It’s not only ICU under pressure

While there’s most focus on ICU, then ED, and sometimes aged care, the pressure of two years of a pandemic followed by opening up (despite the emergence of omicron, which wasn’t factored in to those plans) means nurses are struggling wherever they work. Midwives are coping with a baby boom that hasn’t been accompanied by increased resources, allied health staff have been pulled from their areas of specialty to provide fundamental nursing care assistance, Registered Undergraduate Students of Nursing or Midwifery (RUSONs and RUSOMs) are working alongside nurses and midwives in a team model that was never part of their role, and doctors and working longer hours than their usually unsafe, exhausting schedule.

As one of my medical colleagues wrote, after reading the first version of this post on FB,

“And add to it all that in the current wave, numerous staff are testing positive with (community acquired) Covid, thanks to the nature of Omicron. Most are only very mildly unwell, as we are all vaccinated – but the health service I work at had over 7% of all the work force off with Covid according to an ‘all staff’ email last week, and at least as many more off because a member of their household had tested positive. It simply isn’t possible to do business as usual with that many staff unavailable, and the numbers testing positive (and the numbers of Covid patients adding to usual work loads) rise every day. The system is under strain like never before.”

And the numbers are increasing.

Some people have snidely asked me on Twitter how much the vaccine mandate has had to do with staff shortages. I don’t have official figures but I’ve heard informed estimates of 150-175 Victorian nurses and midwives, from a workforce of some 90,000.

It’s not that, it’s the impact of unrelenting numbers stretching a system that, in every state and territory, was running at or near 100% capacity before COVID existed. When you view healthcare through a financial lens rather than as an essential service, decisions focus on cost cutting, and the highest cost is staffing. The primary reason for in-patient care is for nursing (from monitoring to interventions), and nurses are the biggest part of the workforce – hospital staff are paid fortnightly so pay roll can process our pay one week and everyone else’s pay is processed in a separate cycle.

As hospitals seek to reduce the nursing care we provide through measures like Hospital in the Home, patient churn has dramatically increased. ‘Churn’ is the turnover of hospital beds – nobody gets one unless their care can’t be delivered otherwise, so someone with sub-acute bacterial endocarditis (a bacterial infection that irritates the lining of the heart) now has an RN visit three times a day for IV antibiotics instead of having a six-week inpatient stay. And while this has all kinds of patient benefits (it’s less disruptive, they have far fewer complications) that I fully support, it also means in-patients are more acutely ill: they have more comorbidities, need more interventions, and are at higher risk of suddenly deteriorating. All of which means they need more nursing care.

Add COVID to that mix and my clinical colleagues, wherever they’re working, in whatever role, are weary to the bone.

The problem with “let it rip”

Tags

COVID-19, pandemic, public health

CW: stillbirth, miscarriage, birth defects

After two years of trying, to varying degrees, to minimise COVID transmission by modifying our behaviour (through public health measures including social and physical distancing, masks, episodic lockdowns, check ins, contact tracing, and immunisation) the Australian government has adopted an individualistic, personal responsibility approach it frames as ‘living with the virus.’ This is colloquially referred to as letting COVID rip.

Maybe “let it rip” would work with something like rubella, if you were a monster. Sure, any pregnant woman contracting it would have an increased risk miscarriage, stillbirth, and of her baby developing any combination of congenital cardiohepatosplenic disease, impaired vision and/or hearing, and intellectual disability, but that’s only if she contracts it in the first trimester, and not even a problem for all first trimester foetuses.

And sure, it can cause encephalitis in children and adults, but that’s rare. Joint pain that takes a month or more to settle is more common, but only in women, which means only 35% of adults would be temporarily affected by it, and the disease itself is almost always mild.

But even if you agree that these risks are acceptable on a macro-level, you only get rubella once, and the vaccine is almost 100% effective for life for almost everyone.

“Let it rip” is not a viable aim for a disease you can contract more than once, without guarantee that subsequent episodes will be decreasingly severe, and with each bout carrying the possibility of developing any one of dozens of long term disabilities that can affect almost any system.

COVID is an airborne virus that (most likely) affects small vessels, resulting in tiny clots.* That’s a major simplification, of course – it can also involve hyperinflammatory responses, widespread coagulopathy, blood vessel damage, changes to blood cell morphology, and survivors can be left with damage from infertility and erectile dysfunction to irreversible impairment of any vital organ, extreme fatigue to neurological impairment equivalent to a decade of ageing.

There are international reports of people contracting COVID more than three times, so far, with differing symptoms and post-viral effects (from nothing to profound debility or disability) each time.

Odds are a virulent, genuinely mild variant will evolve, eventually, and become the dominant strain. That this will become something we can vaccinate against annually, and only worry about if we’re older or immune compromised (which is absolutely not me saying either of these groups is okay to be put at risk).

But omicron is not that variant, and we are a long way from being able to live alongside this virus without precautions, whatever business, economists, and politicians more influenced by them than constituents would like to believe.

• One near-universal caution is not to take prophylactic blood-thinning medication, as we don’t even know enough yet to know if that will increase the risk of complications.

We need to give up on herd immunity

Tags

breaking research, COVID-19, health care, nursing, pandemic, population health, science, vaccination

A pre-published Iranian study (https://www.medrxiv.org/content/10.1101/2021.10.04.21264540v1) confirms what experts have been saying from early in the pandemic – striving for herd immunity is hopeless. Contracting COVID-19 doesn’t confer immunity, but vaccines do, at least for a while.

The colour-coding in the map below indicates the average number of times residents in each province have been infected – the darker green, the more instances.

In three provinces (Kurdistan, North Khorasan, Qazvin) the average rate over 5 surges across Iran is >1.5 times for every person – 1.55, 1.57 and 1.63 respectively, over 21 months.

This rate was higher in Baluchistan and Sistan – the average infection rate was 120% by January of this year (i.e. in the first year of the pandemic) but despite this exposure, the fourth and fifth surges were the deadliest, and every person living in these provinces contracted COVID-19 2.5 times on average.

The odds are still good that SARS-CoV-2 will eventually mutate into a flu-like illness that’s predominantly benign for the majority of people, but the question is how long that will take.

While we still can’t say with certainty how long acquired immunity is effective, with over a billion people world-wide double vaccinated we do know that all the available vaccines substantial reduce every risk: contracting the virus, passing it on, being symptomatic, becoming significantly ill, requiring hospitalisation, needing ICU-level care +/- intubation +/- ECMO*, dying, and developing long COVID.

How do we avoid following Iran? Get vaccinated, continue to wear masks and social distance, and support our exhausted frontline workers.

* Extracorporeal membranous oxygenation (ECMO) is like dialysis for lungs that are too damaged to exchange gases. If you need it then you already have a tube down your throat so you can breathe, drugs to sedate and paralyse you, other drugs to keep your blood pressure stable, a catheter into your bladder to drain urine, intravenous fluids, and nutrition either through a tube into your stomach or directly into your blood stream. At a minimum.

Adding ECMO is a big deal. It can only be done in major hospital ICUs, is needed 24-hours a day until you die or your lungs recover enough to exchange oxygen and carbon dioxide again, and requires even more drugs to reduce complications (like blood thinners to stop your blood clotting in the tubing or machine).

How many aged care deaths before the government acts?

CW: although the most graphic photo is censored, the ABC story linked below contains distressing descriptions of abuse and neglect

The COVID-19 pandemic has highlighted many of the problems and inequities in our community, and none more so than the devastating death toll in nursing homes. We saw more deaths In Victoria, which has the most publicly-owned nursing homes (180 out of some 780 across the state), than across the rest of the country combined – but only a handful of cases and no deaths in the state-run facilities. It’s true that the majority of these are in regional and rural settings, where there were fewer cases of COVID, but two of the largest Victorian-owned nursing homes are in Melbourne, and their residents survived virtually unscathed.

The primary difference? Mandated staffing numbers and mix.

There’s a lot of money flowing around the aged care sector, particularly residential aged care but, although it’s obvious just on the face of it that older people who need supervision and/or assistance with daily living activities (which is why they live in nursing homes) have complex medical needs, sometimes complicated by dementia and other psychogeriatric conditions, many providers have cast their role as primarily the provision of food and accommodation. They’ve been allowed to do this because in 1997 the Howard government deregulated the sector, allowing private, for-profit groups to enter the market. That’s also when ‘residential aged care’ began to replace ‘nursing home’, and the numbers of nurses in the sector began to plummet. Providers employed more assistants in nursing (also called aged care workers, patient care attendants, and other variations), but not at the same rate as they shed registered and enrolled nurses, with both trends resulting in an overall reduction in staffing numbers and a precipitous decrease in capacity to deliver expert care.

The majority of AINs care deeply about their work and their residents, but they simply don’t have the education and experience or accountability of enrolled and registered nurses. The tasks of nursing care are, mostly, not that complicated – the reason our education programs are so long is because the key differences between us are understanding what’s going on, why, and how everything interconnects, and our ability to assess, evaluate and review. These are invisible skills, so even AINs often don’t appreciate how their care differs from that of an enrolled nurse, while ENs often see RNs as spending time on paperwork instead of direct patient care without appreciating the importance and abundance of documentation in aged care.

In all cases the staff are overworked, with far too many residents to provide optimal care for, even before they face restrictions in equipment and supplies, and every year their residents become more frail and medically complex.

The Royal Commission into Aged Care Quality and Safety ran for some two years, hearing evidence from nursing home residents, their families, staff, providers, clinicians, regulators, academic experts, and unions. The interim report was titled ‘Neglect’; the final report and recommendations are due to be released tomorrow. Watching witnesses give evidence, even reading the transcripts, was at times harrowing, with far too many stories like those reported on the ABC news program 7:30, which this week published a report about a ‘five star’ residential aged care facility on one of the country’s largest providers.*

Regis Nedland’s resident Brian Hunter’s back after being exposed to the sun on a 40 degree day (photo provided to the ABC and sourced from the linked story)

Throughout the Royal Commission process there were clear accounts that regulation and minimum standards (including English proficiency and training) are needed for assistants in nursing/patient care workers, and consistent advice from experts that no other measures will be effective without the introduction of a mandatory skill mix of registered nurses, enrolled nurses, and assistants in nursing and staff-to-resident ratios.

Despite all of this , the federal government “has already indicated it is opposed to a minimum staff training standard and wants to see better evidence that the regulator should be changed.” If they won’t even require the people caring for some of our most vulnerable citizens to complete a certificate III training program, what hope is there that they’ll act on the devastating shortfalls in care provision by increasing the numbers of nurses?

*Kudos to the six student nurses from Edith Cowan University who reported the neglect they saw – we need more people at every level with that clarity and courage

Is a FIFO workforce the answer for COVID quarantine?

Tags

clinical case study, COVID-19, nursing, quarantine

Through a combination of good luck and good management, Australia has been far more fortunate than almost any other countries when it comes to the COVID-19 pandemic, at least so far. At the time of writing we have had fewer than a thirty thousand cases, less than a thousand deaths (overwhelmingly in one state, and predominantly in residential aged care), and have 39 active cases with only ten of those being treated as inpatients. In contrast, the Netherlands (with some 8 million fewer people) and Canada (with ~140% of our population) have had over a million cases and 15,000 deaths, and some 846,000 cases and over 21,000 deaths respectively.

This is a spectacular achievement, but it also means many Australians have been insulated from the realities of the pandemic that other countries have faced, particularly the pressure on hospitals, health practitioners, and resources, but also the rapidity of COVID-19 spread, especially the newly-emerged B.1.17. and 501.V2 or B.1.351 variants. This means the key driver of precautions (from social distancing to lock down) is not understood as being avoiding overwhelming health care capacity, and a commonly-held expectation that we can (easily) prevent any cases from entering the community. In other words, any cases of transmission are the result of human and/or system errors.

A week ago Victoria came out of a five-day stage four lock down triggered when a single case of the UK COVID variant entered the community at a pace that demonstrated its increased contagability. While this lock down achieved the aim of halting the spread at 25 cases, calls for a regional site with fly in-fly-out staff have increased. This would resolve the issue of community transmission from quarantine hotel workers in a country with little to no community presence of COVID-19 for months. A fly in, fly out workforce housed in purpose-build accommodation is used in a number of industries, particularly (but not solely) mining, so how hard could it be here?

Twitter user @mattiecamp described, in a 28-post thread on 5 February, many of the logistics involved in setting up a best practice quarantine-specific facility, from the physical space needed (single-storey living units separated by 2m buffers on all sides) to minimal capacity to flex numbers up or allow for family units of differing sizes. Some of these issues would be less difficult with a number of small facilities rather than a single national centre, but most of them persist regardless, and the greatest of these is workforce. Set aside, for now, the requirement of a well-equipped hospital with ICU capacity (because people with COVID can deteriorate rapidly) that would mostly be inactive, and focus on security, cleaning, catering, logistics, and waste management staff:

It’s this last restrictions, on staff members’ free time, that I’d like to discuss in a little more detail.

The comparison of a fly -in, fly our workforce for quarantine with mining isn’t as apt as it seems at first sight, because current FIFO workers get to go to the pub, shop, and interact with co-workers and locals in their downtime. Those activities would be prohibited for quarantine staff, whose only face-to-N95-masked-face interactions would be during working hours. That isolation would need to be maintained during the staff quarantine period between finishing their block of work and flying home – another fortnight of solitude or, if you recruited couples, unrelieved intimate proximity. Quarantine leave would need to be paid, take place in a physically separate space from quarantine residents and accommodation for staff on duty, and require its own dedicated catering and cleaning workforce (who also need accommodation and leave time), to avoid any cross infection. That doubles, at least, the number of staff needed.

In Victoria, hotel quarantine workers are screened every shift by an onsite doctor and COVID-tested by nurses; these tests are prioritised, so the results are most often available before the worker has finished their shift. To replicate that speed, so any transmission is detected and curbed before it spreads widely, means an onsite or nearby pathology lab working around the clock, The pathologists and supporting lab staff may not need to isolate, but would still need to fly in and out because regional facilities don’t have an abundance of people with that education and skill unutilised, and they would also need a purpose-built lab that allows them to treat the highly infectious samples without risking transmission.

I briefly mentioned earlier the need for a well-staffed hospital able to provide ICU-level care. That would be for anyone who develops severe COVID, but we would also need health care facilities for anyone who has an acute illness or a chronic condition requiring health care oversight – even, as we saw in the recent Victorian case, an acute asthma attack. At present these needs are managed by two specialty hotels – one for people who have tested negative but have health care requirements (from assistance because of a physical disability to people requiring oxygen from preexisting cardiorespiratory disease), and one for people who’ve tested positive to SARS-CoV-2, whether or not they have signs or symptoms. Anyone in the health hotel who returns a positive test is transferred (with strict precautions) to the hospital hotel for close monitoring.

I haven’t been clinical during the pandemic, but I worked in an infectious disease ward during the swine ‘flu and bird ‘flu pandemics. As with COVID-19, most of my patients were well, with only a few (or no) symptoms, but I’ll never forget the speed with which one patient with H1N1 deteriorated. I’ve changed Mai’s identifying details* to maintain her confidentiality.

A 27-year-old business woman who had been visiting family, Mai had been afebrile when leaving China, but admitted later that she had experienced some low-level cold symptoms (headache, congestion and a sore throat) for the last two or three days of her holiday, but they were very mild and she dismissed them. Over the course of her flight to Melbourne Mai developed a runny nose and a cough, and on screening at Tullamarine had a low-grade fever. She was transferred from the airport and directly admitted to the ward (bypassing the emergency department) with a presumptive diagnosis of  “novel influenza A (H1N1),” which was confirmed when a nasopharyngeal swab was positive for the virus. For the first two days of her admission Mai was mostly bored, rather than ill. Her temperature sat between 37°C and 37.6, her oxygen saturation was at or above 94%, and she had no real difficulty breathing.

On the morning of her third day in hospital Mai reported feeling hot and, for the first time, felt slightly short of breath during her shower, and needed to sit down. She still didn’t have a fever and her vital signs (blood pressure, pulse, respiratory rate and oxygen saturation) were all consistent with her previous readings, but I started monitoring them every two hours instead of every four, and notified the Infectious Diseases team. Although her vital signs were still unremarkable at 10AM, they were all a little off – pulse and respiratory rate a little higher, oxygen saturation and blood pressure a little lower, and she looked less well. A review by her doctors about an hour later found new changes on auscultation (listening to her lungs with a stethoscope during breathing and while tapping different fields), and a portable chest x-ray confirmed pneumonia. I inserted a cannula, took repeat bloods (Mai had already had blood taken for routine biochemistry at 6AM, as usual) and began the intravenous fluids and broad spectrum antibiotics prescribed by her doctors. The blood work revealed that Mai’s kidney function was deteriorating, so I inserted a urinary catheter to monitor her output and rechecked her vital signs.

It was now 12:30, and Mai’s needed oxygen via a mask to keep her saturation above 90%, her respiratory rate had risen from 22 at 10AM to 40 breaths per minute and a lot of effort, and her blood pressure was dropping while her pulse rate was rising – Mai was developing septicaemia, and her increased rate and work of breathing weren’t sustainable for long. The ICU consultant reviewing Mai decided to admit her, she was intubated on the ward, and by 1:30PM she was in intensive care on a ventilator, with intravenous medication helping to maintain her blood pressure and correct her pH.

I’ve included this story to illustrate just how quickly some people can deteriorate, and why high level health facilities are needed alongside any kind of quarantine centre. My experience with Mai (who survived her admission and recovered her renal function) made me concerned when the federal government decided to quarantine the first people returning to Australia on Christmas Island, as it’s a four-hour flight to the nearest major hospital. While her trajectory was unusually rapid, Mai’s case wasn’t unique.

COVID, especially the more contagious variants, requires a high level of vigilance, so staff will need to rotate regularly frequently – say a three week block of work (21 consecutive days on), two weeks of quarantine, and two weeks leave. Attracting people to spend 70% of their time in lock down won’t be easy, even if the work is well remunerated, so we need to factor in ongoing recruitment costs (advertising, assessing applications, interview, HR processing, training and orientation) and retention strategies (including robust mental health support programs) to the budget.

Those are just some of the off-the-top-of-my-head issues with a FIFO quarantine model. It’s not impossible, and it may be necessary, but it would be hugely more expensive in every respect (including environmental), and take a substantial toll on workers. Creating a whole new quarantine system will not only be vastly more expensive but also have its own flaws and hiccups that won’t all be evident until it rolls out.

In comparison, the current system (though absolutely imperfect) avoids most of the issues I’ve identified. Instead of scrapping it, we would be better to address the problems that have been identified with it. There are two that contributed to last week’s cases: ventilatory systems that aren’t hospital quality, and the use of surgical masks that aren’t as effective as more expensive, less comfortable high filter masks.

In response to the transmission, Victoria’s quarantine hotels have rolled out the use of N95 masks for all staff at all times they’re onsite, except for breaks (which are staggered and monitored), which will substantially reduce the risk of another air-borne transmission from a quarantined resident to a staff member, and their infection control protocols are continuously reviewed to identify areas for improved practice. It remains to be seen if this measure will be enough, or if ventilatory systems need to be upgraded in quarantine hotels as well. Testing of existing hotel ventilation in the dedicated hospitals is planned, if not underway, which will inform that decision making. It’s the nature of this virus that we are still learning about it, and the picture is continuing to change, which means many responses are necessarily reactive rather than proactive.

What’s the take home message from all these words? I don’t have a problem with a FIFO-like quarantine worker system, but it’s not the simple answer that critics of the current system portray. If you’re still not convinced, ask yourself how likely you’d be to apply for a position that requires high-level vigilance combined with monotonous work, uncomfortable PPE that must be worn for all but half an hour of your eight or ten hour shift, mandatory shift work, little or no input into your time off, living in an anonymous government-designed suite for five weeks out of seven, with only your colleagues for company (and that only during shared breaks). Victoria had an awfully long lock down last year, and we were still allowed to leave our homes for exercise and essential shopping, care giving, and seeking health care. Only the last of these would be available to FIFO quarantine workers. What salary would be enough to attract you to those conditions? How long could you manage it?

*These changed details may include the type of pandemic influenza she had, her name, age, ethnicity, health background, presentation, and the precise sequence of events, but not the timeframe or outcome

Ensuring Integrity Bill

We have unions because they’re the only way that workers have any power. If we lived in a world where everyone acted in good faith, with honesty, integrity and accountability, there would be no need for unions, but instead we’re here.

Where is ‘here’?

It’s a country where employer after employer has been exposed as systematically ripping off their workers – very often those who are already earning low or minimum wage, and faced minimal consequences apart from restitution. That’s not an option for individual workers caught stealing from their employers, but we need to protect business.

It’s a country where the number of casualised workers rises daily, to the benefit of business and at the cost of people – insecure work means no accrued leave, no certainty, no credit, difficulty securing loans for cars and rental agreements for housing, and no disposable income to support the economy.

This, and hundreds more reasons, is why I wrote to the MPs whose votes will determine whether this legislation is passed. Here’s what I said:

Dear Senators,
I am registered nurse in Victoria. I worked at one of the most acute public hospitals for just under 28 years, caring for some of our state’s sickest patients, plus a small handful airlifted from Tasmania.
In 2000 I made the decision to leave a profession and a field I loved, because I couldn’t provide the standard of care my patients needed and deserved. On most day shifts I was responsible for seven or eight patients, and sometimes as many as twelve. Medications were late, dressings weren’t done, important conversations and patient education had to be cut short because there just wasn’t enough time.
Then Commissioner Blair introduced the world’s first nurse to patient ratios, mandating the number and skill mix of nurses based on the type of unit and acuity of facility. At the Alfred, where I worked, that meant one nurse for four patients. It also meant being able to give my patients timely, quality care, and it kept me at the bedside for another 16 years.
Ratios improve patient outcomes across multiple metrics, including falls, infections, and deaths. They also reduce direct and indirect health care costs – not only are patient admissions shorter and less complicated, staff turnover and absenteeism are reduced.
Despite this, Victoria’s nurses have had to fight to keep ratios. In 2001, 2004, and 2007 we needed to take industrial action when refusing to perform non-nursing duties (like cleaning and clerical work) weren’t enough. In 2007 I was docked a fortnight’s pay because, although I cared for seven patients, was responsible for 28, and supervised three colleagues, I closed a single bed on each shift. Like my colleagues on that ward, and across the state, I did that not for higher pay or better conditions but to keep my patients safe.
In 2012 closing beds wasn’t enough to bring the state government to the negotiating table. They didn’t just want to remove ratios this time, they also tried to introduce a slew of other ‘reforms’ that would have cut short-term costs but disastrously affected both individual patients and the sector. Changes like the reintroduction of short shifts, not seen since the 60s; this would mean working for three or four hours, going home, then returning to work but not necessarily to the same ward, or even campus. The modelling they provided, using the example of a surgical ward, left two nurses on for twenty-four patients at midday. I don’t know what experiences you’ve had with hospitals. but nurses don’t have a lot of down time at any point, and most wards are busiest between 07:00 and 13:00. But I digress.
In 2012, for the first time since 1986, Victorian nurses walked out. We left, at a minimum, the same number of staff that the government proposed, and nurses could be (and were) recalled to the floor if there was clinical need. Members were so determined not to lose ratios and other safeguards that allowed us to care for our patients that we continued to walk out after the Secretary of our union told us to stop the action. Less than a week later, the state government agreed to genuine good faith negotiations, and we kept the ratios that keep us and our patients safe.
Withdrawal of labour should only ever be a last resort, and industrial action shouldn’t be our first response – it should be what we do when lesser measures are unsuccessful. In my three decades of nursing, lesser measures have always been unsuccessful. Industrial action is taken because it works.
While the most common image of unions is of a threatening CFMMEU member, the reality is that there are far more unionists like me – a (late) middle-aged, middle class, tertiary-educated professional woman; there are more nurses, midwives, and teachers who belong to a union than any other occupational group, and under Mr. Morrison’s proposed legislation we will have no voice, no power, no way to do the work we love safely and effectively.
I am writing to ask you to vote against Scott Morrison’s union busting bill.
Repeated Royal Commissions into unions have failed to uncover any systemic corruption, something that is not true of banks. That the government hasn’t enforced that Royal Commission’s recommendations demonstrated their agenda is not about integrity, accountability, and the public interest.
You were elected to represent ordinary Australians. You have the power to stand up for working people, to be our voice. Please – vote against the so-called ‘ensuring integrity’ bill, and allow nurses to do what we do best: caring for others.
Thank you for your time,

Please add your voices to mine, and those of thousands of other Australian workers.

You can send them an email via this link, or call their parliamentary offices:

Jacqui Lambie 02 6277 3614
Rex Patrick 02 6277 3785
Pauline Hanson 02 6277 3184
Malcolm Roberts 02 6277 3694
Stirling Griff 02 6277 3128

Thank you.

Without activism we have nothing

Like so many posts, this started as a Facebook response, in this about an advertised opportunity by my union for student and newly graduated members to participate in Victorian Trades Hall’s summer internship program. in the comments one member wrote: Aren’t there enough issues to resolve under the “nursing” unbrella without turning members into activists.

The page admin replied that part of resolving nursing (and midwifery) issues requires taking an active role in the union, including job representatives and health and safety representatives being activists.

The member acknowledged that, then added:

I bet the focus will be on everything but direct nursing conditions. Climate change, Refugees The homeless, Domestic violence sufferers just to name a few. ALL worthy causes indeed but why does a Nurses Union have so many fingers in so many pies. ANMF should first and foremost be putting nurses first in my opinion.

Which is, of course, where I came in.

Dear member – all the things you list are within ANMF’s remit. First, they’re all connected with health and thus with both our patients and our members, who are nurses, midwives, and carers.

Second, the Federation’s commitment is to members, the professions, and the communities we serve and are part of. That includes those most affected by climate change (people living in rural and remote areas, particularly farmers), people fleeing danger to build new lives (both refugees and family violence survivors), and people whose health needs are made worse and/or more complex by poverty (which includes but is not limited to homeless folk). We have members who care for all these groups, members who are or have been from all these groups – particularly the last: women over fifty are the fastest growing homeless population demographic in Australia.

Third, as demonstrated by ANMF (Vic)’s participation in this program, we are part of a broader union movement. Not only do our brethren in other unions support us in our campaigns, as we surely all remember from 2011/12, their gains contribute to our conditions, starting with Victorian stone masons winning an eight-hour work day. I therefore imagine that, just like with the Anna Stewart Memorial Project, participants will learn about the issues we have in common. That includes casualisation, sub-contracting, the erosion of conditions, increasing productivity demands (i.e. workload), occupational violence and aggression (including sexual harassment), and representation. However, the focus of the program is on what the branch does for members.

Finally, we wouldn’t have achieved or kept any of the conditions we have without the activism of our membership and leadership. Even when directly affected only some of us speak up and fight; how quickly our battles would be won if everyone took action! But few of us can do it on our own.

I will never forget the Neonatal Emergency Transport Service nurses who came to the Alfred during 2012’s industrial action – they weren’t affected by it, as they’re covered by a separate Agreement, but they came in solidarity, in response to a FB request by a nurse from the Royal Children’s Hospital after he saw how few nurses felt comfortable taking action at that site. That was on Saturday, the only day I missed, and so I can take none of the credit for them starting a statewide day of action to support nurses at the Alfred – inspired by their call to abandon action at their own hospitals, nurses as far from Melbourne as Mildura organised buses to support their colleagues for ‘Alfred day’, contacted Trades Hall to seek advice, and notified the press. On Wednesday, March 7, 2012 then-ANF (Vic branch) Secretary Lisa Fitzpatrick announced that the government had finally agreed to sit in good faith at the negotiating table, which they had refused to do for months. She did this from the Alfred steps, to hundreds of members, supporters, and media.

Image courtesy of the ABC: https://mobile.abc.net.au/news/2012-03-07/nurses-agree-to-suspend-industrial-action/3873134?pfmredir=sm

The campaign was a success, thanks to months of tireless work by ANF staff, members, and the support of other unions.

Without activists we have nobody advocating for change. Without a desire for change there’s no need for a union. Without seeing the big picture we don’t know what needs to change. Without organisation we have no direction about how to make change. Without solidarity we only have the involvement of those directly affected, and there’s no pressure for change unless there are lots of people campaigning for it.

It all begins with activism. That, plus vision, organisation, and solidarity get us this, which is why all unionists need to be activists – not only for the issues that directly affect us, but for those that affect us indirectly.

Image via the Australian Nursing and Midwifery Federation (Vic branch)

Lies, misrepresentation, and distortion

Yesterday, my sister (who lives in the Bentleigh district and South Metro region) gave me an interesting pamphlet that was slipped in her letterbox. Authorised (in teeny tiny type at the back) by Margaret Tighe for Right To Life, the three-fold leaflet makes a lot of misleading and outright false claims about the Voluntary Assisted Dying legislation. It needs debunking, and I’m here to do just that.

I’ll take the text in the order it should be read, opening with:

Four claims here, three true but incomplete, and one false:

1) euthanasia is ‘toxic’ – the compounds used are capable of causing death; that’s the prescribed intention.

2) pentobarbital and secobarbital (the generic names for these drugs) are barbiturates, a drug class used for sedation and anxiety management before the introduction of benzodiazepines, which have a far wider therapeutic window, which means they’re safer in higher doses. Barbiturates are the drug class of choice for assisted dying, because they’re painless, generally well tolerated (i.e. unlikely to be vomited up, cause coma without death), available in oral and IV forms, and invariably lethal in high doses.

The NT Rights of the Terminally Ill Act 1995 allowed terminally ill adults, after medical review by three physicians (including a specialist and a psychiatrist), to access physician-assisted suicide via a device created by euthanasia-advocate Dr Philip Nitschke – the Deliverance Machine (above) released a fatal dose of barbiturates into the patient’s bloodstream if they responded ‘yes’ to a series of questions on the attached laptop.

3) Once a schedule 4 drug (available only by prescription), pentobarbital and secobarbital were rescheduled for animal-only use in conjunction with the Liberal Federal government’s Euthanasia Laws Act 1997, which blocked the NT legislation from being used again. The rescheduling was specifically to prevent the use of these drugs for being used for this purpose; they were not banned outright, as the populace would be outraged if vets could not quickly and painlessly euthanise animals.

4) The classification of medications and poisons is federally mandated, and cannot be overruled by a state government – any pharmacist, doctor, or other regulated health professional who documents, distributes, prescribes, or administers medications outside these regulations would have their registration reviewed, which is why you can’t just ask a vet for a dose to help your aunt Vi die peacefully.

The 2017 Victorian legislation does not mention any class of drug, let alone the names of any specific medications, referring only to a compound, which would be individually prescribed by the primary doctor in each case.

Page two is factually correct in all respects :

1) although some 80% of Victorians support the right of competent, dying adults whose suffering cannot be eased to have assistance to die, the legislation did not pass with an overwhelming majority

2) while the word ‘kill’ is emotive, it’s true that the VAD law is a significant change for Victoria

3) while ethicists debate the distinction between withholding life-extending treatment and withdrawing them, there absolutely is a qualitative and real difference between withdrawing an intervention that is prolonging life (like a ventilator) and introducing an agent with the intent of expediting (inevitable, imminent) death

4) and 5) the problem here is that assisted dying is being artificially connected to suicide, for while it is certainly true that VAD is the deliberate ending of a person’s life at their behest and (almost always) by their hand, it is not suicide. How can I say that? Here’s a list of factors that contribute to and reduce suicidality (via The Black Dog Institute)

None of these relates to the situation of someone seeking Assisted Dying. And it’s not just Black Dog – Lifeline’s advice also doesn’t apply to this circumstance:

Suicide is a real and important issue; as is oft said, it is a permanent solution to a temporary problem – assisted dying is about reducing the length of time someone whose death is inevitable and imminent experiences unbelievable suffering, after other options have been exhausted.

There are four claims and two quotes on page three:

While the claims here are true, their juxtaposition presents an argument, without requiring the author/s to do the work of making it valid.

1) Premier Andrews and Health Minister Hennessy correctly state that the VAD legislation is the safest of any kind in this area

2) the phrase ‘out of control’ is undefinable, unsourced, and relates to the very different legislation of Europe

3) while substantively true, this implies that our vulnerable people are at risk of being killed without their consent, something not possible here

4) the UK vote did not have our legislation to take into account.

Interestingly, there is no mention of Oregon, where similar (but less well safeguarded) laws to Victoria’s have been in place for two decades, with no claims of anyone’s life being ended without consent.

Next we see a whole two members of the British parliament quoted to support Ms Tighe’s position; to give some context to those quotes, there are currently 791 Lords, including 92 hereditary peers and 26 Anglican bishops; there are 650 members of the House of Commons.

To page four:

Some doctors absolutely oppose assisted dying, as do some nurses. Other things some medical doctors oppose include contraception, evolution, easing the suffering of the dying, and the idea that the earth is round.

Other doctors, and nurses, support it, here and overseas.

On to page five:

There is so very much wrong here.

1) This is a distortion – people with a mental illness that impairs their competency may not, under any circumstances, access VAD in Victoria. However, just as a competent person with (for example) well-managed depression can drive, vote, enter into contracts, run for office, and make other decisions about their health, a competent person with a previous or controlled mental illness can also pursue VAD.

2) The requirements for competency do not change in the presence of other conditions. A person with suicidal depression can be sectioned under the Mental Health Act and required to have life-saving intervention, including dialysis, against their will.

In addition to this, one of the qualifying requirements is that the suffering cannot be relieved in a way the patient seems tolerable, with two physicians assessing their position and condition – ceasing treatment to change a life-limiting condition to a terminal one would trigger a mental health review and likely undermine competency.

Also, note that the rate of assisted suicide uptake in Oregon is around 0.4%, despite a similar rate of chronic disease and mental ill-health, plus health care inequity that doesn’t exist here. There is no requirement there for suffering, only a six-month life-expectancy, but this scenario drawn by Right To Life has not emerged – most of us want to live, regardless of how hard that living is, and unless you’ve experienced or witnessed it, it’s near impossible to appreciate just how difficult living with chronic illnesses can be.

The last page is incontrovertible:

Catholic Mr Keating does oppose Assisted Dying, and Mr Staikos did vote in favour of the bill, so this is all accurate.

Why I’m running for the Victorian Senate

Tags

human rights, politics

In seventeen days it will be a year since the Andrews government passed Australia’s first state* legalising Voluntary Assisted Dying for adults who are competent, suffering, and have a life expectancy of six months or less (twelve months or less for those with neurodegenerative conditions). It comes into effect mid-June of next year – unless the state election in twelve days changes Victoria’s MP composition, as a number of parties (including the Liberal party and the Shooters and Fishers) want to overturn it before the system and processed have even been completed.

Last year I put my money where my mouth is as a project officer for the Victorian branch of the Australian Nursing and Midwifery Federation, working to get the legislation through; this month I’m working to keep the legislation intact by campaigning as a candidate for the Voluntary Euthanasia Party in the Eastern Metro region.

The Voluntary Euthanasia Party has four, interrelated national policies: to campaign for the legal right for competent, dying people to choose how and when they will die, without fear or pain; to improve the status of Advanced Care Directives so they are binding, educate health staff about their use, and have completed ACDs available on a statewide database for ready access by health practitioners when required; to support improved research and funding for quality palliative care; and improve access to medical marijuana.

As everyone who knows me, follows this blog, or follows me on Twitter knows, I am passionate about a number of things, primarily around health, education, justice, and equity. These policies are all consistent with mine, and my ethical position as a casuist is also consistent with the VEP’s platform of determining positions on other matters as they arrive.

My position on this has been consistent since high school, informed by almost thirty years as a nurse in Victoria’s acute public sector, and honed by my three post-graduate qualifications in health care ethics.

I firmly believe that Voluntary Assisted Dying should be an option only after specialist medical review, and if palliative care interventions have proven inadequate. To ensure this is not just a pleasant theory, I strongly support and have long advocated for increased funding and support for palliative care services, particularly for non-oncological conditions (like end-stage organ failure), and in regional and remote areas.

To listen to me speak about the VAD legislation, listen to this podcast of my address at the Melbourne Unitarian Peace Memorial Church last month: http://melbourneunitarian.org.au/index.php/mp3-service-podcasts/549-tara-nipe-registered-nurse-voluntary-assisted-dying

Over the next week and a half I’ll discuss my positions on alcohol and other drugs, post-secondary education, energy and the environment, the health care system (with additional entries covering the Indigenous health gap, mental health, and sexual health), social support systems, taxation, and workers rights.

* Australia’s first legislation, enacted in 1996 and overturned in 1997, was in the Northern Territory

Assessment tips for undergraduate students

Tags

education, health, hints and tips, students, study

Introduction
The following brief essay covers four sections that undergraduate students often have difficulty with when writing essays or assessments with long answers: how to tackle an assessment (tactics), what to keep in mind when creating an essay plan (key concepts), how to support your argument (referencing), and what to remember before submitting (finishing touches). The most important aspects of each of these sections are then listed, in point form. Though this was written with nursing and midwifery students in mind, as indicated by some examples, much of this advice is transferable to other disciplines that include essay and long answer forms of assessment.

Tactics
As soon as you can after receiving the assessment, read through it. You’re looking for several things: what kind of work is needed (a 1,000-word essay, or eight responses of around 200 words each?), what the parameters or conditions are (anything the subject coordinator brings to your attention, like not including subject headings, or requiring an introduction and conclusion), and the general scope of the project (will you be exploring a particular disease, creating and supporting a diagnostic hypothesis, or crafting an individualised plan or care?).

When you’re ready to start work on the assessment, read through the directions carefully, identifying the key requirements – this is what the marks will be allocated on, so you want to make sure what you submit addresses them. If the marking rubric is available, use this to guide the outline of your assignment. Marking rubrics are used by assessors to determine consistent marking regardless of who is evaluating your assignment, and usually provide very clear guidelines. For example, the referencing section of a marking rubric might specify that full marks can only be awarded if the paper includes:

• a minimum of 10 references
• most of these must be are high quality evidence (e.g. textbook and peer reviewed journal articles)
• that were published within the last 10 years, and
• no or only minor errors in [the required formatting style]

You therefore know that your paper, which has seven references, one of which was published 15 years ago, and one of which is from a blog post, won’t get a high mark for referencing. However, finding relevant information that is more recent, high quality, and by additional authors, will increase the potential for you to earn additional marks. For this reason, you should return to the rubric when you finish writing, and assess your work against it. It may be helpful to summarise your requirement/s to refer to throughout the writing and reviewing process, to make sure everything you’ve written addresses the requirements of the task.

Key concepts
Whatever the content of your writing, at its heart you are creating an argument: why to administer drug X instead of drug Y; why diagnosis A fits better with the case study that diagnosis B; or how guideline S can be applied to this situation T to achieve desired outcomes U and V. When writing an academic piece, every statement and fact should be either building, illustrating, or supporting the argument you’re making – if it doesn’t do that, then it is irrelevant, and a waste of time and word count. Make sure each sentence is clear, strong, and logically leads on from and to the next, with each paragraph containing a new but related idea.

It is essential that you clearly and explicitly connect theory, or information from sources, to the requirements for your paper. This means writing things like:

Culturally safe care has been shown to increase Aboriignal and Torres Strait Islander patients’ trust in health care institutions (Haversmith and York, 2020). Bloggs’ (2017) examples of culturally-safe practices include X, Y, and Z, while staff education addressed at reflection and awareness of how our cultures affect our perspectives (Snap, Crackle, Pop et al. 2019) also contributes to health care facilities that are more welcoming to Aboriginal and/or Torres Strait Islander people. Incorporating these changes will therefore facilitate greater participation in western health care by these marginalised Australians, improving their health outcomes.

(Note: these are imaginary references for the purpose of this example, and do not refer to actual authors or citations)

This paragraph begins with a main concept: this thing [culturally safe care] has this result [increased trust of health care institutions by Aboriginal and Torres Strait Islander patients], which is supported by a reference [this is the reputable source for this statement]. The next sentence explains how the theory in the first sentence [culturally safe care] could be applied in practice [X, Y, and Z], and links this with a fourth intervention [specific staff education] that also encourages the change [culturally safe care] we want. The final sentence summarises the paragraph – as it is not introducing new information, it does not need a reference.

Write for a reader who is educated, but don’t assume they have any underlying knowledge of your topic. This means defining or explaining every relevant term, and ensuring that your work doesn’t contain gaps. A gap is anything that leads your reader to ask a question, and good academic writing should address potential questions before they arise. For example, the reader shouldn’t be let wondering ‘But how does implementing that intervention lead to that outcome?’ or ‘If a CT scan and an MRI can both confirm this diagnosis, are both needed? If so, why; if not, why has the writer mentioned both?’ or ‘Did I miss something in the case study about low vitamin C in the patient’s diet?’

Pay attention to any feedback you’ve received from markers, particularly for the same subject as the current assessment. Even relatively small errors (like forgetting to capitalise ‘Aboriginal’) can make a difference, yet many of my students repeated this error in a second assessment, despite being told about this in class, on line, on the assessment instructions, and in the first assessment. You can prevent this by using Spellcheck in Word, and by utilising the find/replace function at the end of your writing, to confirm that a stray ‘indigenous’ or ‘Paracetamol’ (generic, so not capitalised) hasn’t snuck into your work.

Referencing
While it can seem like an afterthought, both accurate acknowledgement of sources and correct formatting are essential components of academic writing; this significance is reflected in the allocation of marks, both within assessment rubrics and (on occasion) as a separate category, for referencing. This is because everywhere that you state a fact that comes from outside your own experience should be supported by a reference. In the event that the fact or statement is your own, you need to make that clear, while ensuring that it’s both relevant and written in an objective way. Remember from Tactics: you are presenting an argument, and the literature you cite supports that argument or position.

The internet contains a lot of information, and it can sometimes be difficult to distinguish between high-quality and less reputable sources. Text books can be good sources but, given their size, you must make sure you specify the page and paragraph  number/s that contain the information you use. Peer-reviewed journal articles are very often the best source of information, as they are easily searchable, specific, and have been evaluated by experts as part of the publishing process. Using Google Scholar to search for literature will only produce peer-reviewed work, and you can restrict the date for results to within the past decade, increasing the likelihood of finding the most appropriate references to support your work. As an under-graduate, your assignment topics will be on well-researched concepts or issues that are amply covered in contemporary literature.

Referencing well is a skill that comes with practice. Your university’s style guidelines are a start, but you may also find these examples useful:

• If you are providing several references for one or related facts, list them in the same bracket e.g.: there are three kinds of mammals: marsupial, monotreme, and placental (Farrago et al., 2017; Hepplewhite 2018).

• If you are listing several related facts that come from a number of references, indicate the source of each one e.g.: examples of placental mammals include cats (Bornstein, Parker, and Kenan, 2012; Pederson and Geller, 2012), dogs (Pederson and Geller, 2012; O’Sullivan et al. 2014; Aaronson 2016), elephants (Singh 2011), and dolphins (Singh, 2011; Pederson and Geller, 2012; O’Sullivan et al., 2014).

• If you are citing multiple facts from the same source, make it clear that the author/s said all the things you’re attributing to them e.g.: Pederson and Geller (2012) hypothesise that placental mammals achieved dominance over marsupial and monotreme mammals because the longer gestational period a placenta allows gives an evolutionary advantage. They explain that this means young are better able to survive the death of the mother, adding that placental mammals are ambulant at birth, while monotreme and marsupial young are still essentially fetal. Of course, humans are the exception to this independence-from-birth advantage (Singh 2011), due to “a necessary compromise” between fetal head/maternal pelvic circumference on one hand, and longer dependent rearing on the other (Singh 2011).

An easy way to ensure your references are appropriately formatted is to download EndNote or other referencing software program; it should be available to you for free, and though it requires a little set up at first, once you’ve put in the information for each reference (including directly importing them from online sources), it will insert in-text and listed references, with every one in the required format.

Finally, make sure your reference list is alphabetised. You can do this by highlighting the entire list, then hitting the A-Z↓ icon, which is about half way along the control bar when Word is in home mode; this will automatically alphabetise your list, provided you have a new line between each entry.

Finishing touches
When you’ve completed your work, and if you have time, put it aside for a few hours, to give yourself some distance from what you’ve written. Then read it aloud, slowly, or ask someone who doesn’t know the subject matter as well as you do, to do it for you, as they’ll pick up problems you may overlook because you know what you meant to write.

You’re listening for grammatical errors (e.g. ‘is’ where you should have written ‘are’), spelling mistakes (e.g. ‘separate’ instead of ‘separate’) and typos (e.g. ‘on’ instead of ‘in’), and signals for punctuation (a small pause indicates a comma, a longer pause a full stop, and a change of topic often means a new paragraph). Most importantly, you’re also checking for gaps in your work (see Key Concepts) and making sure that your writing is consistently academic in tone.

Take home points

• • Start preliminary thinking about the assessment as soon as you receive it
  • Identify the assessment requirements, and write to them
  • Remember that you’re making an argument: everything you include must support or advance your case
  • Make sure your formatting and referencing meet the instructions given and your department’s requirements
  • Everything that comes from anywhere but your own experience must be referenced
  • Take the time to review your work before submission

Conclusion
This short essay has outlines strategies that, if followed, will allow students to both achieve higher marks on their submission, and develop a stronger relationship with the subject material they’re working with. The key areas covered were tactics, key concepts, the importance of referencing, and finishing touches; these were then summarised in a list of take-home points. As this is not an academic work, there is no reference list, and not all references, formatting, or language are consistent with tertiary-level expectations for academic writing. The references cites are imaginary, and were invented for the purposes of illustration only.