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The opinions expressed in below responses are those of the sender and do not necessarily represent the views of the Australian Nursing Federation (ANF). The ANF does not accept any responsibility for the loss or damage that may result from reliance on, or the use of, the information contained in theses posts. DISCUSSION QUESTION - AJAN Volume 26 Issue 2 What would you suggest to make clinical placements in aged care for undergraduate nursing students more effective and more attractive? RESPONSES Primary objective in undergraduate placements for training registered nurses should be ensuring that trainees are learning the duties of the registered nurse and not being viewed as just 'another pair of hands' in an underfunded and overstretched discipline as it often seems to happen. The aquisition of new skills and appreciations for nursing interventions, not to mention life itself, is enormous within the aged care sector. a checklist of tasks to achieve and experiences to have - including personal care, wound care, palliative care, and simply spending time with the residents talking or doing passive exercises, and spending time with those less able to communicate. DISCUSSION QUESTION - AJAN Volume 26 Issue 1 Do you think the Medicare rebates are enhancing or hindering role development for nurses working in general medical practice? What other factors do you think are barriers to or enablers of role expansion for nurses? RESPONSES Meducare rebates are hindering the role of the nurse - they provide little remunation for skilled treatment, and no coverage for the time spent with the pt. Therefore the practice can operate at a loss by puttng a nurse in a room woith computer and only billing the nurse item numbers for services. To make money for the nurse powition, the GP needs to see each pateint so extra items can be billed - this is professionally insultuing to the nurse, confusing for the patient and a continual interruption to the GP. The rebates are hindering general practice nurses'role development. The rebates are only an encouragement for nurses to be Dr's handmaidens, where the practice is paid for the service the nurse gives, rather than the nurse being recognised and paid accordingly. Australia needs to come on line with other countries and allow nurses role to expand/scope of practice to increase with the financial recognition of the role expansion going to the nurses, not to the medical practice! Most definately hindering development. Whilst GP clinics remain private business and 'employ' practice nurses, the role of the PN will continue to be driven by higher value item numbers. This does not take into account the skills of individual PN's. I feel a better approach would be giving PN's access to provider numbers and referal rights, rather than a prescriptive list of extended nurse item numbers. This would allow nurses to use their skills an experience to the benefit of the patient, rather than revenue raising for GP's. I think it is a barrier as the medicare rebate should be provided to the nurse. Nurses should be given provider numbers to provide nursing care. GPs are being given incentive payments to essentially do their job. It is an expensive way to run primary health care system as poor/disadvantaged people won't pay to see a doctor for health promotion eg smoking cessation. Nurses are well placed to do this in a cost effective way. Medicare rebates are hindering role development. Nurses would not be able to provide a needs based holistic care package if only certain elements of care are reimbursable. Instead monies should be in the form of a grant awarded to general practices which involve the service of a nurse who (together with other clinical colleagues) should be able to develop and collaborate to provide what services patients require and would benefit from utising professional skills. Eg. if giving an injection is not reimbursable, GPs will end up doing this as they can claim a consultation fee. There will be disincentive to let a nurse do it as there will be a loss of income to the surgery. This will result in nurses being under utilised; patients waiting longer; commonwealth funds being misused ... etc. Rebates for nurses giving injections would be useful but if the nurse gives a Hep A injection and provides health education on careful eating while overseas during the same consultation she will not be able to claim reimbursement for "education" if it is not listed as a medicare rebate item. Nurses may be pressurised in not providing services that are not reimbursable. Role development will be hindered by an inherently rigid system. Allowing nurses to charge fee for service under Medicarewould further enhance incentives for recruitmen, reduce the load on G.P.'s and reduce patient waiting times. I have been nursing in general practice and working in General Practice Network for 12 years. I have worked with GPs and GPNs to assist in the application of the rebates currently available for GPs who use practice nurses for wellness promotion and illness prevention. Overall, I believe that the rebate has advanced the role of general practice nursing in that nurses in most general practice settings were used mostly using the "handmaden" model where the nurse was the bidder of the GPs orders but with the injection of more nurses with different specialties and the advancement of the rebates to include wound care, immunisation and pap smear, the nurse's roll can financial expand into independant areas if specialisation. This rebate system has also encouraged general practice to support their nurses to become specialists in chronic disease management, diabetic educators, smoking cessation councilors and asthma nursing specialists etc. All this has happened because the rebates support the expansion into these areas. Also, it has given the general practice nurses a new model to work with in that they are now recognised as a health team member or even manager of chronic disease care planning to work collaboratively with the general practitioner and other allied health. I say, bring more on! General Practice is a small business and the reality is that businessmen/women can only support so much 'not for profit' activity (nurses wage not supported by rebates) so why not encourage more so that dynamic and progressive general practices and general practice nurses can enhance the health care that they are giving to patients, with greater depth and time. Yes I Believe medicare issue needs to be addressed in order for nursing to move forward.Barriers for advancement are Lack of acknowlegement by some such,GP'S,government,AMA that Nurses are capable of contributing in a more meaningful expanded role.Lack of awareness from Public that Nurses are highly educated professionals appears to be slow to catch on. Medicare rebates are enhancing the development of the role of nurses. Factors hindering or barriers: Doctors' attitudes reflect non-awareness of nurses' contribution & positive impact to their practice. Lack of support in undertaking courses eg: study time; payment of course fees. Nurses are in a collaboratively role and practice with medical practitioners to contribute to better management of chronic diseases, wound management and population health issues.Practice nurse role definition is still at a premature stage of development and advancement in career pathways can make a significant contribution to primary health care although nurses need to show the way and ensure they have a say to influence policy and plan to shape the future of this emerging specialty but it must be innovative and nurse driven and have been deemed best practice. It is a great oppotunity to practice autonomy and define the art& science of nursing but it also must be articulated well. Although General Practice suited my family life - work close to home and began close to start of school time, I resigned after only 5 months. I did this because of the lack of value placed on my skills as a nurse. I was continually advised by the practice manager - a glorified receptionist, that it was not my place to talk directly to the doctors at the practice. That all discussion - including management options for patients based on a complicated mixture of information from blood results, xrays, ctscans and or papsmears. This,coupled with low hourly wage rate [NO1.8 - $25.00], with no paid annual or sick leave,and the financial burden of placing two children in after-school care made working in General Practice unbearable. I am now working Agency earning $45 per hour and picking where,when and with whom I work. I feel more valued because facilities are now asking my opinion about procedures based on my varied and wide-ranging experiences. You would think that after 22years I would not have to play the status/qualification game, but now the players are nurses and practice managers instead of nurses and doctors! Having just returned from the UK where I worked for 8 years as an Autonomous Emergency Nurse Practitioner and Nurse Practitioner in a Nurse led walk in center, I was shocked and dismayed how primitive the nursing services were in Primary Health Care in Australia. I think the reason for this is multifactorial. The Medicare system holds so many restrictions with its itemised billing and poor rebates for nurse items. If nurses are to be autonomous in this system they will need to be recognised as experienced practitioners and supplied with their own provider number. This in turn needs to be supported by the AMA and the GP's who, at the moment may feel threatened by the expanding role of the nurse. Canada, UK, USA, NZ have all had Advanced Practitioners in primary and secondary care for the last 20 years! In the UK this expanding role was largely born out of a lack of doctors and a recognition that there were very experienced nurses's who could deliver optimal health care. It's time Australia caught up, recognised and put faith in the expertise and experience of it nurses. Until nurse practitioners have Medicare provider numbers, the delivery of health care will be hindered in Australia. The stranglehold on health by the most powerful union in Australia, the AMA, does nothing to make health care more affordable to the most vulnerable, nor advances the status of nurses as the group most qualified and suitable for providing this care. The AMA is more supportive of importing medical practitioners from overseas, whose qualifications may be inferior and whose cultural awareness is wanting, than creating opportunities for nurse to work in general practice as autonomous practitioners. Medicare has expanded the options, it is unlikely that nurses roles in GP's would develop without federal / Medicare support. Having spent some time working in general practice I have come to the conclusion that medicare rebate do hinder role development for nurses working in general practice. I experienced this personally. I was undertaking the pap smear provider course but was told my the gp's that they would still be in the room when ever I performed a pap smear. this would enable them to bill the patient for their service even tho I would be performing it. This defeats the whole objective of making the service more available. Hindering - practice nurses are providing nursing care that the GP should not be remunerated for. DISCUSSION QUESTION - AJAN Volume 25 Issue 4 Do you consider a structured graduate transition program assists in keeping new graduates in the nursing workforce? How should such a program be structured? RESPONSES As a 3rd year student, I look forward to participating in a structured program. It is one thing to say that as students, we need more clinical prac time to learn nursing skills, but with no partnership between the hospitals and the universities, it is very hard to gain good quality learning experiences. The uni simply finds us a placement and as long as we have our allocated hours signed off, they don't care what we have done. There is no one there to say 'hey, we have something interesting happening in the next ward - come and have a go'. Instead, we are left to our own devices with hopefully a nurse who might let us at least do a pill round. A structured program run by the hospital takes some of the anxiety out of graduate nursing as until we have a permanent position within a ward, we are going to need support systems in place. You cannot possibly know all there is to know after three years at uni. Having experienced structured transition program after I graduated in NSW in the early days of university training, it was seen as an extremely valued component of moving into the work force. One of the problems in recent years is that the running of these programs has moved from being beneficial to both the new starter and the organisation to trying to cater for every wish/whim that new grads may have. There needs to be clearly defined rules for participating on the program, otherwise offer the grad the ability to move to "supported" permanent employment within a ward/unit/service. As a recent graduate nurse I find effective and timely peer support during the transition to full time nursing work extremely beneficial. This highlights the need for skilled preceptors and clinical nurse educators in the area. Yes I do and I believe there needs to be a greater emphasis on integrating the schemes with Community nursing and aged care nursing not just focusing them on acute care. A great deal of nurses learn a lot through these schemes and they would be more rounded with this included within the schemes. As a former NUM, and manager of an education department I feel strongly that a well-structured transition program does assist in retaining graduates. However in our current nursing climate it is difficult to achieve a programs which fully meet the needs of new graduates. Preceptors have no recognition for their advanced role, nor do they have adequate supernumerary time to connect and engage with preceptors. There just aren't enough "numbers" it seems for hospitals in particular to justify "pulling someone off the floor" to support our future workforce, which is very disappointing. The other issue particularly in rural health is that there are often too few members of the education team who are spread far too thinly to provide support, a point which many hospitals (not all) seem to not understand. I agree with the authors of this article that the current system of transition program needs to be reviewed! Programs need to better meet the needs of graduates as beginning practitioners who require a higher degree of support. The supernumerary period for graduate must be increased with a greater focus on skills consolidation, and preceptors should be given adequate recognition for their role and adequate "non-clinical" time to connect with their precipitates. More funding needs to be put towards graduate support nurse roles, with a realistic EFT per graduate. While governments are promising to increase nursing degree places, there is no thought to the vital issue of providing more funding to cope with the demands this places on what is an already stretched workforce of nursing educators. Ideally final year students should also be given the opportunity to begin the transition phase into their chosen hospital. Graduates should also be given the option of entering into a second year of supported practice post their graduate, as is currently on offer in some organisations. Most importantly the nursing culture of treating graduates as a liability because "they don't know anything" needs to stop. Perhaps the reason why graduates don't feel confident and safe to practice is because this is what they are told to believe? I am a newly graduated RN and I am currently completing a graduate program in Queensland. I definitely think that having a graduate program is a good way to keep newly graduated nurses in the workforce. I think is offers a lot of support to us and allows us to see many different aspects of nursing. I feel that in my uni degree I did not have enough clinical placements and the graduate program has helped me to become more comfortable as a nurse. I think that having 4 month rotations is very good because you get more experience in the area. It would be good if everyone could do a placement in a medical setting, a surgical setting and a setting of their own choice. I know it would be difficult to always place them in a setting of their choice but if they had preferences then that would help with that. I feel that a graduate program is a great way to make new nurses feel more welcome and comfortable in the nursing environment. No I don't think they need to continue producing assignments as a post graduate, when they have already completed three years of study as an undergraduate. Their pays are started at the bottom rate, and this becomes a fourth year of intensive learning. I found that the graduates expressed dissatisfaction. The learning should be made more fun and out of curiosity. Facilitation can be encouraged and the graduates need to be oriented to all areas of nursing practice so they can make an informed decision as to where they wish to want to specialise in their own time. DISCUSSION QUESTION 2 - AJAN Volume 25 Issue 3 Do you think the use of sterile water injections to relieve lower back pain during labour is an appropriate form of pain relief? RESPONSES I think that the water injections are an appropriate form of pain relief during labour. I only wish they were available to me during my labour! I think they could be a HUGELY popular way to decrease the use of other forms of pain relief. DISCUSSION QUESTION 1 - AJAN Volume 25 Issue 3 Should adolescents have the right to know their diagnosis and participate in decisions about their treatment even when their parents object? RESPONSES I believe that adolescents should have the right to know about their diseases and treatment options, in just the same way as the elderly. They should also have a say in decision-making. This adolescent is 15 years old. He is old enough to start being responsible for his health, particularly in this day and age of increasing youth independence. This cancer has the possibility of impacting on his quality of life for a significant portion of his life should it not respond well to treatment. Therefore he will eventually become responsible for it's management in the long term regardless of parental interference. I am a strict atheist so I am bias when it comes to religion encroaching upon health issues and believe it should have no place when concerning minors, the best available treatment for conditions should be used in all instances unless the minor does not want that treatment and is deemed to be mentally capable of making such a decision. Once a consenting adult, I am of the belief that you can chose how to live you life as you see fit. Yes, they have the right to know about what is going to happen to them and what choices there are. Some adolescents I know are more on the ball than some of the adults I know and this frame of mind should reflect how they are treated in hospital. One wonders if the parents have not come to terms themselves with the boy's illness when they do not wish to discuss the illness, the treatment and the effects. Does religion play a role here in beliefs in regards to the frozen sperm. It is sad to think the parents are unable to discuss with the boy the illness, treatment and outcomes, because the boy unless he has a mental disability to understand he is becoming progressively unwell or the effects of medication he is going to suspect something is seriously wrong and this may affect him psychologically and delay his healing process. Adolescents have the right to know what is wrong with them. They need to be adequately supported through the process of understanding their illness and the treatment options. Whilst there can be a complex of individual and family dynamics to navigate, treatment and care providers have a responsibility to maintain open lines of communication between all significant decision makers, including the adolescent themselves. Sensitivity and open, honest communication are the key. Difficult as that can be in some circumstances! In short, "Yes". In Australia, we can give weight to the Gillick principle (British, but endorsed by the High Court of Australia in 1992). Therefore, if the adolescent is capable of understanding the situation, the proposed treatment and the possible outcomes, they should be given the right to accept or decline treatment. A typical 15yo should probably be INVOLVED in making their own treatment decisions, although they would probably need guidance and counseling in terms of some of the more serious long term effects/outcomes. Notwithstanding, each case must be assessed on its merits. Response to discussion question: It is the nurse's duty to inform a patient about their illness/condition and how it can be treated regardless of age, sex, race or physical condition. Why do 18 year olds have this privilege of gaining this information without their parents' consent while a 17 year old may have to fight their parents for this right? If an adolescent wishes to know their treatment options, it is the nurse's duty of care to inform them in an appropriate manner. It is a human desire to want to live healthily. Parents may feel they know what is best for their child, but may not know how their adolescent feels about the situation unless the adolescent is included in such important decisions about their health. Such exclusion from these important decisions may lead to resentment towards the parents, particularly if a certain treatment would have saved emotional strain on the adolescent's behalf (very important during such emotional and hormonal turbulence) but the parents refused both the treatment and the adolescent's opinion. I and many others my age would certainly attest to this. I think it depends on the situation surrounding the teenagers care. Also the capacity to which the teen understands the illness needs to be taken into account. A case conference between parents rabbi social work and the Oncology nurses and doctors may assist in understanding of each other's points of view. Nurses can be put in a difficult position if gentle clear communications are not commenced early. There is potential for nurses to be 'made an example of' if there is no clear procedure on the ward so everyone has the same approach to care. It does depend on the maturity of the person, recently we had a 16 year old diagnosed with ALL and she was involved in all the discussions but we soon found out that she was a very young 16 year old, so these are the issues that need to be found out. her mother was not helpful with a previous history of mental illness and a cancer diagnosis herself. Being a younger person in the health care industry I believe that adolescents should have the right to know their diagnosis and be a participating member in the decisions about their treatment. Everyone has a right to know what is wrong with them and how it is going to be treated. You cant leave them out of the loop. I believe a teenager should be consulted at all times regarding their care as they are the people who have to live with the decision made, for the rest of their lives. Being young myself, with the amount of resources out there the patient is able to make an informed choice. No one has the right to choose how a person is treated medically or otherwise uninformed. Having read this case study my gut instinct is to tell the patient of his condition. If you remove this from a medical setting, you would not get behind the wheel of a car without first being taught how to drive. You do not solve a maths equation without first being shown the formula. You cannot beat cancer if you don't know you have it, and don't understand why one day you feel relatively okay but then after some undisclosed medicine you feel 10 times worse and start losing your hair. Not telling this child of his condition plays with his sense of self and identity. How can he sit in a ward amongst other cancer patients receive the same treatment as them but deny he has cancer. The people who are going through the same treatment as him are able to provide support where those who haven't can't. This support will be hampered by his denial that he has cancer. I think the patient has a right to know the full extent of his condition, and all the treatment methods so he can make an informed decision. If he chooses to go along with the doctrines of his faith so be it, but he may in fact want treatment, either way he should have all the information. They should be allowed to be involved, they after all are the ones who will have the treatment, and it may help them accept their condition and treatment if they feel more in control of what is happening.
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