vivian Bullwinkel Chair in Palliative Care Nursing and Kerry Hood is Professional Development Program Coordinator. All are located in the School of Nursing and Midwifery at Monash University in Victoria Mary Ross–Heazlewood is Project Worker Clinical Practice and Education and Vicki Doherty is Consortium Manager, both are located at the Gippsland Region Palliative Care Consortium in Victoria

Palliative Care Supporting transitioning towards end of life

By Peta McVey There has been increased focus on ensuring older Australians in residential care experience high quality care as they approach the final stages of life. To date research has focused on nursing home settings. Less is known about those in hostels. To develop a clearer understanding of the palliative care needs of high-level care residents with complex needs living in hostels, we examined whether a palliative approach was being used and, if so, how it was being incorporated into their care (McVey et al, 2014).

or families. The research also demonstrated that hostel staffing levels were often inadequate to meet the needs of people requiring end of life care.

Our research findings demonstrate that staff understood a palliative approach as bringing together a range of care processes perceived as important for resident comfort. This care was described as ‘special care (requiring) extra care’ and often associated with end of life care. While staff referred to residents as ‘being palliative’, they were not comfortable using this language when speaking with residents and/

In this context, members of the communityof-care include the high-level care resident, their involved family and the staff who provide their care in the hostel setting. The development of a community-of-care takes time and effort. As a resident’s condition changes, staff felt that they could make a difference to their transition towards end of life by providing individualised care that was relationship-focused and involved

Aged care staff in these facilities provided a combination of acute and chronic care, rehabilitation and end of life care. An appropriate way to understand how aged care staff are caring for residents is through the concept of a community-of-care, with a palliative approach being one of the elements.

“The research also demonstrated that hostel staffing levels were often inadequate to meet the needs of people requiring end of life care”

committed engagement and collaboration and shared decision making between the resident, family and staff. Ultimately, an acceptable transition towards end-of-life experience is the desired outcome of the members of a community-of-care.

A model of care that incorporates appropriate language for staff managing people with progressive, incurable, chronic diseases is needed. We argue that using the language of a community-of-care, a person-centred approach is a helpful way for staff to work with residents and families in this setting.

Reference

McVey, P., McKenzie, H. & White, K. 2014.

A community-of-care: the integration of a palliative approach within residential aged care facilities in Australia. Health and Social Care in the Community. 22(2): 197–209.

Dr Peta McVey holds a conjoint appointment – Clinical Nurse Consultant (Palliative Care), HammondCare and Senior Lecturer at the Sydney Nursing School at the University of Sydney

Palliative care for a vulnerable population

By Karen Glaetzer

During February 2014 I undertook a Churchill Fellowship taking me to The Netherlands, UK and Ireland to explore the unique care needs of individuals with intellectual and/or long-term physical disability who require palliative care.

The majority of individuals and their families referred to palliative care services are able to consent to referral and participate in decision making in relation to the care they receive and where this care is provided. This is not always the case for vulnerable groups of people.

Individuals with intellectual or long-term physical disabilities are a particularly vulnerable population in this regard. In the past many individuals with congenital

or acquired disabilities rarely survived beyond childhood. But increasingly, many are now surviving into adulthood and as a result are faced with multiple co-morbid conditions associated with ageing. The de-institutionalisation of disability care to the community setting, where the focus is predominately on their day-to-day living needs, has frequently resulted in inadequate management of the health care needs of this group. The response to any acute change is transfer to hospital, where often due to the lack of advanced care plans or an identified decision maker, inappropriate treatment is instigated.

and Ireland visiting universities and care facilities, before returning to The Netherlands to spend time with an Intellectual Disability Physician in Maastricht.

I began my tour in Nijmegen in The Netherlands by undertaking an intensive course in Biothethics. I then moved onto the UK

Karen Glaetzer is a Palliative Care Nurse Practitioner at Southern Adelaide Palliative Services in South Australia

Through the fellowship I had the opportunity to explore the models of care, ethical considerations and communication issues, advance care planning, approaches to care and management of specific conditions and care options. I intend to use the information, in collaboration with disability providers, to inform best practice guidelines. My overall outcome from this project will be improved care for individuals with intellectual and/or long-term physical disability who require palliative care.

PAGE 39 May 2014 Volume 21, No. 10.

Do you care for patients who are at end-of-life?

“I have become a lot more confident, my communication skills are better when talking about death and dying. I learned a lot about symptom management.” - Nurse How can PEPA enhance your practice?

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PAGE 40

Palliative Care The role of a nurse practitioner in palliative care

By Joanne Kelly

With many years’ experience qualified as a specialist palliative care nurse in Melbourne, I moved to a regional area in 2005 where I commenced working for Bass Coast Community Health (BCCH) palliative care service.

At this service the rate of palliative care clients dying at home was 30% for that first calendar year (the figures for palliative care clients dying at home include death in a residential aged care facility as this is considered the client’s home). Upon reflection, I recognised that at the time, the nurses who were very caring of palliative care clients, needed additional support to develop their palliative care skills and knowledge. The general practitioners (GPs) were overstretched and under resourced, often unable to do home visits due to the geographical vastness of the region. Consequently, the GPs were comfortable in collaborating with me as an advanced practice nurse with recognised knowledge, skills and the ability to educate. Together we provided advice and recommendations regarding palliative care matters to our health consumers. Within the Gippsland region there was an absence of palliative care physicians residing and working regionally, opening up an opportunity for suitably qualified nurses to meet that need.

Together with the support of management and an enthusiastic nursing team, the BCCH palliative care service was able to change its processes to improve the nursing care provided. This saw the rate of palliative care clients dying at home increase to 39%.

After four years, my nursing manager and I sought to research the role of a nurse practitioner (NP). We also sought to attract a GP with an interest in palliative care to work with us directly to undertake home and clinic visits.

Trying to attract a GP that would do home and clinic visits for the palliative care service was not common practice. It was around this time that the Gippsland Regional Palliative Care Consortium (GRPCC) in collaboration with Bass Coast Community Health palliative care service undertook extensive work establishing the role of a NP within a specialist team that would greatly improve access to palliative care/aged care for the

region’s health consumers and their families. With successful funding from the Victorian Department of Health (DH), GRPCC developed a service framework for the palliative care nurse practitioner model of care.

The GP had no idea when she started working with our palliative care team that she would play such a pivotal role in becoming a mentor to me, as I embarked on the path of becoming a NP candidate. As I reflect now it was a great time as we shared our knowledge and had respect for each other’s skill set. In 2010, we saw our home deaths increase to 47%. This particular GP left in 2012, making the role of a NP vital.

Now a NP, I am authorised and licenced by the Australian Health Practitioner Regulation Agency for the Nursing and Midwifery Board of Australia to be an independent practitioner with an advanced and extended clinical role. As a NP, I am educated and endorsed to function independently, autonomously and collaboratively in an advanced and extended clinical role. This role includes comprehensive assessment, differential diagnosis, diagnosing, investigating, management, initiation, alteration, and continuation of treatment using my expertise of palliative care knowledge and skills as well as incorporating my other holistic nursing framework and philosophies.

My role as a NP provides innovative and flexible health care to achieve the best possible health outcome for our health consumers. I am not a substitute GP, however my extended scope of practice allows me to collaborate with the health consumer’s GP to provide the initiation or alteration of prescribed medicines and make referrals to other health professionals which facilitates the client’s continuation of care. This includes variations made to treatment orders when the client’s condition changes.

for the treatment of episodes of illness with the goal of timely access and quality care.

Since my endorsement twelve months ago, together our palliative care team was able to increase the rate of palliative care clients dying at home to 59% for 2013. What better reward is there?

NPs have been in Australia for ten years and our numbers have just reached 1,000. While this sounds like a huge number, I believe there is still a struggle to be acknowledged within the profession. It is time nurses stopped ‘eating their own’ (as discussed in ANMJ’s February’s feature article, ‘Nurses eat their own’). It is time to appreciate the role of the advanced practice nurse and to acknowledge how further study can contribute to the difference a NP can make.

One of the biggest challenges has been educating experienced nurses to accept that it is not just the medical fraternity that can diagnose, treat and prescribe. Some of my biggest supporters have been the local GPs and specialist physicians, for which I am eternally thankful. The other baseless criticism that I constantly hear is that this is not a sustainable role. If Advanced Practice Nurses continue their education to become NPs, and the government increase incentives to have health consumers remain at home through ensuring timely access to innovative and flexible health care, this will go beyond sustainability and lead to significant health savings in other areas.

Joanne Kelly is a nurse practitioner specialising in palliative care

As a NP, I am committed to helping the health consumer stay in the place of their choice, usually their home. This is cost effective for the government by decreasing hospital admissions through effective problem identification and problem-solving; leading to earlier and timelier intervention as part of the enhanced NP scope of practice.

Such a service enables my clientele to receive primary, acute and supportive care PAGE 41 May 2014 Volume 21, No. 10.

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Palliative Care Palliative care online learning modules to help source the evidence

By Kim Devery

resource developed specifically for those providing palliative care in any care setting as well as those receiving palliative care. The online learning modules, My Learning, which have recently been added to the website, is designed to work with nurses on two different levels.

Nurses have ongoing needs in relation to their professional development, and are required to keep up to date. However workloads and shift work can make attending face to face sessions difficult.

Firstly it is a series of interactive learning modules designed to assist and guide users in how to use the core website resources.

Secondly My Learning shows through case studies how evidence based practice (EBP) can be employed to answer common clinical questions and uncertainties.

Online learning is a well received and effective method for continual education for nurses (Karaman, 2011).

As nurses and other health professionals can be in situations where they are unsure what to do in the face of a clinical issue, My Learning shows how uncertainty and EBP can lead to practice based learning. Additionally, the EBP framework can help find relevant evidence to answer clinical questions and can also fulfil the need for ongoing professional development and lifelong learning.

CareSearch is an online evidence based

The learning package includes a quiz and a

demonstration of website resources. A variety of topics are used in case studies including deathbed phenomena, caregiving, dementia, palliative care in aged care and much more.

The modules are free to use, fun and a certificate is available for professional records.

Delivery of information relevant to EBP via this method for nurses is valued due to increased flexibility, accessibility, convenience and cost-effectiveness. CareSearch and My Learning can be found at www. caresearch.com.au

References Gosling A, Westbrook J and Spencer R (2004) J Nurses’ use of online clinical evidence Journal of Advanced Nursing 47(2), 201–211 Karaman S. (2011) Nurses’ perceptions of online continuing education. BMC Medical Education, 11:86 doi:10.1186/1472-6920-11-86

Kim Devery is the Course Coordinator, Palliative Care and Lecturer, Palliative and Support Services at Flinders University.

Kim is also a Research Officer at CareSearch Palliative Care Knowledge Network

Making palliative care everyone’s business Up to half of the deaths in Australia each year are anticipated but not all people approaching their end of life need specialist palliative care, nor does the specialist palliative care workforce have the capacity to deliver all care (National Palliative Care Strategy 2010).

What is needed is an appropriately trained and skilled primary care workforce that can complement specialist providers by providing the right service, in the right place at the right time to people with end of life needs.

The Program of Experience in the Palliative Approach (PEPA) was designed to meet that need.

PEPA offers professional development opportunities in palliative care to general practitioners, registered nurses, enrolled nurses, assistants in nursing, allied health professionals, Aboriginal and Torres Strait Islander health and community professionals in community, inpatient, hospital based

consultancy and aged care settings.

The program is funded by the Australian Government Department of Health and is the only national model offering free placements and workshops in palliative care services to health professionals. PEPA offers placements of up to five days in palliative care specialist services, reverse PEPA placements (where a palliative care specialist travels to a participant to facilitate learning in their workplace) and palliative approach workshop for multidisciplinary, Indigenous and aged care audiences.

The program also offers funding for both backfill and to offset travel and accommodation costs.

More than 3,000 health professionals have attended PEPA placements since the program launched in 2003 and over 16,000 health professionals have attended PEPA workshops.

Nurses are by far the biggest users of the program, accounting for more than half of all placements (52%). General practitioners make up 19% of attendees, followed by allied health

professionals (10%), Aboriginal and Torres Strait Islander health and community workers (8%), specialist palliative care staff (7%) and assistants in nursing/care workers (4%).

Ongoing analysis demonstrates the benefit PEPA provides. Evaluation from January – June 2013 showed nursing and allied health participants had an increased understanding of the principles of the palliative approach to care (on a scale from 1 to 6, pre=5.0; post=5.6; n=71); an increased understanding of the role of their discipline in supporting people who have a life limiting illness (pre=4.8; post=5.4; n=71); and increased confidence to contact a palliative care service to discuss the needs of people in their care who have a life limiting illness (pre=4.7; post=5. 6; n=71).

Outcomes show that PEPA is making a positive impact on participants’ confidence, knowledge and skills in relation to palliative care and is resulting in strengthened collaborations with specialist palliative care services.

For more information visit: www.pepaeducation.com PAGE 43 May 2014 Volume 21, No. 10.

Focus Investigating place of death preference among cancer patients and their carers

By Joanne Cooper

Often you hear and see the saying ‘home is where the heart is’, but for people living with a life-limiting illness in Australia and hoping to die at home, this may not be an option or choice.

In 2011 it was reported that 74% of Australians had actually given place of death some thought and indicated they would prefer to die at home. In reality only 16% actually did so (Palliative Care in NSW, 2011).

is however not necessarily focused on in the ACD process. The most appropriate time to ask a patient about end of life care choices such as where they wish to die is subjective and patient specific (Hannon et al 2012).

UK research indicates similar statistics. Some 55% of people with cancer would prefer to die at home, while only around 25% actually do so. It remains the case that 40% of people who die in hospital have no medical reason to do so (Ward et al 2010).

Recent research has established some correlation of preference for location of death, such as people who lived with somebody (usually a spouse), had trusting family relationships and had frequent social contacts were more likely to prefer home over health care institution as their place of death (Lecovich et al 2009).

Patient preference regarding active treatment in the event of terminal disease is contemporarily addressed by advanced care directive (ACD) initiatives (Lakhani 2011).

Patient preference regarding place of death

Patient vulnerability and cultural background have also been discussed as important.

Certainly it appears true that place of death is a fundamental definer for both patient

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PAGE 44

Subscribe to the new look ANMJ call (03) 9602 8500 or email cathy@anmf.org.au

Palliative Care Death, dying and reflective practice

By Sarah Coulson and family as to whether a ‘good death’ has been achieved. Bereavement outcome for those left behind, has been shown to be influenced by whether place of death preference was achieved (Grande & Ewing 2009).

There remains limited study for the reasons why place of death preference is or isn’t adhered to, which I’m exploring through a project that is unfolding in northern NSW. I am currently undertaking a qualitative hermeneutic study to explore patient preference regarding place of death. This study, which was ethically approved, seeks to explore the reasons for place of death preference. The sample consists of patients of the palliative care service in the Northern NSW Local Health District and their carers or significant others. Participants are interviewed at the time they are admitted to the service, and then follow up interviewing tracks the eventual place of their death scenario. Reasons for preference change and feedback about the palliative care process as it relates to home vs hospital death is being sought from the follow up data. I expect to complete data collection by mid to late 2014. Thematic analysis will then seek to induce models explaining the decision-making process regarding place of death and how and why this may change over time.

References

Grande G, Ewing G (2009) Informal carer bereavement outcome: relation to quality of end of life support and achievement of preferred place of death. Palliative Medicine 23: 248256 Hannon K, Lester H, Campbell S (2012) Recording patient preferences for end of life care as an incentivized quality indicator: what do general practice staff think. Palliative Medicine 26(4):33641 Lakhani M (2011) Lets talk about dying.

BMJ 342:d3018 Lecovich E, Carmel S, Bachner Y (2009) Where they want to die: correlates of elderly persons’ preferences for death site. Social Work in Public Health 24(6): 52742 Palliative Care in NSW (2011) Palliative Care NSW Policy statement: providing informed input to the development of palliative care policy in NSW Ward L, Fenton K, Maher L (2010) The high impact actions for nursing and midwifery: where to die when the time comes. Nursing Times 106(32):1820

Joanne Cooper is a Palliative Care Clinical Nurse Consultant at Richmond Community & Allied Health in Lismore, NSW

Dying is a natural and inevitable part of life which most people don’t spend much time thinking about, however regardless of the location and timing of a person’s death or indeed their age, it is likely a nurse is present or has been involved in that person’s care (Crisp & Taylor, 2005). It is thus important to consider how, as professionals and simply as human beings, we as nurses reflect on our experiences when our work takes us to a place of human suffering and mortality.

• the ability to value the individual and their story; • the offering of human presence; • the ability to identify what can be done, what should be done, and the ability to see the difference; • the therapeutic use of self; • clear and honest communication; • the capacity to provide guidance, balance and leadership, should it be required; • and the need to recognise and reflect on the personal reactions which occur as a natural consequence of working with death and dying (Becker 2009).

Taylor (2000) suggests reflective practice regardless of its means should bring to light the intricate knowledge, attitudes and skills underpinning an individual’s nursing practice. Furthermore Bailey and Graham (2007) suggest reflection on practice allows the practitioner to access, explore, make sense of and learn through experience. The exploration of this experience and the insights gained are then able to be utilised for professional development or to facilitate practice change (Bailey and Graham 2007). However it is important to remember, reflection should not be a replaying of events to justify actions or behaviours, but instead an opportunity to revisit and grow from an experience. Similarly reflection should not only be saved for events which make us feel uncomfortable, vulnerable or guilty. We also need to reflect on those events which we feel good about, as a means of consolidating positive practice and maintain our self-esteem.

Our personal reactions are often underpinned by our values and personal experiences. Speck (2006) highlights that each of us brings our own lived experience to our work, which can be both enhancing and restrictive to our professional practice. It is often the differences in values, beliefs and previous experience which bring about various types of conflict with our colleagues and patients (Speck 2006, p 3-4).

Personal insight into our own values and the ability to respect, explore and learn from the values and experiences of others is fundamental to delivering quality palliative care.

While we do not always have the ability to control, change or improve certain aspects of a person’s care, we always have the ability to think about how we could have done things differently. There are multiple and sometimes unrecognised skills and professional attributes required to provide quality care for those who have advanced life limiting illness. These skills can be developed by the individual through experience and reflective practices. Becker (2009) and Canning et al (2005) have articulated a number of these skills as follows: • the ability to open and close therapeutic relationships with the patient and their social unit;

Being mindful of the inherent vulnerability of a person nearing the end of their life allows us to further reflect on our approach to caring. It gives us the capacity to ask; how do we best give the space for that person to maintain autonomy? How do we show we are able to see the whole person in front of us? (Not just who we think they are). There needs to be a kindness in our conduct, a kindness which finds the balance, a kindness which is given without expectation. Not selfsacrificing niceness, but kindness which is professional and patient centred (Johnstone 2010). As we reflect we develop our skills, we develop the recognition that it only takes a few seconds to be kind. This may be in the way we give people the space to be who they want to be, the way we don’t try to fix everything. The way we use our touch, the way we sometimes don’t say anything at all and the way we are sometimes just present.

References on request Sarah Coulson is a Clinical Nurse Consultant at Community Palliative Care Services THO – North ‘Allambi’ in Launceston, Tasmania PAGE 45 May 2014 Volume 21, No. 10.

Calendar MAY Lung Health Promotion Centre at The Alfred

7–9 May / 11–12 June, Respiratory Course 7–9 May, Respiratory Course (Module A) 29 May, Respiratory Update Lung Health Promotion Centre at The Alfred Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au 6th APNA National Conference Thriving through change

29–31 May, Hilton Sydney, NSW. APNA’s sixth exciting national conference will provide extensive opportunities to network with your nurses colleagues from around Australia, and a fantastic program to enhance clinical expertise and add to your personal and professional development. http://apnaconference.asn.au/

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 Massage workshops for Nurses, Midwives and Carers (6 CPD hours per workshop)

Touch is one of the most essential and fundamental needs for human restfulness. These quality workshops give Nurses, Midwives and Carers, the skills, knowledge and confidence to help clients with their hands, their touch and presence of wellbeing.

Glenelg SA Boutique Training in Luxury Surroundings 13 June, Baby Massage (Afternoon Session) 14 June, Massage in Nursing – An Introduction

15 June, Spa and Wellbeing Day (relax, re energise, re balance in this whole day spa experience for you) 16 June, Massage in Midwifery Care (Women and Babies) – An Intro 17 June, Palliative Care and/or Relaxation Massage 18 June, TBA or Special Booking (book the facilities and/or spa hostesses for your own special group) 19 June, Reflexology for Health 20 June, Shiatsu and Acupressure Contact Angeline von Doussa, RN, RM, Dip Massage Therapies, Spa Therapies, Nurse Educator.

Mobile: 0431 994 618 Email: angeline@nurses–healing.com http://nurses-healing.com APNA Continuing Education Workshops for Nurses in General Practice

20–21 June, Stamford Plaza, Adelaide, SA. For more information and to register go to www.apna.asn.au/nigp 2nd Annual Worldwide Nursing Conference

Health Disparities 23–24 June, Singapore.

Nursing practice is both a science and an art. It requires scientific skill yet demands a strong background in the social sciences and humanities. Nursing makes a significant contribution to the health maintenance, health promotion and wellbeing of individuals, local communities and populations. http://www.nursing–conf.org/

JULY

AUGUST Update’ study day with Kathy Mills, RN, MEd, Credentialled Diabetes Educator.

This study day for enrolled and registered nurses covers contemporary and evidence based research on dietary, exercise, psychological and pharmacological management of diabetes mellitus.

Date: Friday August 8 from 9am–4pm at Inner East Melbourne Medicare Local, 6 Lakeside Drive, Burwood East. There is free onsite parking.

Morning tea, lunch and notes are provided.

Eligible for 6 hours professional education.

Cost: Early bird special (pay by Friday 25 July) is $220. Full registration fee: $250 All queries to Kathy via email only at diabetes.ed@optusnet.com.au Lung Health Promotion Centre at The Alfred

18-19 August, Spirometry Principles & Practice Lung Health Promotion Centre at The Alfred Ph: (03) 9076 2382 Email: lunghealth@alfred.org.au

SEPTEMBER 18th International Conference on Cancer Nursing

7-11 September, Hilton Panama, Panama City. http://www.isncc.org/?page=18th_ICCN CATSINaM 16th National Conference Embrace the difference within our people

Lung Health Promotion Centre at The Alfred

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

23-25 September, Perth WA. http://catsin.org.au/

OCTOBER National Indigenous Mens Conference

13-15 October, Pullman Cairns International Hotel, Cairns, Qld. www.indigenousconferences.com

Network Royal Children’s Hospital past trainees and RCH Grads reunion 17 May 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

Princes Park Carlton Bowls Club, 109 Bowen Crescent, Carlton North, Vic. Contact Helen Savage Ph: (03) 9342 7270 Email: helen. savage@mh.org.au or Robyn Whiting Ph: (03) 9342 7270 Email: robyn.whiting@mh.org.au

RMH operating theatre staff reunion/ social get together

Austin Hospital Heidelberg, 74 2A/B, 40-year reunion

18 May, 2-4pm,

31 May. Contact

PAGE 46

Angela Balon.

Email: angelaveysey@optusnet.com. au Ph: (03) 9870 4801 Mobile. 0412 402 875 Royal Melbourne Hospital, June 1974 PTS, 40-year reunion 1 June, The Atrium Bar, Crown Casino, Southbank at 1230.

Contact Jill Friedman (nee Darby) on Mobile: 0410 416 993 or Email: jfried-

man@rdns.com.au Alfred Hospital, 2/74, 40-year reunion 7 June, Flying Duck Hotel, 12pm, 67 Bendigo Street, Prahran, Vic. Bring some old nursing photos to pin up and share. RSVP to Libby Mitchell (nee Kings) Mobile: 0427 662 009 Email: mitchfam2@ bigpond.com or Michelle Mason Mobile: 0400 719 023

Email: mmason444@ hotmail.com John Fawkner Private Hospital/Sacred Heart Hospital celebrates its 75th anniversary October. We are seeking memorabilia, old photographs, uniforms, books, instruments, stories etc. from past staff, doctors and students.

An open day and other activities are

planned for this milestone event. Contact Chris Papas, Executive Secretary at chris. papas@healthscope. com.au or Ph: (03) 9385 2501 Royal Adelaide Hospital Nurses Training, Group 895, 25-year reunion 29 November, Adelaide. Contact Julia Curley Email: juliacurley@hotmail.com

Mail Letter of the month No Jobs

Why is no one talking about the fact that there are NO nursing jobs for RNs in Adelaide?

I returned to nursing in 2012 completing the refresher course offered by the government.

Since then I have managed to secure a place on the casual pool at one of the major public hospitals. In the last month I have had two shifts. Every other shift has been cancelled.

The explanation is that the hospital is overstaffed. I have been looking for permanent work for nearly two years and never seen jobs

advertised. I do note, however, that there are literally hundreds of overseas nurses working in permanent positions in all the hospitals.

I think it’s really sad that as an Australian citizen, who trained here in South Australia, I cannot get a job. I am leaving nursing as soon as I can get some sort of employment - anywhere - because I simply can’t make enough money to make this career worth my time. What a waste.

Anonymous Registered Nurse, South Australia

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

Bullying needs to stop I was pleased to read your feature in the March ANMJ on workplace bullying at management level. I too have experienced this, the huge impact and the after effects continued for 4 years. This needs to be out in the open and your article helps to do this. For a ‘caring profession’ we don’t do well to each other.

This is a huge problem in nursing and has a long history and continues into the future.

It has to stop.

Thank you for your article.

Wendy, Registered Nurse, Tasmania

Tackling antibiotic resistance Re: Action needed against antibiotic resistance. ANMJ April 2014.

In the early 1980’s I worked in the intensive care unit at Prince of Wales Hospital in Randwick. There, every patient that was admitted was screened for Staphylococcus aureaus and isolated until the results were known, which was approximately 48 hours’ time.

Quite a number of the results came back positive. Thus patients were coming in with staphylococcus aureaus as opposed to acquiring it in hospital. And no wonder when half of the antibiotics produced is used in the agriculture

sector and goes directly into our food chain.

If we are serious about tackling this issue, not only do hospitals need to remain vigilant, we need to look at our husbandry practices.

Instead of looking at a quick buck we need to go back to humane and sustainable methods of farming. As consumers we can demand these through the choices we make at the supermarkets.

As the saying goes: what goes around comes around.

Maria Liew, Registered Nurse and Midwife, Victoria

Waiting for a response I write in support of TN’s letter in the April ANMJ. My experience of AHPRA (or specifically the Nurses and Midwifery Board Australia (NMBA)) has been similar. Each person I’ve spoken to has been helpful and polite.

That’s if you can talk to anyone at all.

I’ve had two issues: Problem 1: I received no reply to four attempts at a phone enquiry about my midwifery recency of practice. Finally, the call centre supervisor, who by then knew me by name, apologetically put me through to an interstate officer (whose advice contradicted the local advice).

Next I returned to email, so I’d have a paper trail. No reply for months. I rang again and was told I would be advised of an outcome

by a couple of weeks ago – I’m still waiting.

Problem 2: Advising NMBA of errors in the midwifery competencies on the website.

I had checked the online (“re-branded”) version against my old 2006 booklet, in a detailed, word-for-word edit. There were several errors and omissions in this national document which influences practice and, in theory, could determine court cases. There was no way of reporting my findings by email as the only way to email is via the “contact us” link where there is a word limit.

In August I mailed a letter with no reply, no action. A second letter was sent and again no reply. In December the PDF on the NMBA site was mysteriously corrected.

I’m confident that it was my intervention, but even if it wasn’t, no reply from NMBA. Adding to TN’s words in the March ANMJ, the moral of the story is: there’s no-one available at NMBA anytime (not just in the registration period).

In relation to the call centres, I found them as helpful as they could be, and obliged to apologise for calls not being returned. All the calls are logged, but I kept my own records too.

My midwifery registration is due. What will I do about it?

Margaret Boyes Registered Nurse, and Midwife, ACT

PAGE 47 May 2014 Volume 21, No. 10.

Coral Coral Levett, Federal President

Zoe’s Law International Women’s Day is normally a day for celebration.

It is an opportunity to celebrate our differences and the many gains women have made throughout history. Sadly, the celebrations for the women in NSW (and ultimately elsewhere) this year was marred by the recent events in the NSW parliament.

Zoe’s Law Bill (No 2) was introduced to the NSW Parliament by the Liberal MP Chris Spence and proposes to allow grievous bodily harm charges to be brought against someone who hurts a foetus of more than 20 weeks or 400 grams. A similar Bill was promulgated by Reverend Fred Nile (a member of the Christian Democrats in the NSW Legislative Council), at the time of the incident, but did not proceed through a lack of support.

The law was prompted by the tragic stillbirth of Brodie Donegan’s daughter, Zoe, after Ms Donegan was hit by a car on Christmas Day in 2009 when she was 32 weeks pregnant.

The Bill in its current form was passed through the NSW Lower House on 21 November 2013, in a vote of 63 in favour and 26 against.

At the time of writing, the intention is to introduce the Bill into the Legislative Council who will vote on the Bill when parliament resumes this year. While at first glance Zoe’s Law represents a compassionate response to a tragic situation, passing it would open up a veritable minefield of legal ramifications that in themselves could cause more trauma and injustice. While there is always concern about the harm done to women including their foetuses (such as through domestic violence), this Bill has the potential to undermine women’s rights by changing the legal status of a foetus.

Under the current law, ‘grievous bodily harm’ includes ‘the destruction (other than in the course of a medical procedure) of the foetus of a pregnant woman, whether or not the woman suffers any other harm’.

Grievous bodily harm at the moment carries a maximum prison sentence of 25 years in NSW. The wider community is of the view that the Bill is neither necessary nor approPAGE 48

priate. The injury must always be interpreted as an injury to the pregnant woman in order to protect a women’s autonomy over her body. This proposed law could potentially be used to impose restrictions on the behaviour of pregnant women.

If passed, the Bill would mean that if someone caused the destruction or harm to a foetus they would be charged with grievous bodily harm to the foetus, instead of being charged with grievous bodily harm to the pregnant woman. There is a legal concern that giving ‘personhood’ status to a foetus may affect the lawfulness and accessibility of abortion in NSW, particularly for procedures carried out later in a pregnancy.

The Hon Michael Campbell QC considered whether these changes to the law were justified. After months of work (which cost the taxpayer a lot of money), the ‘Campbell Review’ decided that not only was there no reason to change the law, but that there would be serious flow-on effects in giving legal recognition to a foetus. One of the central issues is the impact on access to abortion if Zoe’s Law is passed. In NSW, the legal foundation of abortion is very fragile anyway.

Unlike the situation in Victoria and the ACT, where abortion offences have been removed from the criminal law, NSW women seeking abortion (and the doctors performing them) can still be charged with having/performing what is known as ‘an unlawful abortion’.

The NSW Director of Public Prosecutions (DPP) has said that it can’t understand the need for the law to change. It argued that if Zoe’s Law was passed it was likely to ‘result in prosecutions protracted by medical evidence and legal argument, leading to extra distress and cost to those involved.’

The DPP’s views on this are shared by pretty much every reputable legal and medical organisation in NSW that has a view on the matter. The NSW Bar Association, Women’s Legal Services and NSW Community Legal Centres all oppose the changes. So do women’s organisations like the Women’s Electoral Lobby, the National Foundation of Australian Women and Rape Crisis Centres across NSW. The passing of this law could take the women of NSW back decades in time when it comes to women’s rights generally. Let’s hope 2015 brings us a reason to better celebrate International Women’s Day.

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