NSW looking to ban e-cigarettes from smoke-free areas. What’s the big deal?

Once touted as a traditional cigarette replacement on the road to quitting the nicotine habit ‘electronic cigarettes’ or e-cigarettes as they are more commonly known has developed  a bad reputation.  ABC news reported on Thursday that support is growing for New South Wales to join five other Australian states (ACT, Queensland, Victoria, Tasmania and South Australia) in banning the use of e-cigarettes in smoke-free public areas where currently only traditional burned cigarettes are outlawed. So what are e-cigarettes and are they as harmful to the user and bystanders as traditional cigarettes?

What are e-cigarettes

Both traditional cigarettes and e-cigarettes do share one very common trait, the heating of the consumed material to make either smoke or vapor. E-cigarettes, instead of using smoldering or fire to burn the solid material implement an electronic heating element within  the device to vaporize a liquid thereby allowing that liquid to enter the user’s lungs much the same as traditional tobacco smoke. Proponents say that e-cigarettes are less harmful to both the user by eliminating the secondary chemicals normally found in traditional cigarettes and to those affected by traditionally passive smoke as the e-cigarette is less likely to transmit harmful chemicals throughout a space. The latter fact is what is being debated regarding the smoke-free e-cigarette ban.

Traditional cigarette risks versus e-cigarettes

Traditionally burned cigarettes have been widely studied and their harmful health effects well known. The American Cancer Society warns that there could be as many as 70 harmful chemicals in cigarettes which could lead to cancer when burned and inhaled. The same site does state that there are chemicals known to be contained in e-cigarettes which could contribute to cancer formation, however the biggest risk in e-cigarettes is the current lack of regulation and control on the ingredients, both type and quantity, which means that it is difficult to quantify their effects. A publication by New South Wales Health agrees with the American Cancer Society that there are a wide variety of levels of harmful chemicals, including nicotine, in unregulated levels within various e-cigarettes without accurate labeling. Additionally, e-cigarettes could also contain other by-products such as heavy metals which are used in the heating elements of the device. The take-home message for users of e-cigarettes is that there is an inherent danger as the e-cigarette market is mostly unregulated allowing for a range of chemicals, both listed and unlisted, to be included in the liquid active ingredients. This range of chemicals could lead to both short and long-term health effects.

The New South Wales Health fact sheet also state that there is a risk of exposure for people in the immediate vicinity of users of e-cigarettes, known as exposure to second-hand smoke. Again research into second-hand smoke with traditional cigarettes have been widely studied; and this has led to the smoke-free bans seen here in Australia and world-wide to protect non-smokers from the effects. The study into second-hand smoke amongst e-cigarettes and the effect on those around smokers is not as clear cut.

Second-hand e-cigarette smoke research and opinion

A systematic review of the effects of second-hand smoke from e-cigarettes was published by the Public Health Research and Practice group in 2016. The review looked at scholarly articles published between 1996 and 2015 regarding the study of this subject. The results showed that there were particles of nicotine, harmful chemicals similar to traditional cigarettes and heavy metals found within the vicinity of the e-cigarettes. However, the levels of these chemicals were much less. Additionally, the spread of these chemicals was overall less as the authors concluded the exhalation of traditional cigarette smoke could spread the airborne chemicals further than e-cigarettes. However, this study concluded similar results to those listed above that regulation of e-cigarette ingredients and concentrations of those ingredients have led to poor research outcomes.

The ‘vaping’ community has weighed in on this topic. The website “Vaped: by Totally Wicked” has stated:

Though studies are still ongoing on this topic, those that have been done so far strongly indicate that passive vaping poses little danger, if any. In fact, what they have managed to show thus far is that passive vaping is a non-existent problem, with ‘no apparent risk to human health from e-cigarette emissions based on the compounds analysed.’

The study linked to this statement was published in 2012 by the journal Inhaled Toxicology. While I did not have access to the article the synopsis did state that

For all byproducts measured, electronic cigarettes produce very small exposures relative to tobacco cigarettes. The study indicates no apparent risk to human health from e-cigarette emissions based on the compounds analyzed.

The issue is that the study used four e-cigarette liquids and compared to traditionally burned cigarettes. As the discussion has indicated previously there is widespread variation in chemical inclusions and concentrations as well as a lack of clear labelling which makes any comparison impossible. Therefore, research into the effects of passive smoke cannot be generalized at this point.

Another blog site, Vaping 360, lists a 2016 report prepared by the Royal College of Physicians entitled “Nicotine without smoke Tobacco harm reduction” which discussed the use of e-cigarettes as nicotine-replacement- alternatives and how traditional tobacco companies were attempting to gain ground in this market within the UK. The Vaping 360 cite quoted:

Users of e-cigarettes exhale the vapour, which may therefore be inhaled by others, leading to passive exposure to nicotine. There is, so far, no direct evidence that such passive exposure is likely to cause significant harm, although one study has reported levels of polycyclic aromatic hydrocarbons that were outside defined safe-exposure limits. It is clear that passive exposure will vary according to fluid, device and the manner in which it is used. Nicotine from exhaled vapour can be deposited on surfaces, but at such low levels that there is no plausible mechanism by which such deposits could enter the body at doses that would cause physical harm.

Nicotine-replacement legislation in Australia

But the debate over second-hand smoke and e-cigarettes could be moot here in Australia. According to the Royal Australian College of General Practitioners (RACGP) the use of e-cigarettes for nicotine-replacement are illegal.

In all Australian states and territories, it is an offence to manufacture, sell or supply nicotine as an S7 poison without a licence or specific authorisation. This means e-cigarettes containing nicotine cannot be sold in any Australian state or territory. There are several reported instances where individuals have been charged with the illegal supply of liquid nicotine for use in e-cigarettes in Queensland.16,17

A recent clarification from the Federal Department of Health has advised that nicotine can be imported by an individual for use as an unapproved therapeutic good (eg a smoking cessation aid), but the importer must hold a prescription from an Australian registered medical practitioner and only import 3 months’ supply at any one time. The total quantity imported in 12 months cannot exceed 15 months’ supply of the product at the maximum dose recommended by the manufacturer.18 Most current consumers are unlikely to visit medical practitioners for a prescription of products that are readily available over the internet. The purchase and possession of nicotine by individuals are not regulated by Commonwealth legislation except for importation as allowed under Commonwealth law.

Non-nicotine e-cigarettes are not regulated, according to the RACGP site, however if they are not specifically for nicotine-replacement therapy then their use is purely recreational and should be subject to concerns raised by state governments and health authorities as to the additive chemicals and the effects of those chemicals on non-users within the immediate vicinity. Therefore, with no specific medical need for e-cigarettes the health concerns of second-hand smoke should outweigh the desire to have a cigarette-substitute in public and should be banned.

What does all of this mean for e-cigarette use in public?

So what does this mean for Australia, and specifically New South Wales, in the debate over e-cigarettes? The debate, to me, is quite simple. E-cigarettes in Australia at this point cannot contain nicotine as per Commonwealth law. Therefore, they cannot be considered as a replacement to traditional cigarettes as has been touted elsewhere in the world. That also means they have no medical necessity to users. Non-nicotine e-cigarettes at this point are legal, however there are a number of chemicals used in various e-cigarettes which can be as harmful as in traditional cigarettes to individuals standing within close proximity to the user. Additionally, chemicals used in e-cigarettes are not regulated so the quantities and types of chemicals contained do not need to be listed. While e-cigarettes are less harmful than traditional cigarettes there is still a risk of passive second-hand exposure. So there seems to be no reason why the state government should not join the five other states in outlawing e-cigarette use in smoke-free locations throughout the state.

Your thoughts? Until next time,

Ray

 

 

References

ABC News- E-cigarette ban in smoke-free areas of NSW attracts Government support

http://www.abc.net.au/news/2017-11-02/fight-to-ban-e-cigarettes-in-smoke-free-areas-of-nsw/9109858?pfmredir=sm

Web MD- The Vape Debate: What You Need to Know

https://www.webmd.com/smoking-cessation/features/vape-debate-electronic-cigarettes#2

American Cancer Society- Harmful Chemicals in Tobacco Products

https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html

New South Wales- Are electronic cigarettes and e-liquids safe?http://www.health.nsw.gov.au/tobacco/Factsheets/e-cigs-are-they-safe.pdf

Centers for Disease Control- Secondhand Smoke (SHS) Facts

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm

Public Health Research and Practice- A systematic review of the health risks from passive exposure to electronic cigarette vapour

http://www.phrp.com.au/issues/april-2016-volume-26-issue-2/a-systematic-review-of-the-health-risks-from-passive-exposure-to-electronic-cigarette-vapour/

Vaped: by Totally Wicked- SHOULD YOU WORRY ABOUT PASSIVE VAPING?http://www.totallywicked-eliquid.co.uk/vaped/passive-vaping/

Inhaled Toxicology- Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality.

https://www.ncbi.nlm.nih.gov/pubmed/23033998

Vaping 360- Is second hand vapor harmful?

http://vaping360.com/is-second-hand-vapor-harmful/

Royal College of Physicians- Nicotine without smoke: Tobacco harm reduction

https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0

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2017 worst influenza season in Australia since 2012 with New South Wales hit the hardest

Quick facts

  • Influenza is a very contagious respiratory virus which is spread by sneezing or coughing commonly.
  • There are two strains of influenza with many variations due to proteins within the DNA. This allows continual mutations from year to year.
  • Worldwide 3-5 million people become infected every year with 250,000 to 500,000 deaths annually.
  • In Australia approximately 18,000 people are hospitalized each year with 3,500 deaths.
  • The World Health Organization has been monitoring and producing vaccines for influenza since 1952 with 142 monitoring centres in 112 countries.
  • Five international centres produce the vaccines used every year, including one in Melbourne.
  • While criticism of the level of outbreak for 2017 in Australia is mixed statistics showed that there were more reported cases this year than at any point since 2012
  • Of the 217,559 cases of influenza reported in Australia up to October 2017 over half (101,793) were reported in New South Wales.
  • Officials recognize an issue with how the influenza outbreak was handled in Australia this year, however they are divided on possible solutions to prevent a repeat in years to come.

 

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With 2017 thought to have been a horror year for influenza in Australia, I thought I would  research where our flu vaccines come from, how are they chosen and why has this year in particular been so bad?

A little about influenza

Flu, or more correctly known as influenza, is a respiratory virus which has similar symptoms to that of a common cold. The difference is the severity and quality of those symptoms. Surprisingly there are only two strains of influenza: A and B. However, within those two strains are combinations with varying protein chains of H and N. This is what gives the influenza virus the ability to mutate and evade eradication. Influenza can strike at any time of the year; however the colder months are more likely to see the spread of the virus. One possible explanation I heard a few years ago is that during the colder months people are more likely to congregate together indoors which would allow influenza to spread more readily. This could be due to the fact that influenza transmits via airborne means such as sneezing and coughing.

Globally the World Health Organization (WHO) estimates that between three to five million cases of severe influenza occur each year worldwide and of those 250,000 to 500,000 cases result in deaths. Australia specifically sees 18,000 hospitalizations for influenza annually with an average of 3,500 deaths. Influenza is also estimated to account for 10% of all yearly workplace absenteeism in Australia.

Worldwide vaccine efforts

As a virus you cannot cure it with antibiotics; once infected all you can do is wait it out. However, vaccines work by introducing a weak or dead strain of the virus into the body where antibodies can be produced which when confronted with the influenza virus will kill the virus before it takes hold of the host’s body and produce debilitating symptoms. The production of antibodies can take three to four months before fully effective so experts recommend having the flu vaccine early in the season to allow for immunity to develop.

Logo-WHO

The WHO has been responsible since 1952 for the monitoring of influenza and vaccine research through their Global Influenza Surveillance and Response System. Different influenza strains become more prominent from year to year, and strains can mutate. Therefore the WHO runs 142 monitoring centres in 112 countries. Five of those centres host World Health Organization Collaborating Centers for Reference and Research on Influenza:

  • Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC);
  • London, United Kingdom (The Francis Crick Institute);
  • Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory);
  • Tokyo, Japan (National Institute for Infectious Diseases); and
  • Beijing, China (National Institute for Viral Disease Control and Prevention)

These five centres are also produce vaccines for the different influenza strains. Monitoring of influenza occurs year-round, however production of vaccines takes approximately six months and therefore decisions on which strains (usually three to four) are included are made half a year before the major flu season starts. The actual vaccine doses are then manufactured by private companies with the strains produced by the centres above.

The 2017 influenza season

So with all of the knowledge of influenza and the work of the WHO and CDC along with other scientific groups, what happened this year? Well that depends on who you ask. According to the Australian Department of Health the peak of the influenza season was mid-August of this year. The department did state that there appeared to be higher-than-usual numbers of cases being reported, however mitigated that fact by saying that testing was more readily used and could have contributed to the larger number of reports. Influenza A seems to be the dominant culprit this past season. The department’s report also goes on to say that they number of hospital admissions this season were ‘moderate’ compared to previous years, and that the vaccines given seem to have had a good effect.

NSW health minister Brad Hazzard would disagree with the federal department of health report. According to Minister Hazzard “I think at this stage what we got unfortunately was a vaccine, with the benefit of hindsight — and hindsight is a wonderful thing — that wasn’t quite up to it.” Peter Collingnon, executive director of ACT Pathology and a physician at the Canberra Hospital Infectious Diseases, went onto say that he felt the vaccine this year had very low efficacy for the A H(3) strain responsible for so many hospitalizations and deaths. Although the vaccine supplied to Australians was up to the global standard many patients were being seen by GPs with influenza despite being vaccinated.

According to the Immunisation Coalition in Australia as of the 24th of October 2017 there were 217,559 cases of influenza confirmed.  Of those cases over half (101,793) were reported in New South Wales. The next highest rate was Queensland which only had 53,487. So in my state of New South Wales was by far the worst hit this past season. The reported number of cases nationwide, according to the Immunisation Coalition, in 2017 were significantly higher nationwide than at any point in the last five years.

The future?

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So is this a trend, or just a one-off event?  That is very hard to know. According to the information I read the experts are mixed. One possible suggestion is that our vaccine processes are out-dated and we need to re-think how vaccines are produced. Additionally, community hygiene practices could be reviewed to limit spread of influenza, particularly in peak times. What we do know is that influenza won’t be going away anytime soon. And at least for 2017 New South Wales bore the brunt of the outbreak.

As a member of the acute healthcare team I applaud every member of healthcare for their work and dedication during this flu season. Ask any person working in this industry, particularly in New South Wales, and they will tell you it was a very busy and trying time.

Until next time,

Ray

 

National Centre for Immunisation Research and Surveillance- Influenza fact sheet= http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/influenza-FAQs.pdf

Centers for Disease Control and Prevention- CDC’s World Health Organization (WHO) Collaborating Center for Surveillance, Epidemiology and Control of Influenza= https://www.cdc.gov/flu/weekly/who-collaboration.htm

Centers for Disease Control and Prevention- Selecting Viruses for the Seasonal Influenza Vaccine= https://www.cdc.gov/flu/about/season/vaccine-selection.htm

World Health Organisation- Influenza (Seasonal) Fact sheet= http://www.who.int/mediacentre/factsheets/fs211/en/

Influenza Specialist Group- Influenza Fast Facts= http://www.isg.org.au/index.php/clinical-information/influenza-fast-facts-/

Australian Department of Health- Australian Influenza Surveillance Report and Activity Updates= http://www.health.gov.au/flureport

ABC news- Influenza: NSW Health Minister says current vaccine ‘not up to the job’ after deadly flu season= http://www.abc.net.au/news/2017-10-30/influenza-australia-deadly-year-prompts-calls-for-new-vaccine/9098598

Immunisation Coalition- Influenza Activity Surveillance 2017= http://www.immunisationcoalition.org.au/news-media/2017-statistics/

Do we need RNs in nursing homes? The NSW government doesn’t think so

 

It seems that every day I keep being reminded of issues facing the ‘premature death’ debate in Residential Aged Care Facilities (RACFs). An article today again raised this issue on a matter that had gone under my radar, that the New South Wales (NSW) minimum legislative ruling regarding a registered nurse to be on duty in a RACF 24 hours a day seven days a week had been abolished. I must say as a registered nurse, healthcare worker, former aged care registered nurse and aged care manager I was appalled.

A little background

The NSW Public Health Act 2010 superseded the NSW Public Health Act 1991. Section 104 of the 2010 act stated that a nursing home (their definition) MUST be staffed by a registered nurse at ALL times. This act was intended to ensure that RACF residents who were needing what was formerly known as high care would be taken care of by registered nurses. When this act was passed the Commonwealth Aged Care Act of 1997 was in-place and defined what was considered as high and low residential aged care.

Changes to federal funding legislation

In 2013 the Living Longer, Living Better initiative was passed by the Federal Government. This initiative did several things, but the key factor in this initiative was to eliminate the distinction between high and low residential aged care. Essentially, the government, for all intents and purposes, said that every elderly RACF resident only needed basic care, eliminating the complex health care component. This jeopardized the Public Health Act’s nursing home definition, and therefore potentially removed the requirement for registered nurses to be rostered in RACF homes 24 hours a day. However, in July of 2014 the NSW government publishes an amendment upholding section 104 and continuing to require a registered nurse in RACF homes. This amendment was only an interim measure which expired in Demeber 2015.

NSW government inquiry into RACF care

On the 25th of June 2015 the NSW government begins an inquiry entitled “Registered nurses in New South Wales nursing homes“. The inquiry is finished and the report released on the 29th of October 2015. In it the committee makes several very important distinctions about the role of registered nurses within RACFs:

3.2 For many inquiry participants the administration and management of medication in aged care facilities by registered nurses was considered essential to ensure residents’ health and safety.

 

3.4 Leichhardt Council expressed similar concern about unqualified or inappropriately qualified staff administering medications, particularly Schedule 8 drugs, as it could lead to adverse health outcomes for residents.67

 

3.12 The ability of registered nurses to clinically assess the health status of residents was another important role highlighted by stakeholders

 

3.15 The Combined Pensioners and Superannuants Association asserted that the assessment skills and expertise of registered nurses were particularly critical in aged care facilities, as – unlike hospitals – there is generally no immediate access to a doctor and in situations where a resident’s health deteriorates rapidly, a registered nurse can be at hand to make a clinical judgement about the appropriate course of action.

 

3.18 A number of inquiry participants highlighted the fact that registered nurses have the necessary skills training and experience to provide end-of-life care as a reason to mandate their continuous presence in nursing homes.

 

3.26 There was general consensus that aged care staff and enrolled nurses can undertake the personal care needs of residents with dementia, however, some inquiry participants pointed out that registered nurses are still required to administer certain medications (as already discussed throughout this chapter) and manage more challenging behaviours.

 

3.33 Numerous stakeholders noted that the supervision of enrolled nurses and aged care staff is a key accountability for registered nurses in residential aged care facilities.

 

3.37 Registered nurses also supervise aged care workers. NSW Health’s Employment of Assistants in Nursing (AIN) in NSW Health Acute Care dictates that ‘an AIN will work within a plan of care under the supervision and direction of a registered nurse when providing aspects of nursing care’.

A number of groups, such as the Australian College of Nursing (ACN), submitted statements of support for the committee recommending keeping registered nurses within RACF. The highlighted concerns that although the federal government had eliminated the high and low care qualifiers in funding nursing home residents were requiring more skilled care due to their chronic conditions. Additionally, the ACN response highlighted the committee’s evidence that assistants in nursing (AINs) and enrolled nurses (ENs) needed in-person supervision as per the requirements withing their scope of practice.

NSW government refuses to take action

However, in April of 2016 the NSW government disagreed with the committee’s findings and overturned the amendment to the Public Health Act. In an article the then health minister Jillian Skinner stated that RACF facilities were regulated by the federal government, and therefore a NSW specific requirement would constitute double regulation.

The Shooters and Fishers party, led by R.L. Brown introduced an amendment to the Public Health Act 2010 which replaced the term nursing home with a definition more appropriate to the Living Longer, Living Better initiative. This would then bring the Public Health Act of 2010 current and uphold section 104 requiring 24 hour seven day a week registered nurse coverage. The bill was passed by the upper house in May of 2017 and voted down by the lower house on the 11th of May 2017.

What does mean for RACF residents?

Within nursing homes it is often, particularly in the evening/night and weekend hours, that the registered nurse serves as the in-charge for the facility. This means they are ultimately responsible for all care and function of the facility. It is during these times that rates of pay, due to penalties, is highest for registered nurses. So it stands to reason that this is the period where a registered nurse would not be rostered on.

But who will clinically assess a resident’s need for analgesia, and would a RACF allow a non-licensed AIN to administer schedule eight medications such as Endone or Ordine? If a resident falls in a facility during these hours who is going to make the clinical assessment of whether that resident is safe to be lifted, and whether that resident should be sent to hospital? If a resident shows signs of aspiration (coughing after swallowing, difficulty breathing during meals, etc.) on a Saturday morning and no registered nurse is rostered on until Monday morning, will that resident not eat for the weekend? I know these are extreme examples, but they are common within aged care facilities.

Registered nurses within facilities also handle administrative and safety tasks. They are often required to fill sick-calls during their shifts. Registered nurses are also seen as fire wardens and trained to respond to fire alarms if needed. Who is going to undertake these jobs if the registered nurse is absent? I know these are extreme cases, but currently there is NO legislative requirement for registered nurses to be rostered within aged care facilities at ANY time. It is the discretion of the facility to decide when to roster on a registered nurse. I wonder if families of loved ones in aged care facilities would be made aware of periods when a registered nurse was not employed, and how would they feel about this?

What does this mean for the hospital and greater acute health system?

From personal experience and common sense if a registered nurse is not available in an aged care facility if a resident is requiring as needed (PRN) medication an ambulance is called. An issue with aspiration, which could be assessed by the registered nurse, would need to be undertaken by the local hospital who would be the closest access to registered nurses. Any changes in a patient’s condition would require transfer to hospital as there would be no registered nurse on premesis to assess their condition and contact the resident’s medical representative.

This means increased workload on the ambulance service and emergency departments. In a period where the number of ambulance call-outs and emergency presentations is rising do we need a further burden on our health system? And it isn’t fair for the residents themselves. Transferring a elderly person, particularly one with dementia, to hospital can lead to disorientation and further complications in their treatment leading to longer stays in hospital.

Call to action!

Jillian Skinner stated in her 2015 statement that she would encourage federal adoption of the mandatory 24 hour registered nursing requirement through the Council of Australian Governments. NSW through their own inquiry found critical evidence that registered nurses provide an invaluable link to improving a resident’s health and well-being in aged care facilities. Every clinical representative body can attest to the need for trained clinical registered nurses to be on-duty at all times in aged care facilities.

There needs to be action on this subject, not just debate and fact-finding. The evidence is overwhelming for the need for minimum clinical supervision in aged care facilities. We need lawmakers to listen to their constituents and put into place minimum standards.

References

NSW Public Health Act 2010- http://www.legislation.nsw.gov.au/inforce/e20f1d11-6a0d-ec9a-fe79-d31ae57c52c3/2010-127.pdf

Workingcarers.org.au: Living Longer Living Better changes that might affect working carers-  http://www.workingcarers.org.au/index.php/work-n-care/reports/1467-living-longer-living-better-changes-that-might-affect-working-carers

NSWNMA: Timeline of events – registered nurses in NSW nursing homes-  http://www.nswnma.asn.au/wp-content/uploads/2013/09/Timeline-of-events-registered-nurses-in-NSW-nursing-homes.pdf

Legislative Council: Registered nurses in New South Wales nursing homes- https://www.parliament.nsw.gov.au/committees/DBAssets/InquiryReport/ReportAcrobat/5821/Report%2032%20-%20Registered%20nurses%20in%20New%20South%20Wales%20n.pdf

Australian College of Nursing: ACN submission inquiry into RNs in NSW nursing homes-  http://ACN_submission_inquiry_into_RNs_in_NSW_nursing_homes.pdf

Sydney Morning Herald: NSW Government abandons 24/7 nursing in aged care homes-  http://www.smh.com.au/nsw/nsw-government-abandons-247-nursing-in-aged-care-homes-20160430-goium1.html

Talking Aged Care: NSW registered aged care nurses on duty 24/7- https://www.agedcareguide.com.au/talking-aged-care/nsw-registered-aged-care-nurses-on-duty-24-7

NSW Legislature:  Public Health Amendment (Registered Nurses in Nursing Homes) Bill 2016-  http://www.legislation.nsw.gov.au/bills/84bb3a65-4581-4187-a2b8-90a8d6e7c659