Off to the Land of Oz

Life provides us with some twists and turns that seemingly come out of nowhere and leave us in the Land of Oz looking for how to get back to Kansas!
As some of you will already know, earlier this year my daughter was diagnosed with severe anorexia which appeared relatively suddenly after a trekking trip to Nepal late last year. Sudden weight loss on an already slight frame for her 183cm managed to tip her brain into starvation mode, triggering a fairly rapid descent into compulsive exercising, obsessing about food and eventually actively restricting intake. By the end of February she was in hospital with a heart rate of 27, BSL of 1.6 and other chemical imbalances, where she remained for 5 weeks before being medically stable enough to return home.
Since then we have been participating in the Maudsley approach to treating anorexia which places the parents in the driving seat of restoring the child to full nutrition with support from a family based treatment (FBT) support person. The Maudsley approach differs from conventional anorexia treatment in that it recognises the central role of families in treatment, rather than blaming them for the condition.
Practically this means 24hr supervision of the child to minimise physical activity, requiring the child to eat 3 meals and 3 snacks a day, weighing weekly then adjusting activity and intake according to weight gain or loss. Sounds simple but anorexia is a horrific mental condition which torments the child to exercise compulsively and each mouthful is like asking them to throw themselves off a cliff. My daughters anorexia is a female persona who coaches and encourages her to resist our efforts to refeed her and then punishes her awfully when she succumbs to our insistence that she eats or sits still. To get the required food into her, we have to sit with her, remind her to take mouthfuls, not allow any other activity unless she eats and at times take her to emergency department if she absolutely cannot eat. My otherwise beautiful, gentle, honest, witty and caring daughter can turn into a raging violent beast resembling a snarling or cowering wolf when the anorexia voice is very loud. My husband or I must sleep with her to stop her exercising during the night.
I have been managing to work part-time since this started but have been struggling to give APNA the attention it deserves. In a joint decision by the APNA board and myself, it has been deemed in my and APNA's best interests for me to take 3 months leave of absence to focus on my precious daughter and do what it takes to restore her to full health. In the last few weeks I have predominantly been on leave and the chance to apply myself fully to the task of looking after my daughter has seen a 4 kg gain in 4 weeks. We are not sure how much further we have to go as we will be judging the ideal weight by the diminishing of anorexic behaviours rather than a BMI figure as such.
I leave APNA in the very capable hands of the APNA staff who will continue to strongly support the membership, develop the new services we have planned, finish off the projects currently in train etc. The APNA Board is looking at options for an interim CEO and will inform the membership when a decision is made.
Finally, I would love it if nurses could read the websites at the end of this blog regarding the Maudsley approach to treatment of anorexia. We have been so blessed by a GP who took us seriously when I first raised concerns, access to the Royal Children's Hospital Eating Disorders Team through participating in a research trial even though we are out of region, and finding the Around the Dinner Table web forum.

Some key messages for nurses from our experience are

• As nurses you will come into contact with concerned parents - take them seriously. Research has shown at least one general practice visit from a concerned parent is positively correlated with the existence of an eating disorder. The concerning behaviours can occur while child is still in a healthy BMI weight range.





• A heart rate of 37 is not normal even if they are athletic. The clinical markers for hospital admission include a heart rate of 50 or less. At our GP surgery ECGs are done by a private pathology company who did the ECG but let us go home for three days before the GP read the results. A growing teenager who is losing weight and exercising for 2 hrs a day with a low heart rate is medically compromised. We were admitted as an emergency as soon as the GP saw the results and remained in hospital for 5 weeks.





• If parents are concerned and cannot access specialist treatment for a while, there is no reason to not start insisting they eat. Point parents to the websites and books at the end of this blog. The sooner they get started the easier it is to knock it on the head. Do not recommend avoiding making food an issue - if they are anorexic they cannot 'choose' to eat. If they are not, they should be able to eat the food placed in front of them with no issue.





• When refeeding, parents need a lot of encouragement and support. You can feel very much like you did when you bought your newborn home from hospital and family based therapy, while supportive in nature, has to challenge you keep being tougher, be authoritative as a parent at a time when you had loosened the reins a bit and constantly be reviewing your strategies. I have times when my husband is at work, trying to cook a calorie dense and hence generally fried meal, and my daughter takes off upstairs to do star jumps - i have to chase her, avoid burning the dinner but also make sure dinner is not delayed etc. Some days, in my efforts to supervise breakfast and my daughter getting dressed, I drive to school in my PJs with hair going everywhere! Not the professional APNA CEO look I am more used to...





• And finally, while I know my daughter was likely to get this whatever we did as it is predominantly a genetic predisposition and biological response to weight loss, I do sometimes wish we had taken more seriously the nutritional needs, in particular of fats, of growing, athletic teenagers . Like most households these days we have been obesity/cholesterol aware and only had low fat milk, yoghurt etc, lean meats and 'healthy' take away options (well most of the time!). Also like many working families, we often all ate at different times and the kids often made their own individual dinners and no-one ate desserts. The family meal is not just a good social family bonding time, it encourages a good intake and socialisation round eating. An expectation that whatever is placed on the plate is eaten and all of it to boot would potentially be preventative for those predisposed to anorexia. And it can't hurt the others!

As I find myself in the Land of OZ and working our way back to Kansas (Wizard of Oz analogy for the movie illiterate!), keep up teh good work in primary health care land. I look forward to returning with renewed vigour and enthusiasm in September.

Websites

http://www.maudsleyparents.org/

http://www.feast_ed.org/

http://www.aroundthedinnertable.org/

www.aedweb.org/Medical_Care_Standards.htm

Books

Brave Girl Eating by Harriet Brown (easy to read and could be our story in terms of describing the behaviours and treatment)

Help your teenager beat an eating disorder by Lock and Grange ( great How to book on Maudsley method)

Merry Xmas

Apologies for being so absent on the blog lately as things have been very busy in the office here at APNA.

I wanted to finish the year off with a reflection on the year, both within APNA and in the wider political context.

From an internal APNA perspective, the year has been a huge one with many highlights including

• Membership increase from 1532 in December last year to over 2650 currently.
• This time last year we were mid transition to new database and were offline for online joining and renewal.
• New website which has been a big hit with increasing traffic all year
• Creating enews only subscription for non-members with over 1000 subscribers
• CPD portal launch
• Conference 2010 was a big success and extremely well evaluated
• CPD committee commenced and very active and enthusiastic which brings a lovely injection of energy to the office
• Launch of CPD endorsement process for education providers with more and more providers seeing endorsement as of value
• Moving online learning platforms to go live in next week or so, which will enable us to develop many more courses at a more affordable cost for both participants and course developers.
• Over 1000 respondents to salary and conditions survey
• High quality Primary Times and Enews out on time all year

From a broader perspective highlights of the year have included

• May Budget Announcement of the injection of more money and a more flexible payment structure for nurses in general practice through the proposed PN Incentive Program
• Providing members with analysis of the different political parties proposals relating to nursing in the federal election process
• Invitations to sit on PNIP, Diabetes Advisory Group and Telehealth Advisory Group
• Active voice in discussions and workshops around Medicare Locals
• Working with ANF on preliminary moves towards industrial negotiations around the pay and conditions of nurses in general practice

Finally, as always, the highlight for me personally and the staff at APNA, is the interaction with members. We never fail to be inspired by the passion and commitment of our members to improving patient care and contribute to better primary care. From phone calls to emails to events, we always come away with a sense of pride in our membership and a renewed commitment to doing the best we can for our members.

Hope Christmas is a time of relaxing and catching your breath before what promises to be another big year next year. See you after the holidays!

All steam ahead

Over 2010 we have experienced a significant increase in the numbers of members from 1500 to over 2400 so far. Similarly we have had almost 1000 responses to our salary and conditions survey. Numbers of unique visitors to our website has also gone through the roof. Why?
I suspect that the focus on national registration requirements, an increased sense of professional identity and maybe better marketing on our part, has contributed to this level of engagement from nurses in our sector. At a meeting I attended the other day, other nursing organizations commented on a similar increase in membership and engagement. It really feels like we are gathering a level of professional momentum.
Launching the CPD portal this week has been a long work in progress. We hope as many of you as possible will use this new functionality and provide us with feedback on its usefulness and how we can improve it. It is a key part of APNA’s increasing focus on professional development within our specialty, supported by a fantastic CPD committee which is currently recruiting new members. The other aspects of our CPD strategy is a total revamp of our online learning college with a number of new courses coming online; careful endorsement of other providers’ education enabling nurses to know which courses or events are relevant and of high quality; development of a comprehensive event calendar and course information webpage.
The preliminary results from the salary and conditions survey indicate that pay and conditions continue to be problematic for nurses in general practice. And while this is the case we will continue to lose good nurses of this much-needed area of community care. Hence we are pleased to be able to work with the Victorian ANF to provide a workshop next week for practice nurses on industrial issues. As part of the workshop we will be working on describing the different roles and responsibilities of practice nurses at the different potential paypoints. We have gone into this collaboration to support the ANF in its industrial role while providing the benefit of our understanding of the issues of our members. The intent is to work positively with employers to develop agreements which are of advantage to both the nurse and the employer. While the APNA is not an industrial organization, we cannot get away from the impact of the highly variable and at times difficult employment conditions of our members as it directly affects their ability to work professionally and affects retention and morale. We will keep you up-to-date with where this is going.

A state of limbo

Election 2010 did not deliver the result we were expecting and certainly creates a sense of uncertainty within our particular sector with the policies from the ALP and Coalition being significantly different. I have taken heart from some of the independents comments, in particular Rob Oakeshott, that they are keen to see the work of expert committees and reviews implemented. I think for me that is the most potentially disheartening aspect of this election – to see the excellent and highly consultative work of the National Hospital and Health Reform Commission, the National Preventative Healthcare Taskforce and the National Primary Health care Strategy Expert Reference Group, be to no avail. If the independents can influence both parties to ensure that this excellent work is carried forward into policy - that will be a good outcome for all of us. Julianne Badenoch has written to the independents to express our desire for a strong, flexible and well-funded r ole for nurses in general practice and how critical this will be for the growing burden of chronic disease, meeting the needs of the ageing population particularly in areas of GP workforce shortage. If any of you are in electorates with the independents, this may be your opportunity to express what you want to see.

Speaking of a stronger role for nurses within the health system, there is a very interesting article by a range of experts here http://www.sa-lives.com/entry/13/why-nurses-should-be-more-prominent

On another note we have announced this week when and where the APNA conference 2011 will be held – Sydney 7-9 April. The conference committee met for the first time on Monday and comprises a great range of nurses including ENs, RNs, and an NP candidate who come from a range of settings, including rural and urban, indigenous health, academia and sexual health. The enthusiasm in the room was very infectious and is reflected in the theme decided- Roadmap to the Future - Great Expectations. And this in the face of uncertainty about the election outcome!! As well as a very detailed program being developed with a range of fantastic topics, a theme for the dinner of' Route 66' was chosen with a lot of laughter and fun. Please out this date in your diary and hope to see you there.

I had the privilege last week of going out to the East Brunswick Medical Practice where 2 of our members Teresa Reid and Roz O'Reilly had invited me to come and talk with their GPs about the new PN incentive. It was a fabulous experience as the practice is very progressive and we had a very constructive and useful discussion about their desire for a greater role for their nurses, impact of the block grant funding models and their desire to have undergraduate nursing students etc. Teresa AND Roz had presented at the APNA conference on their innovative model on new patient registrations done by practice nurses and the improvement in GP throughput and comprehensive records.

Finally, keep the calls and emails rolling in. Calls this week have included issues around pap test provider numbers, bereavement leave entitlement under new awards, EN supervision issues and much more.

More interesting times

Just in case we all thought life was going to settle down, we have an election! Every year I do a presentation to public policy students at the University of Melbourne where I present on the policy environment within which the APNA operates. At the session this morning I was asked a lot of questions about what impact a change of government at this election would have on health, primary healthcare and specifically nursing in general practice. What struck me as I was talking was a real sense that for health this election is crucial. Most of this government's first term has been spent in developing policies to move forward and if not given a second term in government, not enough on the health reform has been embedded that cannot be undone. For those of us who have been advocating for health reform, even if we don't agree with elements, would find it very frustrating to return to the status quo.

At APNA we have set up an Election 2010 webpage so keep your eyes on this as we get through the next few weeks.

On another note, the presentations for the New Zealand primary healthcare nurse's conference are available at the following website

http://www.nzno.org.nz/groups/colleges/college_of_primary_health_care_nurses/phc_conference_presentations

I am off to New Zealand tomorrow for the World Health Care Networks conference which will be debating and holding the development of our own primary healthcare networks or "Medicare Locals". Evolving from the current Divisions of General Practice Network, we to ensure nurses play a key role in the new organizations from governance through to program management and down to the practice.

Back from the wilderness

It has been a long time since I have written in this blog. It has been a combination of ill health and being a way in New Zealand.
Firstly over 5 weeks ago now, I experienced some chest discomfort and of course immediately thought heart attack. Along with severe chest pain, came waves of anxiety and adrenaline. As those of you who know me know, I can usually manage fairly high levels of stress with equilibrium - so these feelings of anxiety were very foreign to me. After many tests, I was diagnosed with chostochondritis and instructed to take it easy for several weeks. It has been a testament to both my proactive board and my resourceful staff that APNA managed perfectly well without me for a number of weeks.
However, I am conscious that my absence coincided with a lot of e-mails from members regarding the new practice nurse funding. Whilst I tried to reply to as many as possible, I apologize to those of you who did not get a response. Needless to say I have taken on board all of your concerns especially from those of you in large practices, those of you who are enrolled nurses and in fact all of you who feel the incentive may adversely affect your role. The consultation process has not yet begun and we will be taking your concerns into those meetings.
After much debate, I decided to proceed with a long planned trip to New Zealand with our new President, Julianne Badenoch. The purpose of the trip was to attend the New Zealand primary health care nursing conference, where I was presenting a paper, and to visit some of our nursing colleagues working in primary health care. Julianne and I will be putting together a paper on what we learned but in brief we were totally inspired by both the roles of the nurses at the general practice level and the level of engagement of nurses in their primary health care organizations. Nurses are key members of their Boards, leaders of their health programs and writers of their business plans.
The conference was equally interesting in that it brought nurses from a range of primary health care settings together. It marked the beginning of their new New Zealand College of Primary Health Care Nursing and provided us with numerous examples of nurses providing innovative and best practice care, some of whom we hope to entice across to our conference.
The trip also provided Julianne and I the chance to chew the cud and establish good communication channels which will enable us to have the robust President-CEO relationship an effective organization needs.
Whilst I am still not feeling 100%, I am back at work. It has been a significant shock to realize that your body can really only take so much and I think this will be a positive in the long run. Like many of you, I am trying to balance a demanding career with raising teenage daughters and keeping all the family stuff semi-organized. Like many of you, I am passionate about what I do and frequently feel reluctant to let any opportunity to escape me or APNA. However what gets lost is time for myself and I am now looking at ways to make some lifestyle changes and get some more balance in my life. What I really need is a nurse in general pratice to provide me with some lifestyle risk factor management counselling!

Golden Opportunities abounding

I am back in APNA office really for the first time in 10 days. And what a ten day period it has been.
Thursday week ago, we started the APNA conference with a lovely welcome drinks and launch of the first general practice nursing textbook written by Lynne Walker, Elizabeth Patterson et al. I have just been reading the conference evaluations and overall the satisfaction was extremely high. Delegates loved the venue, the speakers and the overall program and obviously felt inspired by the whole conference. There was constructive feedback about running to time, too many choices and poor showing at the concurrent papers which we have definitely taken on board for next year. There were some comments about wanting more warning about the Health Minister coming (we would have told you if we knew!) and again many raised the cost of attending despite us reducing all registration levels by $50 this year. The cost is a real dilemma for us as we want the conference to reflect that nurses deserve a conference which is not second rate compared to medical conferences and reflects your importance in the scheme of things but our delegates are largely self funded and do not have much money. Hence we source the sponsorship levels that we do to make it as affordable as possible. The evaluation had delegates rate affordability as a concern but are less concerned re cost to APNA - unfortunately the only funds we can use to apply to the conference will come from member subscriptions and away from other member services - so it is very challenging! Feedback on how to manage this dilemma is appreciated!
The Health Minister alluded to changes in the Federal Budget on the following Tuesday night and reminded me personally as she left to be ready to go on Tuesday with media etc. I assured us that we were prepared with media releases and footage etc.
I returned home from the conference on the Sunday am (Mothers Day) to go to the opening of the new stadium for Melbourne Storm. I collapsed into bed that night and slept for 12 hours, waking on Monday am at 9am to 10 missed calls on my mobile...ABC Radio, Daily Telegraph, Ged Kearney and so on. Arggh! The PN funding news had been leaked and I then spent the next 5 hours in my PJs in our home office doing radio interviews, organising practices for journalists to visit and nurses to be interviewed. Skynews then rang wanting me to go on their PreBudget show on Tuesday am in the Canberra Studio. So I rearranged flights and accommodation to Canberra, texted my teenage girls at school to say I was disappearing again, cooked a spag bol (which nobody ate!) and headed back out to airport.
Tuesday am saw me in the Parliament House Skynews studio at 7.30am for my first ever TV experience, which went well according to the only 2 people I know who watched it - my 15yr old and hubby. Off to the National Primary Health Care Partnerships meeting and then Budget Lock-up, before retiring to hotel room to write APNA media releases.
The next morning I headed to airport at 6am for flight to Adelaide via Sydney to speak to SA Divisions Network NIGP program officers and then flight back home to Melbourne. Needless to say Thursday and some of Friday were spent in somewhat of a blur...
The Budget announcements are very exciting for nursing in general practice but have also been accompanied by anxiety. I hope you have all had a chance to look at the 'Advice to Members' document we sent out last Friday. We are very keen to have any feedback positive or negative about the changes.
Here's to a quieter couple of weeks!