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Issued by H.E.S.T. Australia Ltd ABN 66 006 818 695 AFSL No. 235249 Trustee of Health Employees Superannuation Trust Australia (HESTA) ABN 64 971 749 321.
2 | February 2013
Grads f ock to
By Amie Larter
lanning and forecasting for the
future workforce should be a
nationwide focus to protect the
needs of our graduate nurses,
says Professor Ged Williams, executive
director of nursing and midwifery at Gold
Coast Hospitals and Health Service.
As the ANF’s “Stop passing the buck,
Australia’s nursing grads need jobs”
campaign reaches full swing with more
than 2650 emails to politicians, Gold Coast
Health (GCH) is using a different approach
to ensure future graduate placements.
GCH has taken on more than 25 per cent
of the total graduate placements allocated
by Queensland for 2013 – 138 graduates in
January, with an expected 30 to 40 more to
come on board midyear. This is an increase
from last year, where the total intake was
Williams suggested this success was due
to planning, and that a planning framework
and strategic initiatives needed to be
applied at a district, state and national level.
“The community cannot afford for all these
graduates to not work this year. Because if
they do not work this year – they are highly
unlikely to come back into the industry
and we are going to lose them for good.
What’s lacking is a sense of urgency and a
sense of proper measurement to inform the
decisions that need to be made,” he said.
The team at GCH uses an in-house
designed commercial workforce planning
tool WorkMAPP, as well as electronic roster
system, eRoster, to effectively manage
workforce supply and demand equations
that inform both long-term and short-term
staff planning respectively.
“Using WorkMAPP, we can model
different scenarios like a high attrition rate,
nursing shortage, or any other situation that
would increase service requirements,” said
Williams. “We put the information into the
tool and it calculates how many nurses we
might require at different levels across the
district in the outgoing years.”
The team uses the eRoster tool to gain
retrospective data on patterns of sick leave
and resignations throughout the year to
ascertain when you are more likely to need
and or lose more nurses. This information is
then applied to prospective forecasting.
“If we know we get a large number of
resignations in October or November or
if we had a high sick leave rate in August
– next year when we are planning our
4 | February 2013
Protecting nursing’s future:
Stacey Pickering is one of
the many graduates heading
to Gold Coast Health.
workforce requirements we make sure we
have buffers lined up for those particular
periods. Such patterns are likely to be
seasonal, and to an extent predictable,”
“These two tools are working
hand in glove to give us a really good
understanding of how our workforce
moves and changes over time, so we can
re-forecast what our requirements are.”
Data is extracted from the tools and GCH
then works collaboratively with universities
and other service providers to align what
they deliver to create the appropriate
amount of opportunities for students once
they have completed their studies.
Professor Jenny Gamble, acting head
of school at Griffith University’s school of
nursing and midwifery, believes that GCH
is one of the most innovative districts in
relation to workforce planning. She said
their collaborative approach allows the
university to hear and respond effectively
to the needs of the industry. “This kind
of approach allows us to be much less
reactive,” she said. “We don’t get caught
up in that loop of changes in the industry
that require sudden tertiary response.”
This system also allows students to focus
their study and energy on areas of future
need for the hospital. “Forward planning
identifies a gap and students know they
will be able to profile themselves strongly,”
“This gives them the cutting edge around
employment because they can then target
their study to identified work gaps.”
GCH also has also implemented a roster
where graduates are only on for three days
a week – which means that they have only
86 full-time positions available, however,
they have a head count of 138.
“We are accepting 138 graduate nurses
and midwives working three days per week
on a 12-month temporary contract. There
is a vulnerability for this year’s graduates
that at the end of 12 months if they do not
secure a permanent job with us, then their
employment will cease, to make room for
next year’s graduates,” explained Williams.
“Our current retention rate following the
graduate year is 95 per cent.”
Of the 119 graduates employed in 2012,
117 are staying on beyond the completion
of the program. “The benefit is, they have
12 months of employment, they have
consolidated their training and they are now
competent RNs,” Williams said. “Even if we
can’t employ them, they will be much more
Gamble confirmed that students
understand that it is a tight market, and
even though many would prefer fulltime employment, they are delighted
and grateful to have a three-day a week
position. “Many are very amenable to the
idea that they and their peers get three
days a week rather than a whole lot of
people missing out because a few people
get five days a week,” she said. n
4 0 en t
e r e v a ll y
O v n a l n nu
t io a
Last year 3148 Australian Nurses trusted us to deliver their Professional Development Points
2013 Q1 Event Schedule
• Clinical Documentation, Coding & Analysis Conference
18 – 19 February 2013 | Hilton on the Park Melbourne
• Medico Legal Congress
21 – 22 March 2013 | Sydney Harbour Marriott
• National Dementia Congress
21 – 22 February 2013 | Novotel Melbourne on Collins
• Developing the Role of the Nurse Practitioner Conference
21 – 22 March 2013 | Novotel Melbourne on Collins
• National Forensic Nursing Conference
21 – 22 February 2013 | Radisson Blu Plaza Hotel Sydney
• Hospital Patient Costing Conference
21 – 22 March 2013 | Stamford Plaza Brisbane
• Hospital Bed Management & Patient Flow Conference
25 – 26 February 2013 | Novotel Melbourne on Collins
• Mental Health Units Conference
25 – 26 March 2013 | Marriott Melbourne
• National Telemedicine Conference
20 – 21 March 2013 | Pullman Hotel, Hyde Park Sydney
• Electronic Medication Management Conference
25 – 26 March 2013 | Hilton on the Park Melbourne
Acknowledging the quality of our conference programs and demonstrating our commitment
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February 2013 | 5
taff at a Brisbane hospital have
been instructed to turn away
patients presenting after 10pm,
with management guidelines
suggesting nursing staff offer sick patients
a “blanket and pillow”.
Nurses and other health professionals
at Wynnum Health Services, formerly
Wynnum Hospital, have been told that
patients presenting between the hours of
10pm and 8am should be treated outside
the facility until an ambulance arrives –
including those in life-threatening situations.
The guidelines from Metro South Health
(MSH) go as far as to state “if BLS [basic
life support] is required commence BLS at
the front door.”
Dr Rosalind Crawford, MSH director
medical services and facility manager
Redland and Wynnum hospitals, said the
decision to deny after-hours access was
first enforced due to staff and patient safety
concerns, and that the staff’s main priority
was the patients in the 21-bed ward.
She said the majority of patients at the
hospital were frail and elderly and should
not be left unattended.
However, Des Elder, Queensland Nurses
Union assistant secretary, believes this puts
nurses in an untenable situation of having
to assess patients without any medical
officer support or necessary equipment.
“This means they are torn between
their duty of care to the patient and their
professional obligations to work within their
scope of practice,” Elder said.
“Clearly requiring staff to perform
BLS at the front is what is expected.
This is clearly an inappropriate and
dangerous requirement. The guidelines are
unreasonable and seek to transfer the risk
and liability from the health service to the
plan to once again
make their voices
heard, Elder stating
that the community
does not accept
the “spin” from the
board as to why
service was axed in the first place.
“It is on the public record that the
hospital board believes the service should
be provided by the private sector. It is a
plan to slowly privatise health in the area. It
is another example of the ham-fisted and
disgraceful way the government is handling
health services,” Elder said.
MSH has confirmed that the directive is
now under review. n
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• With breast cancer causing
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The funding will allow the program
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• The University of Western Sydney’s
school of nursing and midwifery will
investigate a new side of traumatic
births – looking at the impacts on male
partners. Researchers will explore
men’s experiences of labour and birth
where the partners have experienced
complications or needed urgent
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WA nursing shortage
Community package help
• According to a major survey conducted
by the Australian Nursing Federation, WA
will face major shortages with only about
44 per cent of nurses planning to stay in
the industry for longer than a decade. In
addition, almost 36 per cent of nurses said
they experienced regular shortages, while
nearly 16 per cent said the shortages were
getting to dangerous levels. Describing the
results as alarming, Mark Olson, ANF state
secretary, called for the government to act
quickly to retain and attract more staff with
better pay and conditions.
• Among other providers, Care Connect
has recently been awarded a ComPacks
(Community Package) contract – a NSW
Ministry of Health initiative to minimise the
risk of hospital readmissions. The service will
allow appropriate patients to be supported
for up to six weeks in an early transition
home – helping to free vital beds in the
state’s public hospitals. Care Connect will
be responsible for delivering the program
to 5000 patients in six local health districts,
providing much needed non-clinical
community support to people after they
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National Forensic Nursing Conference
February 21 to 22
Radisson Blu Plaza Hotel Sydney
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February 25 to 26
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provided is of a general nature. It does not take into account your objectives, financial situation or specific needs. You should look at your own financial position and requirements before
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February 2013 | 7
out of primary
care will cost more
in the long term,
say nurses and
SA $14m cut
eading South Australian health
groups have joined forces
to launch a petition against
recommendations for cuts made in the
McCann review of non-hospital health
SA Health appointed Warren McCann,
internal consultant for the Office of Public
Employment and Review, last August to
undertake the review.
More than 100 jobs and a range of
different health programs and services are
in the firing line, in a move which the review
suggests will save about $14.6 million.
The Australian Nursing and Midwifery
Federation (SA Branch), SA Council of
Social Service, Health Consumers Alliance
of SA, the Public Health Association and
the Australian Health Promotion Association
have joined forces to fight recommendations
they describe as “short-sighted” and “not
based on sound evidence”.
ANMF state secretary Elizabeth Dabars
said the recommendations contained in
McCann’s review are entirely at odds with
international research and the Menadue
Generational Health review, which
emphasises the need for investment
in preventative and primary healthcare
and was adopted and is in current state
8 | February 2013
“If you can address issues now, then
you can address the long-term costs of
healthcare by intervention sooner rather
than later,” she said. “This goes back to
the basic principle that prevention is better
than a cure.”
The groups believe that McCann’s
approach will increase the burden on an
already overstretched hospital system.
Rather than strip money away from
primary healthcare, they suggest putting
more investment into it.
“We can save money at the other end
– which is not having people lining up at
the emergency department which is a very
costly exercise,” Dabars said.
“As an example, if you have people that
do become obese and morbidly obese
– the cost to the system is significant.
You have to buy additional infrastructure,
beds, wheelchairs and you would need
“Rather than having one nurse at a time
you have to at least have four people just
to assist them with their basic care needs.
“This is going to be a significant cost
to the public and one that is much better
Dabars said the community will be the
emotional and financial beneficiaries of a
health system where investment is based
and it is up to
the SA health
community to make it happen.
“As health professionals we are
advocates for our patients and really part
of our advocacy should always be trying
to avoid people from becoming patients in
the first instance.
“I see the role of nursing and midwifery
at this point to be part of that advocacy
and as result I would encourage anyone in
the nursing and midwifery professions to
sign the petition but also encourage their
family and friends and loved ones to also
sign,” she said.
SA Health said the review “supports a
number of new recommendations which
constitute significant reforms to the delivery
of some non-hospital based services” and
that a two-month public consultation on
these services and strategies is currently
underway, concluding on February 4.
The department said it welcomes and
encourages all feedback as part of this
process and “will consider all feedback on
the new recommendations before finalising
a proposed response to the report for
government’s consideration”. n
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February 2013 | 9
to get involved
A joint university research project will examine the
success of encouraging patients to have more of a say
in their care. Amie Larter reports
atient participation in care (PPC)
is not a new concept, however,
little research has been done in
Australia into how hospitals would deliver
changes, and whether patients are ready
and willing to participate.
The World Health Organisation as well
as the Australian Commission on Safety
and Quality in Healthcare have been
long-time promoters, and recent statistics
suggest that this could decrease the rate
that patients pick up a secondary illness or
injury in hospital.
An Australian Research Discovery grant
has recently been awarded to Griffith
University’s National Centre for Research
Excellence in Nursing (NCREN) and Deakin
University to explore patient and nurse
responses to PPC and their willingness to
participate in it.
“The first phase is exploratory, and we
will find out from nurses and patients what
they think of active participation in their
care,” said Professor Wendy Chaboyer,
director of Griffith’s NCREN, who will lead
the three-year study.
“We want to find out what nurses think,
as we would like to understand some
of the barriers and drivers for this actual
participation because it means a power
10 | February 2013
sharing.” Chaboyer said patients will now
be acting as partners in their care.
The second phase, led by Griffith
health economist Dr Jenny Whitty, will be
an experiment where scenarios will be
presented to nurses and patients to explore
preference in care.
Results from this will be used in the
third phase to develop recommendations
on how hospitals might be able to have
patients participate more actively.
The Australian Nursing Federation
federal secretary, Lee Thomas, said
that nurses try to promote a positive
therapeutic relationship using effective
communication and advocating for
patients. This demonstrates their support
for patients making decisions about their
own healthcare management.
“Patients need to believe that they can
ask questions and feel confident they
understand the answers they are given.
By providing empowerment, nurses
encourage people to choose and negotiate
about their care and take the lead in
Thomas suggested that in order for
nurses to build upon the PPC approach,
they would need time to educate patients
– something that was not always available
within an acute setting where patients have
relatively short stays.
“They need the staffing and resources
to do this. Shared decision making and
working in partnership with people is
important in ensuring a fairer service.
“A PPC approach has great potential
and it is our hope that the research will
demonstrate whether it will improve patient
care and the resources required to achieve
this,” Thomas said.
International research suggests that
nurses’ responses to the PPC approach
have been varied.
“Some nurses feel threatened and
challenged if patients speak up,” Chaboyer
“On the positive, from these small
studies, some nurses embrace patients
participation; they value it and see its
importance, thus are dedicated to
supporting patient participation.
“However, nurses report they still need to
maintain some control,” Chaboyer said. n
February 2013 | 11
policy & reform
12 | February 2013
ae dic/s p i
urg ica l
periopera t i ve
Considine believes it was inevitable that the medical
profession would become more specialised as
medical research revealed more details about
particular illnesses and diseases.
The more complex a sickness, the more it
requires each area within the medical profession to
have greater knowledge and that invariably leads to
“If I had a cardiac arrest, I would want an expert
emergency nurse, if I was having a baby, I would
want an expert midwife, if I've had a stroke, I would
want an expert stroke nurse,” Considine says. “No
one ever suggests that orthopaedic surgeons take
over the plastic surgery list.”
General medical training has advanced greatly
in all areas since Considine started out 30 years
ago. “When I trained in the late 1980s, there were
still general medical and surgical units, but it was
common for surgical specialties to be clustered
on the same wards like plastics, orthopaedics,
gastrointestinal,” she says.
“Now medicine has also sub-specialised and your
find medical units with specific expertise in stroke,
respiratory problems, diabetes and new areas are
developing too. There are many benefits to nurses
specialising … such as patients receiving expert
care in that area and the nurses can help out with
answering questions, thereby comforting the patient.
“It improves the outcome for the patient and
specialised nurses might notice something that a
general nurse doesn’t. A patient may have broken
his or her leg and that is what they are treated for.
A nurse who may have worked with stroke victims
would naturally look to see if there was any head
trauma rather than just treating the immediate injury.
“Of course, there can also be some
disadvantages to nurses specialising as it can
lead to a less flexible workforce and nurses
might become deskilled in areas other than their
s a patient, we are both relieved and fraught
with nerves when we are told we need to
see a specialist doctor. Relieved that there
is someone in the field of the unknown illness that our
body is carrying, which eases our mind that a cure
may be found sooner rather than later.
We are also very nervous that something may be
seriously wrong with our health and it may result in
a prolonged illness or even death. It is as if our body
and feelings are facing a dichotomy.
But where there remains hope, which will always
prevail when we know there is a specialist doctor
in the field of illness for which we are currently
diagnosed, the more positive feeling will generally
While patients take comfort in seeing a specialist
doctor, there are mixed feelings within and outside
the nursing profession regarding more nurses
specialising – in fields such as emergency, aged
care, coronary care, midwifery, oncology and
palliative care amongst others.
Some see this as a negative, resulting in nurses
losing general skills and unable or unwilling to
transfer their skills to another section of the hospital
or to a completely different area in nursing. This
is because of the difficult processes involved
in applying for another job, such as getting the
required police and reference checks, interviews and
preparation. However, others see it as a positive.
“I have never heard anyone complain that we
have too many specialist doctors,” says Julie
Considine, professor in nursing at the school of
nursing and midwifery at Deakin University. “So,
I am not sure why people would complain about
there being too many specialist nurses?
“Nurses have always specialised but I know a
lot of nurses that transfer their specialist skills. For
example, I have emergency nursing colleagues who
now work in ICU and hospital in the home and they
have benefited from the experience.
“Personally, I have always worked in emergency
care and relished the challenges that it presents.”
Letting too many nurses
concentrate on narrow
areas of practice depletes
the number of general
duties staff, say critics. But
educators argue that medical
advances make it necessary.
Louis White reports
c om m
an ag e r
si n g
e nsiv e care •
policy & reform
ag e d
i t ion
i d wi
t io n
t ri c
speciality, which means hospitals have
decreased ability to move nurses within
their organisation. But I don’t see any of
these conversations happening about
The Nursing and Midwifery Board of
Australia says there are just under 337,000
registered nurses and midwifes in Australia
as of September 2012.
There about 238,000 registered nurses,
59,000 enrolled nurses and 33,000
registered nurse/midwives. These are the
three largest categories in the profession.
The biggest worry for Australia is the age
of nurses. There are 51,055 nurses and
midwives in the 51- to 55-year-old category.
In the 41- to 60-year-old bracket there are a
total of 178,567 nurses and midwives.
Surveys conducted by Monash
University, Health Workforce Australia and
the Australian Nursing Federation indicate
that more and more nurses are looking
to leave the profession for a multitude of
reasons, including poor pay and lack of
By creating more and more specialist nurse
roles it increases the opportunities for
nurses to gain broader skills, higher pay as
well as more job satisfaction.
“There are often better career
progression opportunities for specialist
nurses,” says Dr Colleen Smith, associate
head of the University of South Australia’s
school of nursing and midwifery.
“For instance, nurses with specialist
qualifications can extend their scope of
specialist practice by undertaking the
Master of Nursing (Nurse Practitioner)
program. By offering specialist nursing
positions, nurses can undertake that option
and study the necessary qualifications to
progress in that field.”
Smith believes there are far more
advantages than disadvantages to
nurses being able to specialise and it was
inevitable that this genre would open up
due to medical research.
“Nurses specialising in particular areas
of medicine is a response to an increase in
technology and advances in medical and
health care knowledge,” she says.
“Patient care is much more complex
resulting in the need for more specialist
nurses to drive the safety and quality
agenda and improve patient outcomes.”
The reality is that we are an ageing
population. The Australian Bureau of
February 2013 | 13
policy & reform
Statistics states that 13.5 per cent of the
population are currently aged over 65 years.
By 2050 this age group will make up
almost 23 per cent of the population. There
will be just 2.7 people of working age (15 to
64 years old) compared with five now for
each Australian aged 65 years and over.
The risk of having a stroke rises as you get
older. Australians are exercising less, eating
more junk food and obesity is on the rise,
meaning that diabetes will only increase.
As we get older more illnesses and
injuries occur and each year medical
research makes discoveries resulting in
new diseases coming to the fore requiring
more specialist knowledge in that area.
This will flow from what children are
immunised with to the way people are
treated in hospital to the design and care of
patients in hospitals in the future.
“The advantages of nurses having
specific knowledge is that they acquire
in-depth knowledge and skills in their
specialist area of practice and provide
advice and support within their specialist
scope of practice to other health
professionals,” Smith says.
“Of course there is the disadvantage of
specialist knowledge and skills not readily
transferrable to other areas of nursing
practice, so this could result in the potential
to lose skills.
“Overall, their needs to be a sufficient
mix of generalist and specialist nurses to
ensure a flexible workforce that caters for
the needs of the healthcare industry.”
Thomas Harding, professional officer
at the NSW Nurses and Midwives
Association, believes that it has always
been a trend for nurses to find a niche and
“I don’t think it is that different from
other professions, where you find a niche
within your field of expertise and choose to
remain there,” Harding says.
This school of thought is backed up by
the Australian Nursing Federation federal
secretary, Lee Thomas, who says that like
all occupations some nurses choose to
stay in a particular area for many years of
their working life.
She says this choice is not unusual
and is made generally because of the
preference for that type of nursing.
“Skills are broadened and many new
skills learned over the years, as medical
technology and techniques change. But
nurses remain nurses with broad skills
irrespective of the areas in which they
might choose to spend their working life.
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“However, nurses in rural and remote
areas, working in the outback and in small
country hospitals don’t have the same
opportunities to stay in one area for many
years,” says Thomas.
Harding, however, points out that the
general public fails to differentiate nurses
like they do with doctors.
“Most patients just see a nurse as a
nurse,” he says.
“That is unfortunate in that all nurses
should be recognised for the skills that they
bring on board and specialised nurses do
extra study and training.”
He does agree that processes in place
within the healthcare sector don’t make it
as easy as once before for nurses to chop
and change their career path.
“There is no doubt that through all
the processes in place these days it is
harder for nurses to move from one area
of specialty to another or even back to a
general nurse once they have specialised,”
“The reality is that in the future we will
need more specialised nurses due to the
advancements in medical technology.
Doctors too want more specialised nurses
to work with.
“While this benefits the city we also
need to take into consideration that in
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14 | February 2013
All courses have been endorsed by APEC number 080806016 as authorised by the Royal College
of Nursing, Australia (RCNA) according to approved criteria. Attendance attracts between
4 and 25 RCNA Continuing Nurse Education (CNE) points as part of the RCNA’s Life Long
learning Program (3LP). Many courses are also approved by the RACGP QI&CPD Program and
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Registration for any seminar, conference or course includes tea breaks, lunches, comprehensive
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These programs & many others are available to be
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policy & reform
the country, with less medical assistance
available in all areas, we need more general
Harding, who previously held a senior
position at the Australian Catholic
University, says that undergraduate and
postgraduate degrees have developed
substantially and offer more comprehensive
learning, enabling students to better
demonstrate their skills and knowledge.
“Nursing degrees offer greater flexibility
and improved learning facilities thereby
enabling students to have increased
“The result of that is students will then
want to know more about speciality and
there are greater opportunities for them
now to undertake such post-graduate
courses and training than there has been in
“Of course, this is all determined by
labour market activity but the greater
skillset one possess the more opportunities
afforded to them.
“I don’t believe nurses lose skills if they
specialise, they just acquire new ones and
that is to everyone’s benefit.”
Professor Ramon Shaban, deputy head
of school of nursing and midwifery at
Griffith University, actually believes there is
less specialisation now than in the past.
Nurses have always specialised but I know a lot
that transfer their specialist skills. I have emergency
nursing colleagues who now work in ICU and
hospital in the home and they have benefited from
“I don't know that I believe that nursing
specialisation is more common,” Shaban
says. “Specialisation has been [this way]
for many years, and in fact to some extent
there is less specialisation.
“Generally speaking, the growth
of some specialty areas of practice
has been supported by research and
evidence-based practice, along with
the move of nursing education from the
vocational sector to the tertiary sector.
These have afforded the development
of specialist, research and evidencebased practice. There is a need for the
Shaban says that specialisation offers
mastery of skills, professional standing,
expert patient and practice care and
flexibility for nurses.
“Increasing specialisation, and multiple
specialisation, increases professional
portability and employment,” he says.
“In addition, nurses change and expand
specialisation as their careers evolve, as
their personal circumstances change.
“To some extent they lose skills,
but they gain others. Their skill and
expertise evolves – evolution is the
best way to describe it. All skills and
abilities acquired are relevant to future
practice and specialisation. It adds to the
individual's practice base. Specialisation is
fundamental and important.”
Expect more of the specialised nurse and
less of the generalist nurse in the future,
though both are needed all around the
country. The more money, effort and time
invested into medical research means more
discoveries and more knowledge acquired.
We all take relief when we hear that a
specialist doctor is available, perhaps we
should start doing the same with specialist
nurses. After all, we generally end up
spending more time with them than the
doctor anyway. n
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February 2013 | 15
policy & reform
The effects of a warming
planet may already
be on us and nursing
he Australian Senate is running an
inquiry to examine “Recent trends
in and preparedness for extreme
weather events”. Calls for submission
closed on January 18. Our politicians
are clearly concerned about Australia’s
This is a call to arms for the health
workforce to step up and prepare. A new
world is bearing down upon us in the form
of new climate frontiers.
Following the unheralded fire conditions
of Black Saturday, in February 2009,
fire authorities were obliged to add in
the new category of “Catastrophic” to
accommodate the increased intensity we
are now seeing in fire conditions.
In January this year, the Bureau of
Meteorology added two new colours –
deep purple and pink – to the interactive
weather forecasting chart to extend
its previous temperature range. Once
capped at 50 degrees, the bureau
needed to extend its capability to 54°C, to
accommodate these new heat extremes
that are now occurring.
Also in January the average maximum
temperature across Australia peaked at
40.3°C, a new record, and it remained over
39°C for seven consecutive days, twice as
long as the previous record.
This follows a warm end to last year,
where for the last four months, the average
16 | February 2013
Australian maximum temperature was the
highest on record with a national anomaly
of +1.61°C, from records dating back to
1910. On January 4, Hobart reached a
maximum of 41.8°C, breaking a record held
for 120 years.
We must face it, the world is warming.
Heat extremes are an increasing global
phenomenon. Last year was the warmest
on record (since 1895) for the 48
contiguous US states. The 2011/12 winter
season was nearly non-existent for much of
the eastern half of the nation.
2012 was, for the US, the second-worst
for weather extremes including drought,
hurricanes and wildfires. In addition to
the summer being hot, it was also dry,
resulting in a drought footprint comparable
to the drought episodes of the 1950s.
These aberrant weather patterns are being
experienced all across the globe.
Heat extremes which were once at the
frequency of 0.1 per cent of the time are
now coving 10 per cent of the planet at
any one time. Extreme weather events
have increased three fold. Globally, climate
change is already costing an estimated
$US1.6 trillion ($1.5 trillion) per year, rising to
over $US4 trillion by 2030.
The summer of 2009 brought extreme
heat waves to southern Australia,
accompanied by Black Saturday bushfires.
More than 500 people lost their lives in
Victoria due to these climatic events;
either due to heat exposure or through
severe burns and smoke inhalation from
those fires. Then 2010 and 2011 were the
two wettest years in Australia’s recorded
history, flooding Queensland, NSW and
Among the developed nations, Australia
is at the forefront of vulnerability to the
ravages of climate change, as we face
increased threats of droughts, floods,
storms, fires and heat waves. We are
entering a new and wildly disparate climate
to the one in which humans evolved and
agriculture flourished allowing villages and
cities to develop. Our future will be warmer,
with greater extremes of temperatures
and precipitation; more intense and more
frequent droughts, floods, and storms.
There is now wide scientific agreement
that the world is heading for at least 2°C
warming, and possibly 4°C, by 2070, and
this will bring greater extremes. With global
warming currently less than one degree,
hot countries, such as Australia are already
beginning to experience temperatures
that are not compatible with a healthy and
active life. It is difficult to imagine how this
can further amplify, to a state where a
“normal” hot day is 48°C and extremely hot
days approach 58°C.
Such horrors are inherently difficult to
fathom, however, without mitigation, we
policy & reform
are on a trajectory to these unimaginable
heat extremes. With such warming,
outdoor activity will not be possible. Using
CSIRO’s projections for Australia of the
likely increase in mean annual temperature
by 2070 if no mitigation strategies are
adopted, a Perth study identified that
outdoor activity would be impossible for
unacclimatised people on 33–45 days per
year, compared with four to six days per
year at present. Their core temperature
would rise by 2.5°C in less than 2 hours.
Not only will this be too hot for humans
to move, work and exercise, but it
will also be too hot for animals,
cattle and sheep, and for plants.
Their leaves will burn. Even at
lesser temperature extremes,
our stable food crops will
wither, and food production
in Australia and globally will
decline. By this stage, the
oceans will be warmer
and more acidic, so we
cannot expect protein
sources from fish. Food
shortages will drive conflict and political
Unfortunately, this gloomy forecast is not
a horror movie, it is realistic. What we do
not know is how soon this will occur. But
the trend has already begun, and experts
are now convinced that current emissions
interruptions to infrastructure caused
have now exceeded the barrier of keeping
by damage to roads, bridges, electricity
warming to less than 2°C. [It passed the
The geographic range of mosquito borne
2°C threshold when the concentration of
CO2 reached 330 ppm. It reached 394 ppm diseases will spread southwards. Food
borne diseases also increase with rising
by the end of 2012]. If nations continue to
temperatures. Personal loss will bring
procrastinate about reducing greenhouse
stress, grief and despair
as people struggle
to cope with these
range of mosquito
changes. These will
between 4°C and
manifest as generating
5.6°C will occur
greater demand for
before the end of
mental health services,
the century. Some
and health sector
children alive today
responses to other
will live to see this.
borne diseases also
chronic diseases that
The pathway to
are exacerbated by
this sorry state will
increase with rising
stress, and by stress
involve an increasing
array of health
Personal loss will
such as drug and
problems. The need
alcohol abuse. Mental
for expanded nursing
bring stress, grief
roles will demand
and despair as
services, are lacking in
nursing training and
care provision. In the
to cope with these
In the short term, all
near future, there will
new nursing courses
be increasing health
must prepare nurses
threats arising from
for a future world, one
heat exposure, and
quite unlike the one for which we prepared.
from exposure to droughts, floods and
Australia’s health burden will shift, and
health service priorities will change in
This will occur against a backdrop of
response to economic shifts as countries
crop damage, and therefore rising food
direct increasing proportions of GDP into
prices, potentially food shortages, and
reparation of damaged infrastructure.
There is an urgent need for health
promotion, as after mitigation,
preparedness offers the greatest
protection. Preparedness must occur at
all levels: individual, community, industry,
institutional and government. The health
sector and health sector workforce have a
key role to protect and advance Australia’s
health. The health impacts of climate
change should feature prominently in the
education curricula of undergraduate and
postgraduate health professionals. n
Dr. Liz Hanna convenes the National
Climate Change Adaptation Research
Network for Human Health, and is
president of the Climate and Health
Alliance. She transitioned from an
Intensive Care Nurse to focus on health
related research. Hanna is director of the
NHMRC research project investigating
Working in the heat under climate
change: health risks and adaptation
needs, and is chief investigator on several
A fully referenced version of this story is
available at www.nursingreview.com.au
February 2013 | 17
policy & reform
Amie Larter talks
to Neroli Ellis about
the state of nursing
shortages within three years if all graduates
were employed. Tasmanian nurses and
midwives, on average, are the eldest in the
country and the impending retirements will
create added pressure in the near future.
What were the main challenges for
nurses in Tasmania throughout
The significant budget cuts in health in
this financial year resulted in the closure of
over 100 acute hospital beds, 280 nursing
positions slashed, theatres closed, mental
health and family child health service and
access reduced resulting in major issues
with bed block and subsequent ambulance
ramping and 25 per cent elective surgery
The pressures were on all major
Tasmanian hospitals which were operating
at about 100 per cent occupancy, which
is unsustainable for safe patient care over
the long term. This resulted in ambulance
ramping, re-admissions, and increasing
complexity of medical illnesses due to
delays in elective surgery and delayed
18 | February 2013
diagnosis of cancer, which are some of the
symptoms demonstrating the poor state of
our health system in Tasmania.
Front-line nurses wore the brunt of most
of the effects of the budget cuts and yet
continued to do their best to deliver quality
services. All sectors of primary heatlh
were also reduced with cancellations
of mental health and family child health
apppointments, and community nursing
access reduced. Nurses and midwives
received enormous public support. The
federal Minister for Health, Tanya Plibesek,
announced a $325 million four-year
package, which if allocated to the crisis
areas would have made a difference.
Concurrently, nursing graduate
employment was cut by 40 per cent of
pre-budget numbers (FTE) despite the
Health Workforce Australia projections of
There was extensive coverage of the
staff shortages, funding cuts and
extensive work hours for nurses. What
plans need to be put in place to ensure
it’s not the same throughout 2013?
The outcome of this short-term strategy is
evident now with nursing roster shortages,
reliance of casual staff and ongoing fixedterm contracts and job insecurity and many
of the 280 nurses who lost their jobs last
financial year have already moved their
The ongoing delay in the implementation
of the new nursing career structure due to
budget cuts is also affecting recruitment
with a lack of recognition of the value of
nursing and midwifery.
The Australian Nursing Federation (ANF)
will pursue the classification reviews and
implementation of new classifications
through ongoing conciliation in the
Tasmanian Industrial Commission and
pursuit of the finalisation of the working
party for a new career structure for
The human resources processes
must be improved and the ANF has
recommended implementing KPI’s to
improve the recruitment timeframe, which
is unacceptable at the current four months
for a permanent appointment.
The graduate nurse campaign will
continue to ensure our graduates can stay
in Tasmania for a career pathway.
The ANF will be monitoring and
intervening in workload issues through the
local workload committees and ensuring
that permanent employment is offered to
assist in retention.
How did the state government respond
to the issues, and was the response
The government made a policy decision
to cut the health budgets and reviewed
the forward estimates to maintain current
policy & reform
cuts without proposed additional cuts this
However, the cuts remain unsustainable
and despite the additional federal funding,
which only offers less than $8 million for the
state elective surgery per annum, access to
both acute and primary care will continue
to be compromised for Tasmanians. The
government’s response has not been
satisfactory and the preliminary findings
of the Legislative Council inquiry have
determined that the community is being
Coming into an election year, what
will be the main issues on the agenda
for nurses and the ANF in the state?
1. Development of a statewide health
strategic plan. Many expensive consultant
reviews have been undertaken over the
last 10 years but yet the health system
continues to lack direction and strong
leadership. Regional parochialism has to be
removed and services offered based on a
2. Appropriate resources to implement
this plan must be allocated in the relevant
3. Implementation and funding for the
new nursing career structure, which must
include models of care recognising the
scope of practice of all levels of nurses
including funding for nurse practitioners,
nurse-led discharge, walk-in clinics and
4. Development and commitment
to a Tasmanian nursing and midwifery
workforce plan and graduate nurse
5. Funding to reopen critical services
in health and ensure Tasmanians have
equitable access to the universal health
What is your vision for nursing in
Strong nursing leadership to advocate and
lead and promote our profession forward.
Support for research and ongoing
education to enable nurses and midwives
to work at full scope of practice, and value
and recognition of the great innovation
that continues despite the hardship of the
system due to the budget cuts.
Clinical information systems to support
our practice and enable accurate data to
enable practice improvements.
The ability to deliver quality care that
is supported by the appropriate skill mix
and support staff re-employed to enable
nurses and midwives to be relieved of the
non-nursing duties, which continue to be
absorbed by nurses particularly as positions
are removed through budget cuts.
A dynamic system to enable positive
change led by nurses and recognising
made a policy
decision to cut the
health budgets and
reviewed the forward
estimates to maintain
current cuts without
cuts this financial
those nurses in clinical leadership
positions. Support and recognition for
nurses and midwives without the constant
fight through the obstructions of the
A sustainable nursing workforce plan to
be developed and supported to avert the
predicted workforce crisis.
Aged care funding to ensure nurses and
care staffing levels and skill mix to provide
quality care to our ageing demographic. n
Neroli Ellis is the Tasmanian branch
secretary of the Australian Nursing
It’s never too late to study. We’re in
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February 2013 | 19
Practice nurses perform myriad
tasks in doctors’ surgeries,
one of the most important is to
communicate with patients.
By Flynn Murphy
t is 1pm on a Wednesday
at Glebe Medical Centre in
Sydney’s inner west, and
nurse Jessica Turner is sneaking a
sandwich in between patients.
“It’s very busy, especially now
that I do pap smears as well,” the
full-time practice nurse explains
Last month, Turner completed
a course in women’s health at
Family Planning NSW, which
has allowed her to expand her
scope of practice at the centre,
qualifying her to perform breast
examinations and pap smears. The course
was part-funded by the clinic she works at,
and part by a government subsidy.
“We encourage our nurses to improve
their skill sets in private practice. We see it
as an investment in our staff,” says Dr Ryan
Quan Vo, co-director of the centre, which
took out the Sydney Small Business of the
Year award last year.
Glebe Medical Centre is a 10-room,
multi-disciplinary practice with GPs, allied
health practitioners, and full-time nursing
support. It’s busy right now but not chaotic,
a wall poster advertises a new smartphone
app that lets patients book an appointment
at the touch of their screen.
Vo says his clinic caters to a diverse
demography, from the socio-economically
disadvantaged to young professionals, and
is open seven days a week, bulk billing
for five. It has sister-clinics in Rozelle and
Drummoyne, each of which has a fulltime nurse. Turner joined the centre last
20 | February 2013
September, after six months working in the
transplant ward of the Royal Prince Alfred
Hospital. She previously worked at a drug
and alcohol clinic in Ultimo.
“It’s a completely different skill set here,”
she says. Being a practice nurse means
“less drama” than working in the hospital
system. It also meant a pay cut – with no
possibility of overtime – but offers a work/
life balance that suits her better than regular
night shifts at the hospital down the road.
“Having practice nurses greatly benefits
doctors and patients,” says Vo. “Nurses
can provide additional services that
the doctor may not have time for – for
instance our nurses are responsible for our
vaccines inventory: ordering, checking, and
administering vaccines to children. This can
take quite a while, and having a nurse to
do that can really take the pressure off the
“These extra skills do greatly help patients
because they mean patients
can see nurses to get these
procedures done, and often that
means there are very minimal
waiting times, as opposed to
having to book in to see a doctor.”
For Vo, nurses are ideally suited to
handle follow-up care and inquiries.
“Also, a lot of the time a patient, when they
see a doctor, may not have an opportunity
to [get an] answer to all the questions they
wanted, or they’ve forgotten during the
consultation. Seeing a nurse gives us an
opportunity to get more feedback from the
patient. If a patient calls up the practice with
a query, most of the clinical questions are
directed to our nurse first.”
Julianne Badenoch, president of the
Australian Practice Nurse Association, which
represents about 3500 nurses, says the core
benefits offered by practice nurses were in
the realm of time, and access. “[Patients will]
get time, they will get a qualified professional
who knows what they are talking about, and
they will be given more opportunities to selfmanage their care.”
“There’s a good business case for
practice nurses,” she adds.
Vo says Glebe Medical Centre receives
incentive payments from Medicare for
employing a practice nurse, but that the
practice has been financially worse off
since the federal government replaced
the nursing item number system with the
Practice Nurse Incentive Program last year.
“But there’s a huge benefit to the
practice having a full-time nurse,” he said.
“We still see the benefits outweighing the
financial costs. It also lets the doctors see
“The GPs that have had nurses in their
clinics for a long time, most of them tell me
they wouldn’t survive without them,” adds
Badenoch. “They may well say that with a
smile, but I think they actually mean it. We
share the load.”
For a former actor, and a direct
descendent of legendary Irish writer James
Joyce, Turner is plain-spoken. For her, this
is just part of the job.
“We free [doctors] up to get more
patients, but between the two of us,
patients get that complete, holistic care. I
can’t tell you the amount of times I’ve been
researching stuff out of work hours and
contacting patients with information. That’s
what nurses do. It’s our job to manage
vulnerability and fear.
“Good doctors know the value of
nurses, and know how we’re supposed to
work as a team. Half the time that means
explaining to patients in language they can
understand what their issue is, and what
the treatment is. A lot of time patients come
to me and are still a bit confused about
what it all means. They need reassurance.
“I had a woman recently who was
diagnosed with gestational diabetes,
and she walked out of the doctor’s
office thinking it was her fault. Her way
of rectifying that was she was just not
going to eat. I explained what it was, how
it wasn’t her fault, and that by all means
she had to keep eating and just lay off the
sugar. English was her second language,
and she needed a simple explanation.”
Badenoch would like to see the scope
of practice expanded for more practice
nurses like Turner. “I think it’s happening –
at the end of the day, nurses just need to
be able to demonstrate they are educated,
authorised and competent to perform new
roles. They just need to back them up and
[doctors] up to
get more patients,
but between the
two of us, patients
get that complete,
holistic care. I can’t
tell you the amount
of times I’ve been
out of work hours
February 2013 | 21
Turner is positive about her career
prospects, and says nurses need to
be proactive about building careers for
themselves in clinics.
Vo agrees: “There are a gamut of roles
within private practice, and opportunities
for nurses to expand their skill sets and
do more procedures in women’s health,
chronic disease management, diabetes,
and then further on if a practice is large
enough they will run clinics and manage
clinics, overseeing junior nurses. There are
opportunities to become senior nurses and
Asked whether these opportunities would
be available at his own clinics, Vo said
he wanted to bring on more nurses, and
planned to open a women’s health clinic –
the lynchpin of which would be Turner.
Badenoch said the “negativity and turf
wars of the past” were coming to an end
when it came to GPs and practice nurses,
though the nurse practitioner role, which
included the expansion of the scope of
nurses to prescribe certain medications,
Badenoch, who herself works as an RN
at a beach resort clinic in South Australia,
said at her site, collaboration was key.
“You never know what it’s going to
be next – a broken arm, a kid scalping
themselves on the pool – in the practice I
work in it’s a team effort. We are consulted
all the way along. Patients generally see the
nurse before they see the doctor, and half
the work is done.
“[APNA is] still constantly told by our
members that they want a career pathway,
The busy Glebe Medical Centre is open seven days a week.
they want a direction that lets them build on
their skills,” she said.
To that end, this year APNA is working on
a proposed education and career pathways
structure for nurses in primary health care.
“We’ve found that a lot of practice nurses
love the work they’re doing, their hours
and the variety of their care, but far fewer
were satisfied with the recognition they
received, and their opportunities [for career
Badenoch said the organisation would
invite the Australian Nurses Federation to
partner with them in order to tackle unioncentred issues such as equitable pay.
“The practices that welcome nurses
benefit, and the community benefits.
Particularly in rural areas where there are
such significant workforce shortages.”
Turner says when it comes to
collaborations between GPs and practice
nurses, as long as the patients come first, it
doesn’t matter whose egos are bruised.
“Many doctors don’t mean to come off
as being dismissive, but often they are so
busy, and patients don’t understand what’s
going through their heads – so they feel
like they’re not getting listened to, or that
the doctor doesn’t care. If you look at the
reality of some doctors, they’ve spent their
whole life studying, and then you’ve got
these very intelligent people who lack social
skills and whose identity is wrapped up in
being a doctor.
“I was doing a pap smear the other day
with a woman, who is about 50. She’d
been having crazy menopausal symptoms
for years, but was still menstruating. So
the doctor said ‘nope, it’s not menopause,
“So I get to her and she’s saying ‘I’m
going crazy, I’m having mood swings, I’m
newly married and accusing my husband
of cheating but I know he’s not cheating!’
– the symptoms were unmanageable for
her. It was just a case of listening to her and
saying ‘you’re perimenopausal, you’re not
crazy, it’s going to come’.
“Problem shared, problem halved.” n
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Australian College of Nursing
Nursing’s role in
the use of
place of expert
urses have a key role in supporting the
appropriate management of medication.
Late last year ABC’s Lateline program
sparked debate about the potential over-use of
antipsychotic medications in the management of
dementia within residential aged care settings.
The program interviewed the Minister for Ageing,
Mark Butler, about the issue. Subsequent to the
program airing, a round table discussion was called
by Butler to shed further light on the issue. The
Australian College of Nursing (ACN) was one of the
key stakeholders invited to attend the discussion.
Following the airing of the Lateline program,
various organisations released media statements
condemning the overuse of antipsychotic
medications in the management of people with
dementia. There was a strong view expressed that
antipsychotics should only be used in the short term
and should not be used as an intentional form of
The definition of “chemical restraint” that is used
by the federal government is, “the intentional use
of medication to control a resident’s behaviour
when no medically identified condition is being
treated, where the treatment is not necessary for
the condition or amounts to over-treatment of the
condition (DoHA, 2004).”
It is acknowledged that early diagnosis of
dementia itself can be a difficult process due to
a range of other conditions presenting similar
symptoms to that of dementia. As a result of
misdiagnosis, patients may receive incorrect
treatment (including medication), symptoms may
persist unnecessarily and the underlying cause of
symptoms may go unaddressed.
ACN supports a greater role for nurses in the care
of people with dementia including the assessment
Side effects seriously impair the self-care
capacity of those receiving the medication and
increase the need for assistance and very close
of client behaviours, dedicated nursing time within
a client’s day, care planning developed around
behaviours associated with dementia, and coordination of care.
The Therapeutic Goods Administration has
proposed the rescheduling of benzodiazepines from
Schedule 4 to Schedule 8. These drugs include:
diazepam, nitrazepam, oxazepam and temazepam
and are used for sedation, chemical control of
behaviours and anxiety, usually in the presence of a
A range of adverse effects may be experienced
by those receiving benzodiazepine and include
confusion, impaired memory, drowsiness, unsteady
gait, falls and fracture risk, depression, dependency,
blurred vision and amnesia. Such side effects
seriously impair the self-care capacity of those
receiving the medication and increase the need for
assistance and very close supervision.
ACN is aware of reports of the increasing use
of benzodiazepines in residential care to control
“behaviours” in people with dementia symptoms
and advocates for increased registered nurse (RN)
participation in the care of the elderly in residential
settings. The alternative to using these drugs is
having RNs assess behavioural patterns and plan
care that will maximise options for residents with
minimal use of powerful medications.
RNs can then provide support and guidance
to other members of the care team. Appropriate
staffing levels are required in all care settings and
ACN does not support the use of medications as
chemical restraints in the place of expert nursing
ACN looks forward to the progress on
discussions and the development of strategies
across the country on this important issue. n
Reference: Department of Health and Ageing (DoHA).
(2004). Decision Making Tool: Responding to issues of
restraint in aged care. Retrieved from www.health.gov.au
Adjunct Professor Debra Thoms is chief executive
of the Australian College of Nursing.
February 2013 | 23
Private providers and government
must work together to keep costs
down in this growing area of nursing.
By Mary Casey
here have been many changes in
the care and nursing industry in
the past 10 years, especially in the
community sector. However, there is much
more to do to fill the enormous gaps that
exist in the system.
There is a silent crisis lurking that the
general public do not notice, unless they
have someone who requires care; it is only
then that people realise how enormous the
With an increasing aging population and
the concept of keeping the aged community
in their homes for as long as possible, doing
so does not go without its challenges.
Admissions to nursing homes is not as
easy as it used to be because of the criteria
that needs to be met before becoming a
candidate. There are also long waiting lists,
so government incentives to maintain care
or assistance to the elderly within the home
is much needed. Service provision is often
only an hour a day or much less.
Due to society’s changes whereby
families used to care for sick or aged
relatives, this no longer occurs. As a result,
many aged citizens are left to fend for
themselves and/or their partner and while
they manage to survive, in many cases it is
with great difficulty.
Service providers are the ones who see
the need for aged care, however, they are
restricted by lack of funding to meet those
needs. Therefore care is only provided on a
“high needs” or “dire straits” basis.
The nursing side of things has also
changed dramatically in the past decade
whereby care provision was once only
attended by registered nurses. While
this was satisfactory at the time, it was
24 | February 2013
recognised that basic personal care or
assistance with menial tasks did not require
the need for university trained nurses.
Carers were therefore introduced
into the industry, however, there we no
guidelines in place as to what training
was required. There were many untrained
personnel going into homes without proper
knowledge, not just in nursing duties,
but also safety education, professional
boundaries or knowledge of aged care.
For some time it was a case of anything
goes and nursing care and assistance
were of poor quality. Thank goodness
this situation has been addressed and no
longer exists. Tougher guidelines were
introduced with the training of assistant
nurses and personal carers. This of course
increased the quality of care and assisted
in the nursing shortage in general but it has
not resolved the shortage of care.
I lead a nursing service, Nursing Group,
which has been operating for 20 years.
We have seen firsthand the problems
associated with this silent crisis and
believe that with some proper planning, the
government could resolve the problem.
Nursing Group added an educative
component to our service and established
Casey College to train and upskill nurses to
resolve the shortage of quality staff in the
community for our own company.
Assistant nurses and personal carers
are in good supply so it is not the lack of
staff that is causing the crisis. The training
of assistant nurses has increased to such
a level that nurses now have a career path
whereby they can start with the basic
course and choose to continue.
In fact, I believe that we will see a
healthcare system receiving a long needed
influx of highly trained, competent and
confident assistants in nursing that have the
knowledge and skill set to jump between
community care and our public hospitals.
Once these nurses reach the appropriate
level with their training it won’t be long
before we see them being classed as vital
and prominent figures in healthcare industry.
Due to the increase in the need for
community nursing and the nursing
shortage in hospitals, this pathway to a
career might very well be one of the fastest
growing professional occupations we have
seen in the industry for many years.
More funding is always the answer to
additional care provision, however, I think
that good planning by both the government
and private sector could see a well thought
out, comprehensive and structured care
plan that will be cost effective – with a high
standard of care provision for our aged
Currently there are many community
services that provide packages for aged
care. These consist of personal care,
transport, dressings, medication, palliative
The care can be provided by the
community service or outsourced to private
agencies. The latter of course incurs a
“middle man” fee which is not cost effective.
In my opinion this is the reason why both
private and government agencies need to
work closer to cut out the additional costs
that are incurred by not understanding the
broader picture of care provision. Coming
up with a solution that will work is what is
I believe that community care in all
We will see a
receiving a long
needed influx of
in nursing that have
the knowledge and
skill set to jump
care and public
aspects is slowly improving but as always
the success is in the planning and to
consider both private and public sectors to
be involved is necessary because just one
sector cannot do the lot. We need backup
and to build relationships so we support
one another and work well together.
It is possible for this to occur because
many years ago our company worked
alongside a local area health service
providing a 24-hour palliative care service.
The service worked extremely effectively
and efficiently for many years until the
funding was cut.
Over those years we (the public
community centre and Nursing Group)
provided a quality service to those with
a terminal illness. The community centre
provided the service between 8am and
4.30pm and Nursing Group did the
afterhours, weekends and public holidays.
The reason why the service was so
successful was because the clients knew
that they had access to a nurse at any
time. In the beginning, we did numerous
call-out visits but the number decreased
because we were available via phone and
could support and guide the clients or their
loved one. We could tell them what they
needed to do and they were satisfied to do
many things themselves that they would
otherwise be afraid to do.
They mostly needed the support more
than anything else; it gave them the
confidence to do those things that they
hadn’t done before. Patients and relatives
over time became much more independent
and that was because they knew we were
there for them. Of course there were times
when we did need to visit or there were
planned visits for one reason or another,
however, overall it was a very cost-effective
Dr Mary Casey (PhD psychology) has
more than 30 years’ experience in health
and education. She is founder and CEO
of the Casey Centre, an integrated health
and education service with more than 250
nurses and carers, and 700 graduates
a year in three centres across NSW,
see www.caseycentre.com.au. Through
the centre, Casey also specialises in
designing and implementing health and
education programs and products. She
also has qualifications in nursing and
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service and became more so.
A similar model for aged care services
would work in the same way. Obviously in
the beginning all the leg work needs to be
done such as patient or carer education,
information packages, visits, etc.
Once implemented the service becomes
more streamlined and effective in every
regard. The upfront costs are also high,
however, by looking at the bigger picture in
time we have a service that is cost effective
and at the same time meets the needs of
all those requiring care in the community. n
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February 2013 | 25
pressure on the
is being eased
by a scheme
patients to be
treated in their
he Hospital in the Home
(HITH) program is
popular with patients, and
contributed to the NSW
government’s allocation of a
further 2009 beds last year.
Reports from patients
and medical staff have been
positive, with the program being
as clinically effective as in-hospital
In Sydney’s Campbelltown region,
there are about 30 beds allocated under
the program, which is the equivalent of
a regular ward full of patients. This frees
up much needed space in the standard
The director of Ambulatory Care at
Campbelltown Hospital, Dr Nicholas
Collins, said that patients receive the
26 | February 2013
same treatment as they would in hospital
for a variety of acute and subacute
“The aspiration of most Hospital in the
Home services is to provide an equivalent
care to that which you would get in
hospitals,” he said.
“They will get everything from nurses
who will perform standard observations
– blood pressure, pulse and the like, who
may have the ability to perform point of
care testing for certain things like blood
sugar or INR monitoring.”
Pauline Dobson, a clinical nurse
consultant in the immunology and
infectious diseases unit at John Hunter
Hospital, Newcastle, has witnessed the
positive impacts of this alternate model
She says that patients experience a
variety of benefits from receiving care in an environment that
Dobson explained that the nurse may tailor treatment to a
once or twice daily visit. Everything is undertaken at this visit
– so a daily/continuous antibiotic may be given rather than
one that need to be given bolus qid.
“Point of care testing may be utilised to give the HITH nurse
an immediate pathology result and some services are using
mobile technology as well,” she said.
A systematic review printed in
the Medical Journal of Australia
last year suggested that the review
“demonstrated that HITH reduces
delirium, but it may also reduce
iatrogenic infections, galls and adverse
Dr Collins said that the majority of
patients think the program is a great
idea, with about 99 per cent taking up
the opportunity of a hospital in the home
program when offered.
“They get to sleep in their own bed,
eat their own food, watch their own TV,
and for some there is an opportunity to
engage with the workforce – through
mobile technology and internet-based
technology,” he said.
There is not only significant patient and carer satisfaction
and confidence with such programs, but nurses and medical
professionals are quick to provide positive feedback of the
privileges of working within someone’s home. “Generally,
once being managed on their own turf and not in a foreign
environment of a clinical unit or ward, patients are far more
receptive,” Collins said.
“So I think staff get a greater level of satisfaction out of the
There is presently much concern around the country over
emergency departments failing to meet national standards
and governments are also seeking to reign in health costs.
This program could help ease the financial
pressure on hospitals by reducing bed block by
allowing patients to be discharged earlier and
cutting inpatient bed day costs.
Cost depends on the individual clinical case,
so there are some situations where this is clearly
more cost effective – such as the management
of deep vein thrombosis.
With a suggested $775 million being pulled
from the NSW health budget, Collins believes
that this is effective alternative model to providing
acute care in hospitals.
“What it does is utilise the available technology
and clinical experience of usually very
experienced nursing staff in particular – medical
and allied health staff also,” he said.
“It uses those staff in a very patient-focused
multidisciplinary way to deliver care in an
alternative setting – so it’s able to identify and
risk manage patients.
“It’s not all rocket science, some of it is pretty simple, but
is a logistical change moving slightly away from the bigger
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February 2013 | 27
on road to
provision of acute care
for those with mental
health problems and
what is lacking for
ursing professionals working in
acute care settings frequently
provide the only clinical contact
such patients receive. Acute care teams in
mental health services encounter clinical
problems including adjustment reactions,
episodes or deteriorations in established
severe mental illnesses, and problems
arising from the abuse of illicit drugs and
The challenges faced by those clinicians
include the assessment and initial
engagement of the patient or “client”,
formulation of the risks posed by these
problems, provision of psychological
interventions and the co-ordination of
A typical day for a nurse clinician working
on an acute care mental health service may
• assessments of “walk-in presentations”,
referrals from other health services,
government agencies or police
• provision of education, counselling,
clinical review and psychological therapies
• home visits, medication supervision and
clinical review of patients in their homes
• transporting patients to medical
appointments, liaising with psychiatrists
or GPs and the implementation and
supervision of medications
• participation in care planning or
multidisciplinary meetings with other mental
• counselling and supporting carers and
Nursing clinicians are part of the patient
journey for a patient with an acute mental
health problem at every point.
28 | February 2013
Like many people with mental health
difficulties, the primary challenges faced
by people in acute distress arise from
the lack of resources needed to provide
Consider the example of a young
man with an adjustment disorder who
has expressed suicidal ideas to his GP.
The GP contacts the acute care service
and the patient is assessed by a nurse
clinician including details of symptoms, life
stressors, personal background, current
lifestyle choices and previous history.
The nurse clinician then formulates an
initial management plan focused on risk,
and the patient’s clinical team is tasked
with this care. Nurse clinicians will then
engage the patient in a care program,
regularly assessing the patient’s progress
and modifying the management plan in
response to this.
The patient may require advocacy to
different government agencies, clinical
services or interventions aimed at resolving
the crisis that brought the patient to the
point of distress. Once the crisis resolves,
the nurse clinicians participate in discharge
planning, referral to further medical care
and provision of follow-up. The process
of appropriate continuity of care requires
close attention to clinical handover and the
provision of a comprehensive account of
the patient’s care.
Like many people with mental health
difficulties, the primary challenges faced by
people in acute distress arise from the lack
of resources needed to provide adequate
services. Mental health services have been
consistently under-resourced and politically
attractive funding programs are usually
“one-off” and tended to flow towards the
well-advocated needs of the youth mental
The kind of mental health services
needed to contain patients with severe
disturbances are state-funded, meaning
that any funds directed towards them tend
to disappear into the quagmire of state
Nurses working in acute care mental
health settings face increasing burdens
of administrative duties, and work in
institutions with low-tolerance of risk. They
are tasked with multiple responsibilities
in the face of an ever-diminishing
pot of resources. Despite this, their
professionalism, dedication and the high
standards of care they provide to those in
distress is an inspiration to work beside. n
Michael Robertson is a clinical associate
professor of psychiatric ethics at the
Centre for Values, Ethics and the Law in
Medicine at the University of Sydney. He
has worked in community mental health
for well over a decade and works as a
psychiatrist in the Marrickville Community
Mental Health Service.
talk about it
Getting men to discuss health
issues, especially with their mates,
could help reduce the gap between
male and female life expectancy.
By Amie Larter
ompared with their counterparts
around the world, Australian
men fair well and generally can
expect better health and longer
life expectancy than males in most other
countries. However, on average Australian
men have a shorter life expectancy than the
women, leaving many questioning why this
Mens’ lifestyle choices could be
contributing factors seen in the results of
recent research that suggests they are 84
per cent more likely to die from gendercommon cancers than women.
According to research from Cancer
Council NSW in 2011- 2012, by combining
less healthy lifestyles that include smoking,
obesity and excessive alcohol consumption
with ignoring warning signs of a health
problem – men are more likely to develop
these serious conditions.
Professor David Smith, research fellow
in the Cancer Research Division says there
are a number of reasons for this.
“Firstly, men are more likely to develop the
cancers that are deadly – they have higher
rates of lung cancer, bowel cancer and
cancers of the head and neck,” he said.
“In 2011–2012, more men were
overweight or obese than women (70.3
per cent compared with 56.2 per cent),
men were more likely to smoke daily than
women (18.2 per cent compared with 14.4
per cent) and men were also three times
more likely to exceed the alcohol guidelines
than women (29.1 per cent compared with
10.1 per cent).”
Men are more likely
to develop the cancers
that are deadly – they
have higher rates of
lung cancer, bowel
cancer and cancers of
the head and neck.
This leads Smith to the second element
skewing the health outcomes of Australian
males – lifestyle choices.
“Men are putting their lives in danger
by drinking more alcohol, smoking more
tobacco and having higher overweight and
obesity rates than women.”
Smith said health professionals should
be vigilant by checking male patients’
health, ensure they are adhering to
screening guidelines, talk to them about
their general diet, lifestyle habits and
wellbeing. Encouraging them to actively
look after their health and to come forward
with symptoms rather than ignoring them.
The Cancer Council NSW has launched
the Sh*t Mates Don’t Say campaign to get
blokes talking and acting on their health.
The campaign is the first in a number of
Cancer Council initiatives solely aimed at
men, in particular those in the 30-50 age
“This is the age where lifestyle habits
and behaviours can have the greatest
impact on later risks for deadly cancers,”
Smith said. “Men are encouraged at any
age to look after their health, but we are
encouraging men to start good habits early
in the hope they stick with them throughout
The professor of primary healthcare and
director of the Men’s Health Information
& Resource Centre at the University of
Western Sydney, John McDonald, believes
that a lack of communication and engaging
with males could be part of the problem.
“Why is it that the health services –
doctors, clinical health and nurses – have
not been as involved in engaging men as
they have been in engaging women?” he
“Some of these answers are easy to get
because of child-bearing, but that doesn’t
justify the neglect I perceive in the services
reaching out to men.”
While he does admit that overall men do
attend fewer services, he believes that a
lack of communication in general should be
to blame, rather than “only blaming men for
not taking care of their health”.
In order for medical professionals to
be able to connect with males on a more
effective basis, MacDonald says our
medical services need to become more
“We want men to men – we want part
of men’s agenda to be able to talk to
their mates, talk to doctors and nurses
– given the occasion. It also requires
genders sensitivity. We need to think
February 2013 | 29
about men and how nurses, doctors and
other professionals can be more gender
MacDonald’s thoughts are backed up by
the National Male Health Policy, created in
2010 as a framework for improving male
health across Australia – with a focus on
taking action on multiple fronts.
It listed six main priority areas to focus
on which included a greater focus on
health equity between population groups
of males, improved health for males at
different life stages and improved access to
healthcare for males.
Accessibility and personal ownership
Stephen Lillie, men’s health co-ordinator
at Hawkesbury District Health Service
believes that in addition to better
engagement with men, which should
include a focus on making services
more accessible, that men need to be
encouraged to take personal ownership
over their health.
“In some sense, the best way of saying
it is: ‘why would you take your car for a
service every six to 12 months but forget
“Men do need to take their own health
more seriously – it’s the biggest vehicle
they have got, it’s going to last them a
lifetime so they need to look after it.”
Dr Devesh Oberoi, doctoral research fellow
at Curtin Health Innovation Research
Institute (CHIRI), believes greater education
is necessary to encourage men to take
better care of their health.
“There is a need for mass education
programs to emphasise the requirement
for being more careful about health, not
neglecting or ignoring symptoms and
to curb delay in seeing a GP for their
symptoms even if they are non-specific,”
“Mass screening programs for various
cancers and limited use of cigarettes
and alcohol should be promoted and
implemented in the society. There is also a
need to check if medical and nursing staff
are adequately prepared to address the
health needs of men.”
Oberoi is currently conducting research
into the help-seeking behavior of men in
regard to the lower bowel symptoms such
as rectal bleeding, persistent change in
bowel habit and abdominal pain.
In Western countries, these symptoms
are common – with 15-20 per cent of
people experiencing these problems.
However, the problem lies in how many
people are actually addressing the problem
with medical attention.
“The rate of seeking medical advice for
lower bowel symptoms is quite low with 6080 per cent of people with these symptoms
not seeking medical advice,” Oberoi said.
“Thus, my research focuses on the
factors that may influence men’s decision
to seek help.” n
According to Cancer Council NSW
and the Australian Bureau of Statistics:
• Compared with women, Australian
men are 84 per cent more likely to die
of cancers that are common to both.
(Source ABS:3303.0_1 – Causes of
• In 2007–08, men were less likely to
report that they have GP check-ups at
least annually than were women (49%
compared with 62%). (ABS: 4102.0 Australian Social Trends, Jun 2010)
• Overweight and obesity: in 2011-12,
more men were overweight or obese
than women (70.3% compared with
56.2%). (ABS: 4364.0.55.001 - Australian
Health Survey: First Results, 2011-12)
• Smoking: Men were more likely to
smoke daily than women in 2011-12
(18.2% compared with 14.4%)
• Alcohol consumption: Overall,
men were almost three times more
likely to exceed the guidelines than
women (29.1% compared with 10.1%,
• Fruit and vegetable intake: taking
both guidelines into account, only
5.6% of Australian adults had an
adequate usual daily intake of fruit and
vegetables. Women were more likely to
meet both guidelines than men (6.6%
and 4.5% respectively).
30 | February 2013
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February 2013 | 31
Looking after the sick can be
demanding so nurses need to keep fit
and healthy and plan for holidays.
Crafting a plan on how you anticipate and
envision the year ahead is the first step.
However, it’s important to be realistic,
“Take baby steps – too grand an
ambition could cause early disappointment
when things don’t go as we hoped,” she
said. Plans and goals need to be attainable
and should focus on both personal
Stay motivated and focused
Nurses are constantly exposed to sickness,
which is always stressful for the patient and
their families, as well as the carers. Murray
suggests that it is important to be able to
step back and remain strong, in order to
successfully help others.
“It is best to be empathetic,
however, not involved or we can
become emotional wrecks.”
contributor of workplace
stress can be other
staff. Office politics
are rife throughout
all industries –
and nursing is
32 | February 2013
Make a plan
and skills is an
excellent tool for
as well as opening
up career opportunities
and pathways. A key element
of the job, professional development
courses and training will help nurses stay
abreast of new standards, methods and
Murray said to remember that some of
the worst things that happen can turn out
to be blessings in disguise – though at the
time it never seems that way.
“Often it presents as a ‘crossroads’ and
it is why you make the decision you do that
will determine the next path you choose.”
he normal cycle of events means
we return to work after a break
feeling refreshed and ready to
tackle a new year of work. However,
planning how to maintain that feeling and
survive the rest of the working year can be
Patricia Murray, author, positive life coach
and nursing veteran of more than 50 years,
gave Nursing Review her tips on how to
ensure the year ahead is a good one – on a
personal and professional level.
If you look at
the Wheel of Life
the sections are for
other, fitness, family,
fun and recreation,
health and physical
before you start the year to be professional,
and not enter into discussing other staff
will bode well for your sanity as well as
reputation. When people know that you
don’t gossip, you build up respect and will
not involve you.
Murray explains that the working
environment itself poses its own
“Accident and emergency work has
its own problems with inebriated and
sometimes violent patients, there should be
protocols in place to protect you, report it
if not. Join the nurses association, they are
there for you.”
Realistically, there will be a couple of bad
days, but Murray suggests it is how you
cope with problems when they arise. “Of
course there will be some disappointments,
but if we have strategies to turn problems
into stepping stones we will grow through
the process,” she said. “The Zen saying
is that the road that appears to be the
hardest is often the best road to take.”
If you look at the Wheel of Life the sections
are for career, personal growth, friends,
money, significant other, fitness, family,
fun and recreation, health and physical
environment. All segments need to be
fulfilled for a well-balanced life.
Creating an effective work/life balance
is essential to make it through the working
“When you are on duty, be on duty –
not discussing the great night out you
had with patients having to listen in,”
Murray explains. “It is inconsiderate and
unprofessional but I have seen it happen
Just as important, is not letting work
occupy you when you are off duty. Time
off is precious and relaxation is a must. If
you get the opportunity for a change of
scenery, even if it is just for a weekend, this
can be a fantastic way to break up routine.
“Hobbies, cultural pursuits, dancing and
most important friends and family all help
keep us sane and revitalised off duty,”
Murray said. “It is not called REcreation for
Maintaining a healthy diet might sound
cliched, but choosing the right foods not
only reduces the risk of serious illness
but also improves mental and emotional
health. Regularly adding fruit, salads and
vegetables to your diet will keep you on the
Staying fit will also increase your physical
and mental health – we live in a great
country where outdoor exercise can be
enjoyed nearly all year round.
“Make your own health a top priority,
good dietary choices and lots of healthy
outdoor exercise is important to maintain
wellness so you can care for others,”
“Plan the years’ holidays and breaks
as well as the work; get sufficient sleep
especially if doing shift work. Our circadian
rhythms are really upset with night duty or
travelling overseas.” n
• Make a conscious decision about
your career in regard to where you
are heading. Consider long-term
ambitions and plans on how to get
• When you decide what your goals
are, decide what you need to do to
achieve them. Do you require further
training or to complete additional
• Make sure your plans are
congruent with your beliefs and
ideals in life, not someone else’s.
• Eliminate self-limiting behaviours
and build up your self-confidence.
• If you decide to undergo further
training, make sure you have enough
in the bank to fund it.
Choose HIP for Super Benefits
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February 2013 | 33
15/01/13 2:18 PM
he implicit – and often explicit - message
received during my study was: “Aged
care – it’s not real nursing.” This care was
apparently for those who themselves were only one
step from moving from nurse to resident.
It wasn’t real nursing; just baby-sitting with
copious hygiene regimes. Real nursing was gung-ho
procedures and fast critical thinking.
Well that might be so on television, but in the real
world it seems to this writer that aged care comes
closer to real nursing than one finds on the average
ward in an urban hospital.
Jazwiec says it really well. Paraphrased she
writes: “Healthcare, and especially nursing, was
created to make people feel better. Even in its most
basic, original form, it made people less anxious and
more comfortable. It made a difference.
“Many say: ‘No, healthcare was started to heal
and cure’. But this is wrong.
“When healthcare first began, we didn’t know
how to heal and cure. All those first caretakers
could do is make people more comfortable, help
them feel better, and do a lot of praying that they
hoped would make a difference.” (Liz Jazwiec, Eat
that Cookie, 2009).
In aged care often all that can be done is to
give care and comfort, but this is the original
and hopefully still the essence of nursing. When
compared to ward nursing it is, arguably, aged care
that is real nursing.
Consider the facts. Ward nursing in many instances
resembles a conveyer belt of endless medications,
observations, hygiene and ordered procedures. There
is usually simply not enough time amidst all the tasks,
and especially amidst all the paperwork, to truly see
the individuality of each patient.
There is little time for the healing touches of
meaningful conversation, reminiscence therapy, or
even the moisturising of dry skin; and time to share
Healthcare, and especially nursing, was
created to make people feel better. Even in
its most basic, original form, it made people
less anxious and more comfortable. It made a
34 | February 2013
a cup of tea with a patient is a fantasy. There is little
time for the basic human connection that was once
the soul of nursing.
Yet in age care the opportunity for such gentleness
is often not only possible but it in fact forms a
therapeutic cornerstone of the person-centred care
that aged care nurses strive to deliver.
Oh yes, says the haughty ward nurse, but there is
little scope for critical thinking in aged care. Again,
the facts. Ward nurses may do all the critical thinking
they like, but the only autonomy they really have is to
consult the doctor.
Most ward nurses, even with years of experience,
can not initiate as much as a paracetamol table
without written permission.
In contrast, it is the aged care nurse who most
often makes the routine, and the critical decisions,
in a nursing home. Nurse initiated medication and
procedures are second nature to the aged care
nurse. For these nurses there is no safety net of a
ward doctor to call upon when in doubt.
It is the aged care nurse who most needs critical
thinking to assess deterioration in a patient and to
make and enact intervention decisions; decisions
usually made alone or with only fellow nurses to
This is only an opinion but perhaps it is time that
many in the profession ceased their condescending
and often degrading comments of aged care nursing
because it is in fact, very much real nursing. n
Peter Kieseker is in the second half of a graduate
transition year (mature age graduate). He is currently
working on a medical ward at Caloundra Hospital
and before that worked at an aged care/aged
Internationally recognised palliative care nurse
Molly Carlile spoke to Amie Larter about her
career, recent awards and thoughts on the future
When did you realise you wanted to
have a career in nursing?
I fell into nursing through circumstance and
if I’m honest, struggled for the first couple
of years. The change for me came when I
looked after my first dying patient.
It was then I knew I’d found my purpose
and from that point on, I specialised in
palliative care and my subsequent studies
and experience were guided by what I
needed to learn to help people die in a way
that was right for them.
I knew I needed to be able to support
grieving patients and families so I studied
counselling, then grief and loss, as well as
education to be able to teach young nurses
how to care for dying patients.
I then went on to study management
and leadership, so I could make sure that
structures were in place to support personcentred care for dying patients and families.
Finally, I became drawn to health promotion
by the need to inform and educate
communities so that death would no longer
be a taboo subject and that people would
feel confident to support grieving friends,
families and neighbours.
Is this how you acquired the title
‘Deathtalker’ and what does it involve?
I call myself the Deathtalker because that’s
what I do. I encourage people to talk about
death in order to become better informed
and empowered to have meaningful
conversations in their families and in the
wider community. What does dying look
like? What happens? What can I say to a
dying or grieving person? How can I help?
These are all questions that the public
struggle with, because no one has
conversations about stuff that matters. I try
to raise awareness by speaking at public
events, in the media and at conferences,
etc, and have written books and plays as a
way of getting people to think about these
What does your current Monday to
Friday job role entail?
I manage palliative care services at
Austin Health in Melbourne. We have a
20-bed unit and an acute consultancy
team that provides services to our acute
tertiary hospital. My role is a strategic
and operational one. I’m responsible for
ensuring that patients and families get the
best possible care, that staff are supported
in providing that care and that our services
constantly evolve based on the needs of
people in our community.
I’m also responsible for planning the
transition of our services into the new
Olivia Newton-John Cancer and Wellness
Centre, which will open for inpatient
services in July, so there’s lots going on at
the moment. My other role is as manager
of arts in healthcare at the cancer and
wellness centre, which involves planning an
integrated arts program for the centre that
will humanise the facility and provide arts
based programs that engage patients and
families and create a “safe space” for them.
person to express their fears and concerns,
a nurse can change a dying person’s whole
experience and facilitate a “good death”
as defined by that person. So I try to get
nurses to explore their own feelings about
death, their own “hang-ups” and reflect on
how their personal views can influence the
care they provide to dying patients.
What prompted your passion for
generating awareness of death and
grief issues for nurses?
Nurses are no different from the general
public, we are a people first, nursing is
just what we do, so lots of nurses have
the same “hang-ups” as everybody else.
Most nurses choose their career because
they want to make people better, they want
to make a difference and when they are
caring for a person for whom cure is an
unrealistic expectation, they feel like they’ve
failed and they take it personally.
This can really eat away at them. They
too, don’t know what to say, don’t know
what to do - they feel like they can’t make
a difference. But you know what? They
can. They can make a huge difference,
by connecting with the person, listening,
supporting, nurturing and allowing the
You received an international,
national and state award last year.
What were the awards and what were
What advice do you have for nurses
that are regularly faced with death?
Understand yourself first. What are your
fears and apprehensions you have about
your eventual death? What does a “good
death” look like to you? What are the
elements of caring for dying people that
stress you? Once you are more self-aware,
you are better able to establish self-care
practices that ensure your resilience and
once you are more resilient you are better
equipped to provide truly individualised
care for patients that is not influenced by
your own judgments, beliefs and values.
Self-awareness, self-knowledge and selfcare … that’s the trifecta!
I received the International Journal of
Palliative Nursing Educator of the Year
Award in London, in March, for my work
in educating nurses about death, grief
and palliative care. The Deakin University
and HealthSuper Leadership in Nursing
and Midwifery Award was for outstanding
leadership and commitment to the
profession, for my work promoting and
educating nurses. And the Minister’s
Award for outstanding achievement by an
individual or team in healthcare, at the 2012
Victorian Public Healthcare Awards was for
work in palliative care in the public health
environment and for my health promotion
work in the community. n
February 2013 | 35
Anorexics force legal decision
with a lifethreatening
36 | February 2013
highly cherished ethical principle that
courts jealously guard is that of autonomy;
the patient’s right to exercise selfdetermining choice.
Accordingly, it is for the patient to decide
what treatment or procedure they consent to.
The principle does come under challenge in
circumstances where a patient is not competent
(lacks capacity) to make such decisions.
The difficulty is that a person’s level of
“competency” is not always easy to determine.
Perceived unreasonableness of a patient’s decision
is not enough, it must be that the patient lacks the
ability to undertake rational decision making.
The eating disorder anorexia nervosa can pose
many dilemmas in this area; at what stage is it an
illness which triggers provisions under a Mental
Health Act (thereby overriding issues of consent on
the basis of treatment being in the patient’s “best
At what stage of malnutrition does the patient
physically become cognitively incompetent, if the
patient gives an Advanced Directive when competent
can this be overridden or should a patient be allowed
to die by not eating if that is their choice?
A 2012 case is enlightening in response to these
questions. It related to a UK woman, referred to as
patient E, who as a former medical student was
suffering from several chronic health conditions,
including alcoholism, anorexia nervosa and unstable
Her anorexia was thought to stem from sexual
abuse she suffered, unbeknown to her family, earlier
in her life. She had a long history of admissions to
hospitals for physical and mental conditions.
In mid-2012, she signed advance consent forms
stipulating that she did not want any medical
intervention to prolong her life. At the time of the
court hearing later in 2012 patient E had not eaten
solid foods for more than a year, had a BMI of 11 to
12 and she was in poor physical condition. Patient
E described her life as “pure torment”. According
to a psychiatrist and eating disorder specialist her
chances of recovery in any event was between 10
and 20 per cent.
There existed a number of unique circumstances
that made decisions very challenging for the
court. Patient E appeared to be fully aware of her
circumstances in that, whilst she did not desire to
die (i.e. no suicide ideation) she did not desire to eat,
she was aware of the certainty of death from such a
decision and the actions of being “force fed” would
deprive her of a relatively peaceful death.
Further complicating the matter was the
existence of two previously drawn up Advance
Directives, written whilst not subject to any Mental
Health legislation, making her intentions and wishes
A question which the court (retrospectively) had
to determine was whether patient E had capacity at
the time of making the Advanced Directives; could
she understand all relevant information, retain it, use
or weigh it to make a rational decision.
Such an assessment necessarily employs inexact
science and a degree of subjectivity. Patient E was
found to lack capacity to make a rational judgment
at the time of the Advanced Directives and hence,
her wishes (and autonomy) would be overridden. On
the balance of probabilities, the court thought that
force feeding would do more good than harm, whilst
acknowledging it would deprive her of a relatively
The other concept is that of “best interests” often
at the heart of thorny decisions involving medical
ethics. Would patient E’s best interests be served by
letting her die or by forcing her to live? How does a
court define what are those best interests in the face
of someone wishing to die?
The court believed that, although force feeding
patient E would be intrusive and difficult, this course
of action had a chance of saving her life. The court
stated it would not have ordered so if it felt that force
feeding would be futile.
The judgment makes it clear that preservation
of life must be accorded a very high value and in
this case justified intervention. Yet in the balancing
act of respecting the right to autonomy, against
overriding the same the court acknowledged there
were no prescriptive set of guidelines or rules
which it could follow. In the final analysis the court
stated it had to rely on “intuition” that it was making
the right decision.
It may be that a civil libertarian does not
believe in patient E’s wishes being overridden
due to the violence, duration, and trauma of
forced feeding (with evidence equating this to
being re-traumatisation of the child sexual abuse
experiences) in circumstances of a grim prognosis,
and that patient E’s clearly articulated wishes (even
without legal capacity) outweigh the preservation
of life. In such a weighing process there is no easy
and certainly no definitive “right” answer provided by
either law or ethics.
As a footnote, contrast patient E’s case with that
of patient L who was 29 and during her last 15 years
of life spent 90 per cent as an in-patient. At the time
of the court hearing she weighed just 20kg and
her BMI was 7.7. Like E, patient L did not express a
desire to die, but stated that her severe anorexia “did
not allow her to eat” – a “morbid fear” of ingesting
any calories might lead to an increase in weight. In
patient L ’s case the court concluded that although
nutrition and hydration should be offered, staff were
not permitted to use force to administer food, water
or medicine. Her autonomy was preserved; she died
just as she wished. n
Scott Trueman is a lecturer in the school of nursing,
midwifery and nutrition at James Cook University.
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February 2013 | 37
1/25/2013 12:01:55 PM
Community nurses will be assisted by an online course to help
them understand the health issues of war veterans.
new online course launched by
the federal government will give
nurses greater understanding of
the common mental health issues faced by
Australia’s 325,000 war veterans, widows
The issue of mental health
disorders amongst Australian
Defence Force personnel,
both serving and retired, has
gained prominence in recent
years, with health officials
expressing concern at the
extent of illnesses.
The vetAWARE course
was developed to raise
further awareness and
provide up-to-date information
to nurses supporting these
Minister for Veterans’
Affairs Warren Snowdon
announced the course in
January, a commitment from
the government to provide
based mental health care for veterans.
“Working with the medical community
to increase their awareness and
understanding of veterans’ mental health
conditions is an important part of this
work,” he said.
“The vetAWARE course increases
nurses’ understanding of the common
mental health challenges faced by
veterans, and how best support them and
Dr Stephanie Hodson, mental health
adviser for the Department of Veterans’
Affairs, is a ADF veteran herself – awarded
the Conspicuous Service Cross for service
in the Middle East area of operations and
She described the course as an
interactive tool that focused on using a
range of different techniques to appeal to
different types of learners.
“The course has a number of different
media platforms in the online training to
make it engaging. It has short videos,
short presentations from military experts,
engaging hypothetical scenarios and
includes puzzles to solve and regular
quizzes to test knowledge.”
Those that undertake the 90-minute
course can expect to gain a better
understanding of a range of mental health
issues faced by veterans including how
to identify them, what’s the best ways
to initially deal with them – and what
are the specific issues you should
be looking at for veterans in
“Community nurses in
particular have regular
contact with and are major
parts of the lives of some of
our very vulnerable clients,”
Hodson said. “They
are likely to be some
of the first people
who are likely to
Mental health problems common to
those who have served in the military
include post-traumatic stress disorder,
depression and alcohol-related disorders.
“Across a service or military career,
veterans will have been through a number
of potentially traumatic events or stressful
deployments,” Hodson said. “This is
training specifically for nurses dealing with
veterans who may have more complex
The vetAWARE course is endorsed
by the RCNA and offers 10 Continuing
Nursing Education points and Continuing
Professional Development points.
At present it is only available to DVA
contracted community nurses, however,
due to positive feedback the department is
now working to make it generally available
to nurses. n
For more information, visit the DVA
of the training
• Understanding the veteran
• Overcoming the stigma related to
mental health issues
• Understanding the role of
• Identifying factors that can affect or
co-exist with mental disorders
• Recognising and responding to
mental health disorders
• Building skills to establish trust,
communicate effectively and work
• Setting boundaries and applying
• Understanding referral pathways
and available resources
38 | February 2013
February 2013 | 39
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