Why I support Victoria’s voluntary assisted dying bill

Content warning: graphic discussions of dying symptoms

I wrote last week about the best kinds of dying trajectories, and about the difference quality palliative care makes to those whose deaths are inevitable and symptomatic. In many ways, palliative care nurses are midwives of death – helping a natural event progress with comfort, tranquillity, and a minimum of distress. Unfortunately, for a minority of people on dying trajectories, even the best care can’t relieve their symptoms.

When, as a student nurse, I first cared for a patient whose symptoms were intractable, I was distressed by but understood the pain – he had tumours in his bones, and was on massive doses of morphine (over a gram per hour, with breakthrough dosing of 300mg up to three times/hour), which helped. It was the other end-stage symptoms that he, and other patients I’ve cared for since, which most affected me: terminal dyspnea, where every single breath is fought for; intractable nausea, that persists, despite the best anti-nausea drugs, even through sleep; the gradual and relentless inability to perform activities of daily living, and the distress of this ever-growing helplessness; and losing not just the capacity to swallow, to eat, but even to manage one’s own saliva.

I have cared for many people who died gently, who drifted into sleep and never woke. They’re not the deaths I remember, though. Those memories are of the patients who struggled for each breath, faces etched with fatigue.

Of the woman who finally escaped the nausea that had relentlessly accompanied her for months, but died retching.

Of a man I assisted another nurse to turn, his deep, low moans reminding us every moment of the pain from tissues so filled with fluid that it leaked out of his skin to soak his linen every few hours.

Of the young woman with end-stage HIV, whose doctors were in denial about her dying and sent her to die in ICU, instead of on the ward surrounded by nurses who knew her, and family who loved her.

Of my dialysis-dependent gentleman who was “sick of being sick” but treated for depression he didn’t have, instead of being allowed to die.

Of the patient not quite dead of motor neurone disease, whose partner literally begged me on their knees to bring her merciful death. I had to say no, their form blurred by tears that filled my eyes then, and now.

Thinking of these men and women always brings tears to my eyes – not only because of what they experienced before they died, but because we failed them. Our role is to care for all our patients, and to comfort those we cannot cure. To relieve suffering, not prolong it.

I have witnessed other awful deaths, but we were working to save those patients – replacing fluid, infusing new blood, restarting their hearts, combating infection, reversing life-threatening biochemical imbalances. For my patients whose dying is inexorable, inevitable, and wanted, delay is not only heart-breaking, it’s cruel.

Palliative care has transformed the lives of the dying, but there are some that even the most expert palliative care cannot help. From overseas figures, this amounts to somewhere between 0.5% and 2% of those who are dying – their symptoms will be resistant to our best interventions, and they will have suffering beyond pain, beyond our capacity to ameliorate. For this small proportion of our population, their only option now is premature death by suicide (while they have capacity), or an agonizing death witnessed by helpless, often guilt-ridden loved ones whose trauma persists long after the dying.

For these few we need another option. A carefully considered, strongly contained, rigorously monitored, compassionate alternative that allows those who are dying a voice, and a choice. We need a legalized process of assessment that the person applying for assistance is competent, is making an unpressured and consistent choice, is dying, and is or will experience suffering

Victoria’s government will be introducing a voluntary assisted dying bill to parliament in the second half of this year. If it passes, it will be the most rigorous legislation in the world, and will be informed by the experiences and data from those North American states and European countries who have legalized these acts for up to two decades. It will be an option for adults resident in Victoria who have a finite (to be determined) time to live, who are competent at the time they make repeated, consistent requests for assistance to die, and who are experiencing symptoms of their condition that are unbearable.

I support this bill because I have seen too many people die agonizing deaths. We absolutely need to do this with attention to detail and awareness of the potential for misuse, which is why proposed legislation is clear, strong, and well regulated.

Even before I became a nurse I was in support of people who were suffering being able to choose when they had had enough; it seemed then, as it does now, that they were the ones with most at stake, and should therefore have most say. It’s past time to let dying Victorians have a voice and a choice regarding the ends of their lives.

In praise of palliative care

Like most laypeople, before I started nursing I had scarcely any understanding of just how much someone can endure before they die – my only experiences of pain were acute, so I had no awareness of the toll that chronic pain takes on one’s psychological defences, or how it affects endurance, sleep, tolerance, and the ability to withstand other symptoms. And that’s before you get to the emotional distress of leaving before you’re ready, or leaving those you love behind

Fortunately palliative care interventions can reduce most dying people’s pain to a manageable level. Other symptoms can also be managed – nausea, restlessness, and breathlessness are common – can also be well managed most of the time, for the majority of people who are dying. I’ll write about the exceptions next week.

I have cared for people who wanted to live every second available to them, and I respected and facilitated that. More common have been the patients who were dying well, their terminal symptoms managed by palliative care measures. And I’ve looked after too many people who should have had formal palliative care input, for this specialty is still too often confined to those with cancer, when we also need this expertise for those with end-stage diseases like heart, respiratory, and liver failure.

We need better palliative care services – improved access, especially in rural areas; early intervention; more funding for research, and for family support; and acceptance of its necessity in a wider range of cases, for anyone whose illness has assumed a dying trajectory. </span> Last year the Victorian government announced a long-term plan for the state’s palliative care services, including additional funding and goals that:

  • people experience the best end of life care
  • people’s pain and symptoms are well managed
  • people’s preferences and values are recognised and respected in their end of life care
  • better support for carers
  • people are cared for in their place of choice
  • where possible, people die in their place of choice (source)

These measures will make a significant difference to the overwhelming majority of people who are dying; for them, it will be what they need to die.

I love being a nurse; I love having the knowledge, skill, and compassion to improve my patients’ lives, to make them more comfortable with just the repositioning of a pillow, to reduce fatigue and pain with massage, to allay or hear their fears, to be able to explain what’s happening in language they can understand, to assess their condition and intervene before they deteriorate… and I appreciate the privilege of being able to make a little easier my dying patients’ transition from life.

I have witnessed some beautiful deaths – patients who were comfortable and at peace, who slipped away between one breath and the next, with families present or, sometimes, absent, because some people wait until they’re alone or at least only with nurses. I have helped implement care planned by expert palliative nurses and doctors, managed symptoms so that patients and their families could say goodbye without distress, performed mouth care to relieve the only discomfort of withdrawing hydration, massaged cream into cramped limbs, and read their unconscious faces and bodies to give boluses when pain or restlessness still reached them. These are the ideal – the deaths we all want for ourselves and for those we love. Thanks to the skill, knowledge, and expertise of palliative care nurses and physicians, these gentle and caring, comfortable and peaceful transitions are more common, and becoming available to more people.

876 days, and counting…

One year and two days after ANF (Vic. branch) released our log of claims, the public sector EBA has gone into effect – look for pay rate increases, back pay (to March 31) and CPD funds (where applicable) from your next pay.

Our officials are at FWA today, in Conciliation proceedings with RDNS; an acceptable final offer from VHIA for Mental Health nurses is looking promising; and Forensicare negotiations continue.
Even if all our EBAs were resolved tomorrow, I know none of us will quickly forget what it took to get even modest outcomes in the face of a government determined to erode conditions, remove ratios, deskill the workforce, weaken the profession, increase burnout and turnover, and compromise care – all for a dollar, and not even cost-effective in the medium term.

Victorians go to the polls in 876 days, which is just under 29 months away, Australians will vote some time in the next 511 days, around 17 months from now. In both cases we need to look not only at the leader we’re voting for, but the principles of their party. I know I don’t want to do this again in 2016, and I’m sure I’m not alone.

It’s okay, not to be okay 

I’ve just read a post on the FB page of the same name as this post – It’s okay, not to be okay post stories and support for and about Astralian men battling (and too often the ultimate victims of) depression. 

The story I read was exceptionally well written by the partner of a man whose depression overwhelmed him. Nicole’s pain was heightened by the fact that the notification of his death, by police accompanied by her mum, occurred hours after the birth of their baby. 

For me, the biggest takeaway message was a regret expressed to Nicole by one of Pat’s friends:

None of Pat’s friends were aware he’s suffered from depression…

One of his mates told me how much he wish[ed] he knew Pat had suffered, as [he] was a sufferer too and wished they could have talked about it. 

This is the silence that makes so many people with depression, particularly men, think they’re alone – not Pat’s mate, but society’s silence. And I understand it – for 29 years I told nobody of my episodic, far less malignant, depression, which is a long overdue story for another post. 

Though saddened and troubled by this account, what stirred me to write this post were the comments from people who, despite Nicole’s clear descriptions of Pat’s pain, still saw his death as “weak,” “selfish,” “a coward’s act,” and not something anyone would do if they really loved those they leave behind. 

MRI and PET scan imaging shows that major depression alters the way our brains work – it’s not something you can overcome through strength of will, fortitude, determination, or the live and support of those around you, and more than these would stop asthma or diabetes. 

This outcome may have been different if Pat had help (antidepressants, therapy, inpatient care in crisis, even much maligned but sometimes invaluable ECT), but mental ill health is so strongly stigmatised, and this ‘snap out of it’ mentality so prevalent, that he fought alone. 

For many people with major depression, the utter bleakness and pain of living is overwhelming. They may think their existence is a burden on those they love, that everyone would be better off without them. They’re wrong, but that feels so true they believe it. Surviving every day takes more work and courage for some people than many of these commenters will ever need to draw on. 

(by Matthew Johnstone, for SANE)

For people who still can’t or don’t get that, know this – first, you are luckier than you realise. Second, if you don’t understand, shut up. Your uninformed opinions about depression are not just unhelpful, they’re actively damaging to those surviving with depression, and those left behind when the disease was too much. 

If anything here has distressed you, or prompted you to seek help:
(Vic) SuicideLine 1300 651 251
(Aus) LifeLine 13 11 14
(Aus) SANE Australia 1800 18 72 63 (business hours, AEST)
(Aus) Suicide Call Back Service 1300 659 467
(Aus) Kids Helpline 1800 55 1800

Expressing frustration – how injudious venting can kill careers

Nurses are not alone in having positions where our work includes the potential for misuse of power over vulnerable people. As Australians have been appalled to learn in the last week, as footage of barbaric treatment of detained children was broadcast on Four Corners, there are professional cultures where egregious mistreatment (and that is an unquestionably mild categorisation) appears to not only be accepted but almost expected. 

Nursing is not immune to that – several years ago I wrote about the horrifying treatment of patients at Mid Staffordshire in the UK, the contributing institutional factors, and the injustice of focusing on clinicians alone instead of the managers whose policies not only facilitated but almost demanded it. 

It’s reasonable to expect that, at a bare minimum, those in our care are treated humanely and with respect. As I’ve commented several times on social media since the ABC broadcast, excusing corrections officers’ actions because of juvenile detainees’ behaviour misses the mark. I have been spat at, sworn at, threatened, slapped, pinched, bruised, groped, scratched, punched, and had projectiles from faeces to metal bed pans thrown at me; my colleagues have been sexually assaulted, knocked unconscious, partially scalped, contracted infectious diseases after being spat on, had bones fractured, and needed breast reconstruction after biting. Not only do we not retaliate  by dropping patients naked and leaving them, restrained and alone, to do so would justifiably be condemned, by our profession and the public. 

We are, however, human. We carry with us to work the same stressors everyone else does – relationship woes, family worries, financial concerns, inadequate sleep, colds that are enough to cause misery but not enough to warrant time off work… When work frustrations are added to that, sometimes something has to give. 

I love what I do. I get to make positive differences to people’s lives every day: my colleague said, through education and support; family members, with explanation and reassurance; most of all my patients, through skilled, compassionate, experienced nursing care. After returning to the bedside after over a year of illness, my commitment to providing that care is even stronger. 

I am proud of few things – I am privileged that most of my positive attributes come without work, so taking pride in something I have by good fortune would be ridiculous. I am, however, proud of managing my temper (which was once significant), and my still-evolving capacity to step back rather than engage and escalate conflict. These are not qualities that came effortlessly, for all their necessity in my position. 

Despite one’s very best efforts at calm, professional, therapeutic distance, sometimes someone manage to find your last nerve and play it like a virtuoso. And I recently had a shift that was dominated by a patient for whom I could do no good, as I was repeatedly told, but who nonetheless called for me multiple times each hour, only to react with anger and disparagement despite my genuine best efforts to help. 

It is fortunate that my other patients were stable, needing few interventions; I was certainly unable to assist and support my colleagues as much as I’d have liked. 

I know my patient was scared, distressed, anxious, panicked on occasion, enormously fatigued, sleep deprived, and angry. I also know that we are often safe targets – our patients know we won’t abandon them, or retaliate. I certainly hope they know that. 

And, despite my experience, my empathy, my knowledge, and decades of honing professional distance, I became frustrated – by not being able to meet my patient’s needs, by their expectation that I should know what they wanted without asking, by my every suggestion being shot down, by going over the same ground with repeated futility, by hours of belittlement. 

I didn’t express any of my frustration to my patient – though I took a slow, deep breath before responding to each call, every interaction was polite, warmly professional, as long as my patient needed, and I responded in under a minute on every singly occasion. 

The reason I was able to maintain this for my whole shift was because I vented my frustration to my colleagues. A little hyperbole, some fantasy, and I was able to optimistically smile the next time I walked through the patient’s doorway. 

All of this has been preamble to the point of this post. I also wrote a Facebook entry where I described my venting. There, as here, as always, I omitted identifying details. I made it clear that the issue was not so much my patient as my frustration. And I wrote about how this informal debriefing allowed me to work effectively, to provide professional care, to put my patient’s needs first. 

And I was reminded today that none of those aspects matter, because my post could have been enough to jeopardise my registration. The days of acknowledging the emotion labour of dealing with ‘difficult’ patients have gone – when text, absent tone, can make jest indistinguishable from the corrosive, toxic culture revealed last week, staying silent is the safest option. 

Every week nurses and midwives attend disciplinaries, recieve warnings, and face employment and registration consequences of social media activity. Oftentimes this is completely warranted, because of confidentiality breeches, employment conditions (don’t take sick leave then tweet about being at a music festival!), and the like. Sometimes it may seem like an overreach. Either way, determination isn’t made by those who know us and our intent – it’s made by people whose job is to safeguard the public, and who understandably err on the side of caution. 

I am no social media neophyte. As a union rep I have a better idea than most how inappropriate social media posts comprise a significant, and growing, number of disciplinary procedures. And even as I wrote my post I wondered how wise it was, even adorned with caveats and clarifying notes. 

So, for myself and for any health professional who’s made it this far, a reminder: before posting anything remotely work- or profession-related, think twice. And if even the smallest part of you has any doubt, hold back – you can always write it later, you may not be able to retract it. 

Nurses, death, and mourning

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Like all nurses of any length of practice, my clinical experience includes the most intimate moments of people’s lives. I suspect most laypeople think first of physical intimacies – bedpans and nakedness, though those are the least intrusive; for me and most of my colleagues, though, the real intimacies are less tangible – people who need to be strong for their families allowing themselves to be vulnerable with us; confiding long-held secrets and fears; making their dying days comfortable and calm; continuing care after their lives end. 

While nursing care and death work have been the foundation of my academic career, I realised today, after starting a response to ‘Nurses Grieve Too,’ an excellent guest post by Emily Rankin on Ian Miller’s blog The Nurse Path, that I haven’t written about it here. 

Like one of my favourite medical authors, American surgeon Atul Gawande, Emily introduces and closes her writing with the dying of a specific patient, while the body of her piece explores the emotion labour of grieving for and with our dying patients, wondering if we could have done more, and of needing to contain our emotions as we continue to care for our other patients.

Approaching her second year of registration, Emily is near the beginning of her career; I commemorated the 27th anniversary of my hospital-based education 45 days ago, and I long ago lost track of how many of my patients have died on my shift. I certainly don’t remember all of them, though there are some I will never forget. 

Like many nurses, I prioritise the care of the dying – as well as pain relief, sedation, and secretion management (do they stiffen or grimace when turned? Are their eye movements rapid? Is their breathing shallow, rapid, laboured, moist?), fundamental nursing practices like smoothing sheets to prevent uncomfortable wrinkles, flipping pillows to the cool side, frequent mouth care to avoid caked secretions and dry lips, position changes, and back rubs make a huge difference. Helping someone die well is a mitzvah, for them, their loved ones, and it also helps us.  

The deaths most of my friends and I remember most vividly are where the dying was not peaceful. Where the medical team, the family, sometimes (but rarely) the patient themselves pursued treatment long after the benefits outweighed the toll; where someone bleeds to death as we stand by, helpless to stop it; where end-stage organ failure means the only doses of pain relief high enough to treat condition A would kill them thanks to underlying disease B, so we have to see them suffering on their inevitable trajectory to death. 

We remember the young people, whose time was cut cruelly short; the confused and demented people, terrified by things only they can see; and the unexpected deaths of those who seemed to be doing well. 

I have shed tears for my patients, and for the grieving loved ones they’ve left behind; I hope that those who’ve seen the glisten of tears, the pinkening of my nose, also see compassion, without loss of professionalism. But I have not wept – whatever distress we feel, whatever we’ve seen and felt, the expectation is always that we keep going, absorb the experience, because it’s part of the job. 

I have once been offered formal debriefing, after a patient I didn’t know committed suicide on site. It was disruptive, distressing, and chaotic on several levels, but not close to the most traumatic experience I’ve had. Without in any way blaming my management (for this attitude pervades the profession at all levels), it is only these spectacular deaths that we’re ‘supposed’ to be troubled by – not the elderly man drowning in secretions we can’t stop, the young mum with congenital vasculopathy, the younger man with breathtakingly rapid progression to advanced HIV, the woman who’s been cared for by us over the eight year decline from neurodegenerative diagnosis to death, or the man whose decision to end dialysis was received with a diagnosis of depression and course of electroconvulsive therapy. 

I believe this lack of acknowledgement, along with intimacy, little direct control, the honour and responsibility of caring for people at their most vulnerable, and only rare opportunities to direct the residue of that labour and emotion, plays a part in why some of us speak to our patients while performing post-mortem care: we get to say goodbye, give uninterrupted care, and complete a journey that we have uniquely travelled.

Should we return to hospital training?

I woke this morning to heated discussion among my social media peers about One Nation’s policy on nursing education in Australia 

[source, via Ian Miller at The Nurse Path]

I was part of one of Victoria’s last hospital-based nurse training groups, so I had opportunities to compare our experience and knowledge with my then-college educated peers, and with university-educated nurses in the two-plus decades that RN qualifications have been solely via university. 

There were undoubtedly advantages to the way I learned how to be a nurse. To start, we were paid from day one, whether we were in class, on the floor, on specialty placements, or on leave – 40 hours a week, 52 weeks a year, until we qualified. That meant that, unlike the majority of today’s students, we didn’t have to balance the needs of study and placement with survival. 

We knew early on whether or not actual nursing was really what we wanted to do – shift work, short changeovers, abusive doctors, terrifying charge nurses, rude relatives, violent patients, every single disgusting fluid our bodies produce, bursting wounds, maggots, caring for people sicker than we knew it was possible to be and still breathe, the helplessness of not being able to make a difference to someone’s anguish, watching people treated past usefulness and into cruelty, caring for the bodies of the dead, making mistakes that could have (and sometimes did) make patients worse or even die, the heavy cloak of being literally responsible for strangers’ lives every single day, were all known to us within months. 

Our educators taught us in the classroom and on the floor – they knew all of us by name, because each intake (three per year) was capped at 60-65 students; when I graduated I confided in one of my teachers that, had there been cardiac questions on our state exam paper, I’d have failed. Though she’d taught our cardiology block more than 18 months earlier, June drily replied, “Yes, Tara, I know.”

Our progress was monitored consistently, every step of the way, with ward reports for every rotation longer than two weeks. Those charge nurses cut no slack, and we lived in fear of bad reports – we could lose our career, job, and home in one fell swoop. 

We lived together on site, at least for the first six months, which meant both strong team building and ready access to peers and students ahead of us when we had questions or needed debriefing. 

And there’s no question we had strong clinical skills: well over 4,000 hours (100 weeks+ of 40 hours of patient care) of general and specialty medical, surgical, theatre, emergency, paeds, radiology, midwifery and neonates, psychiatry, RDNS, community health – I knew where I wanted to work as an RN, and what I had no interest in at all. 

All of which sounds like a really good grounding for our nursing workforce. Here’s the other side. 

We were employees first, students a poor second – our rotations were based on where they needed hands. I remember a two month period of fortnightly rotations: two days off, a PM shift, nine AMs, two days off, and a new ward – no time to become part of a team, to learn the specialty, to even know where all the equipment was. 

We were frequently frighteningly out of our depth. I vividly remember being told six hours into one shift that I was needed on another ward to special (nurse 1:1) a patient. I had almost no time to hand over my patients to colleagues whose workloads just jumped without warning, and my sole introduction to the patient was, in essence, “they’ve got an axilla DVT [clot in a  deep vein running under the armpit]. This infusion’s [a medication that breaks down clots]; don’t leave their side; don’t take down the dressing; buzz if they’re symptomatic [have signs the clot’s moved or the medication’s caused abnormal bleeding].” Then she left. 

I was so terrified I didn’t speak to the patient. At all. 

I wasn’t familiar with the kind of pump used. I’d only ever heard of streptokinase, and didn’t even know it could be used as a continuous infusion. 

I didn’t know what I was looking for, or what the management plan was. I had no access to the patient’s history, and my only way to contact other nurses or a doctor was to press my patient’s button, then wait. 

Nobody checked in on me until the night special came. 

I was so relieved to see her that I almost cried – and I can count on my digits how often I’ve cried at work. My overwhelming feeling as I left was relief that my patient was alive. 

When I arrived on my ward at 7AM the next morning as was told I was going back to the special, I thought I’d vomit. 

The plan was to transfer my patient from this ward to another ward I didn’t know, via radiology. We went down to imaging, then waited in a corridor for an hour until an orderly took us up to the new ward – I had no way to get help, should I have needed it, except to yell. 

On the new ward I was reminded by the charge nurse not to leave the patient, who I was still afraid to talk to. Whenever I buzzed to get a pan for my patient, a responding nurse would tell me the pan room was just outside. Whenever I went to the pan room the charge nurse would see me and tell me not to leave the patient. 

I found blood in the infusion line. I had no idea how to get it out, how long the IV could be stopped for, and I was afraid to ask. Fortunately I knew not to bolus [give a larger dose over a short time] streptokinase, and went out to the desk. The charge nurse was irate that I’d once again left my patient. When I told her about the blood, she directed me to get a new infusion set. As I didn’t know where anything was on this ward, I ran down two flights of stairs the old ward, got a set, ran up the stairs, and found the nurses had fixed it already. 

Nothing bad happened – I don’t know what happened in the long term, but when I finished my shift the patient was fine. But 25 years later than remains one of my ten worst shifts – and the others include a Coroner’s case, a patient fall with fractures, a patient so severely vomiting blood that the room looked like a murder scene, a patient bleeding to death in front of me, accidentally increasing an IV medication that could have been fatal, and the death of a young mum. 

We were thrown in the deep end with one floaty, and expected to swim. 

And here’s the thing. Our patients are so much sicker now, they have more comorbidities, and their stays are shorter. Almost without exception our patients are too vulnerable to entrust to early-level students with almost no supervision. If you take nothing else away, know this: patients would die, and it would be the individual students, not the system, held to account. 

Nursing and midwifery have transitioned from vocations to professions, and education has been a vital part of that change. Health care today demands a far more technical, detailed, complete knowledge base than hospitals can provide. The old method of half a dozen interchangeable students, overseen by one or two RNs, is long gone, and that means better patient outcomes. 

Which is not to say that change isn’t needed. 

Our students should be able to survive without working on top of study and placements – increasing Austudy to a reasonable amount would allow student nurses and midwives to focus on learning. 

Students’ placement assessments are currently done by clinicians, who have no training in it, often have no guide to expectations of proficiency at this placement, no easy access to processes for unsatisfactory performance, and who are supervising students and completing their assessments in addition to their workload, without compensation. Returning educators to the floor, one per ward, would help catch struggling students before they’re registered. 

The idea of nursing and midwifery as apprenticeships is right, though my analogy would be with medicos rather than tradies. 

Doctors must complete an accredited program post-graduation, that includes an intern year, residency, registrar experience, exams, and then specialist training. 

Nurses and midwives can apply for a graduate year position, somewhat like an intern year – they include a supernumary period, a preceptor, study days, supervision of clinical educators, and individualised goal setting. The cost of this is met by state government funding. 

Unfortunately, graduate funding is grossly inadequate – in Victoria alone we have 800 or so graduates, every year, who are unable to find a position. While the programs are theoretically optional, in practice it’s next to impossible to work without one. This is fiscally short-sighted: tax payers have subsidised the education of needed professionals, who now also have a hefty HECS debt they can’t repay, for a career they can’t pursue. 

Instead hospitals hire overseas-educated nurse said, who cost less in the short term because they don’t need as much support. Some of the best nurses I’ve worked with have come here after qualifying, and easily half of my locally-educated nurse friends have worked overseas. This reciprocity is a good thing all around, for individuals and the system. But it shouldn’t come at the cost of our early career nurses and midwives. 

Our nursing and midwifery work forces are aging – the average Australian nurse is mid-forties, and global shortages are projected within a decade. It makes sense to encourage the next generation to join us, but we need the funding to ensure the best candidates are attracted to degrees that will lead to jobs. Not debt. 

TL;DR? There was a time when hospitals were the best place to educate nurses. That time has passed, and it’s in all our interests not to go back. 

8/7/16
01:25
Addit: as The Conversation recently noted, patients are more likely to survive when cared for by a nurse with a degree (with thanks to Meta4RN) 

My feminism is inclusive: some thoughts on trans folk

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There has been a lot of coverage of trans gender issues in the media recently. In principle I think this is a good thing – visibility and awareness are first steps towards acceptance, and with trans youth suicide disproportionately high even among the cruelly elevated rate for LGBTIQ+ teens, knowing they’re not alone, that being trans isn’t synonymous with being rejected, alone, ostrasised, a freak, helps survival through these hardest years.

I’ve been saddened but unsurprised by many of the responses from the uninformed; I have been dismayed and bitterly disappointed by the positions of many who call themselves feminists.

I am a feminist for the same reason I’m a unionist – because I strongly believe that those without power, without a heard voice, whose contributions are underrecognised and under appreciated, need and deserve representation and organisation, a voice, recognition of their value and contribution, and power.

I am a cis woman. I have had my share of body hate and shame, but I have never felt as though my assigned gender was at odds with who I felt like. I have never been misgendered by my family, by my colleagues, by the world.

I have had people insult my size, but I have never had people deny who I am by deliberately using the wrong pronouns, or by using a name that is associated with all the pain, sadness, and erasure of my true self – what trans people often refer to as a dead name.

Nobody will deny me my identified gender based on how much I ‘look like a woman’ or feel comfortable interrogating me about my genitals. And if I have bilateral mastectomies, a hysterectomy, bilateral oopherectomy, a vulvectomy, and take hormone replacement, nobody will tell me that I’m no longer a woman.

I recognise that this is a privilege not afforded to my trans sisters, to gender queer and gender fluid people, and while I can’t and won’t speak for them, I can support them in private and aloud.

If you’ve made it this far, had you noticed that almost all the focus has been on trans women? If not, that’s not surprising – from talk shows to TV series, almost without exception coverage is of trans women like Laverne Cox and Caitlin Jenner. Chaz Bono is a rare exception, and that more because of his parents’ fame.

This relentless gaze on trans women is interesting. Perhaps it’s because some see trans women choosing to give up male privilege as more transgressive.* I suspect, though, that it’s at least as much about male sensibilities – first, the idea that trans women are somehow setting out to trick unsuspecting cis, straight men into thinking they’re cis women (because being attracted to a trans woman, in this Neanderthal mindset, is emasculating and shameful); and second, because we police female appearance far more than male appearance, so trans women who ‘pass’ are threatening, and trans women who aren’t sufficiently feminine (whatever the hell that means) are parodies or imitations or something. And all of this presupposes that trans women are transitioning for some reason other than a need to express and be recognised as their true selves.

Oh, and I hope all these exclusionary radical feminists embrace trans men as women. Well, I don’t hope that for the men, because that’s vile and I don’t want their identities erased, but I hope they TERFs are at least internally consistent. That means being happy with trans men in female bathrooms, women’s spaces, and taking positions intended for women. Because they don’t get to have it both ways.

* to be clear, I’ve phrased it this way to reflect a mindset I don’t ascribe to – being trans is no more a choice than being gay or straight, left- or right-handed, or having an allergy

Edited to correct “trans excepting radical feminists” to “trans exclusionary” – 16.36 15/1/16

I’m back!

After a difficult year, which has included a prolonged period of time off work due to injury, I am ready to resume blogging regularly. I’m not really a resolution person, so I’ll say instead that I’ll be aiming for weekly posts, with more as the spirit of rant or activism moves me. As before, my focus will primarily be on health and union issues, with politics, social justice, and the odd apparently random topic thrown in. Happy 2016!