Support for voluntarily assisted suicide coming from the AMSA

As reported in Sky News, and validated by myself from the Australian Medical Students’ Association (AMSA), that the AMSA members have voted to endorse a policy which supports Voluntarily Assisted Suicide (VAS) should it become legal in Australia.

The press release (which can be accessed here) details that the association recognizes that VAS is not yet legal in Australia, and can only be implemented once legalized. Additionally, VAS should not be a replacement for a quality palliative care program; nor should it be implemented unless all other treatment options have been exhausted.

The press release by the AMSA is a measured and logical approach to the idea of physician assisted euthanasia. There has been discussion recently in the media regarding this issue, with quite far-flung statements being made both ways. Here is my opinion on the matter which has come from work as a palliative care social worker, aged care manager, aged care nurse and emergency department nurse:

  1. Reasonable and sound-minded individuals do not want to end their life.
  2. Certain illnesses and chronic conditions can cause such pain and suffering that NO palliative treatment can mitigate the debilitating symptoms and lead to a good quality existence.
  3. All treatment options, assisted suicide amongst them, need to be measured against that quality of life test.
  4. In this country, as in many others, when the family pet has become too sick to lead such a quality existence their owners are given the choice to end the animal’s life with dignity and without suffering. However, because we are human and not a domesticated animal some are meant to suffer a painful and meaningless existence while their body deteriorates to the point of failure. If our beloved pets are given such an option why not our human family members?
  5. Voluntarily assisted suicide (or physician assisted suicide) does not mean the doctor or health professional is condoning people ending their life. Neither is it (as I heard on the radio yesterday) a violation of the Hippocratic Oath. It is a trained health professional allowing a person-centered care plan which details how they wish to proceed with their medical care. This, to me, is similar to how we now implement not-for-resuscitation orders.

The Australian Medical Association’s code of ethics expands on the Hippocratic Oath, and point 1.4 section c I think says it succinctly

Respect the right of a severely and terminally ill patient to receive treatment for pain and suffering, even when such therapy may shorten a patient’s life.

For those in the medical community I can hear you already saying “but Ray, that’s not what this statement is intended for.” I know that. But what it does is highlight the need for ALL health professionals to recognize that there comes a point where we must pull back and allow patients to shorten their life; if that shortening comes with dignity, control and comfort.

I have been, and always will be a supporter of a balanced and reasonable assisted dying policy. Let us make sure there are safeguards in place to prevent misuse. Let us make sure there are processes in place to ensure death is peaceful and quick. But most of all let us allow an individual with no hope of recovery and only staring at a prolonged existence of suffering and decay to choose when they decide to end their life.

I would very much like to hear your opinions.

Until next time,

Ray

Sky News- Doctors in training support assisted dying

Australian Medical Student Association- press release

Australian Medical Association- code of ethics

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A champion amongst their own. Former patient becomes mental health nurse of the year

 

An article on the ABC news website has highlighted the great achievement of nurse Matthew Ball, a former patient of the mental health system who later went on to register as a nurse and as of today has become the Mental Health nurse of the year according to the Australian College of Mental Health Nurses.

According to the article Matthew was diagnosed with a psychotic illness which left him hearing voices. Through his work and that of mental health nurses he has rid himself of the voices, rather he can now understand what triggers the voices and allow himself to overcome their debilitating effect.

I applaud Matthew and all others who choose to turn their situation around and overcome what stops them to achieve goals. I am sure Matthew makes a great registered nurse as he has not only the understanding of what living with a mental illness is like, but has also been a consumer of mental health services and understands that perspective.

I am not a mental health nurse, nor have I ever suffered from a mental health illness. However, in the emergency department we see those who do suffer and work closely with mental health nurses. It is an invaluable area of nursing which deserves such good-news stories.

Until next time

Ray

 

ABC News- Mental health patient becomes Australia’s best mental health nurse

Sorry for the time away

To my followers and the greater WordPress community I want to apologize for the lack of posts in the recent months. I have had some personal issues going on, including moving to a new suburb. This has kept me away from the computer (which was also packed away).

I am back and ready to again bring Australian-based health news to the greater health community.

Look for new articles coming soon!

Ray

Can too much weed kill you?

 

The idea for this post came from a Facebook friend who indicated they were concerned about the US’s recent push to legalize marijuana, particularly in light of the chances of death from an overdose. Myself and another ED colleague had never heard of a death resulting from THC. So off to research I went.

Scouring the search engines I could find no credible evidence to say overdosing on marijuana has, in fact, been attributed to a death. Having too much marijuana can cause a number of unwanted conditions within the body which can make you VERY uncomfortable:

  • Temporary feelings of paranoia, fear and anxiety
  • Shortness of breath
  • Pupil dilation
  • Vomiting and/or nausea
  • Fast heart rate
  • Shaking that is hard to control, feeling cold
  • Disorientation or hallucinations
  • Hangover

But these symptoms are also common with other illicit and legal drugs, such as alcohol. Studies have shown that a person would have to receive a massive amount of THC, the active high-producing ingredient in marijuana, to die from it- this would equate to pounds being used at a time. Very unlikely.

So marijuana is harmless?

Not so fast! The question is whether you can die from a single overdose of marijuana. But just like other chemicals that humans used for pleasure marijuana can have serious effects which could indirectly lead to death. It is these items I think many are talking about when they discuss the dangers of marijuana consumption.

A report from Colorado USA where marijuana is legal has found that traffic fatalities with drivers showing marijuana in their system at the time of the accident rose by 154%! Hospital presentations were also mentioned as increasing due to marijuana consumption, however the evidence was not clear that marijuana definitely had an impact. School suspensions from marijuana use were also mentioned.

Marijuana also has shown long-term health affects in terms of memory and brain function. There can also be secondary effects from smoking the drug and there are associated birth defects when women who are pregnant use marijuana.

The bottom line…

The actual THC in marijuana can kill you if consumed in large enough quantities. However, obtaining and using those quantities will either land you in jail for a very long time or be practically impossible. There are no known attributed cases to anyone dying from consumption of marijuana.

However, there are dangers in misuse of marijuana. As with all other chemicals consumed by individuals to obtain a euphoric state marijuana can alter a person’s functioning and cause health concerns. Therefore, any use of this or any other substance must be done so with full knowledge of the effects. And there it goes without saying a careful review of current laws on consumption in your area.

Should it be legal?

The eternal debate in modern society. Like other legal substances marijuana has very negative side-effects both short and long term, however that has not stopped tobacco and alcohol from remaining legal. Some would argue that it is a ‘gateway’ drug and could lead to greater abuse. However we do not know the numbers of individuals who use marijuana and never progress to harder drugs, so how can we really know? Like alcohol marijuana can impair a person’s driving and other complex and fine motor skills. So policies and laws would need to be put in place outlining legal limits on consumption and operation.

There is growing credible evidence that marijuana is beneficial to relieving pain and other neurological symptoms. Therefore, I think it’s use as a medical alternative to stronger and harsher medications is welcomed. Especially if those with severe and chronic pain can be helped. These individuals are often struggling, and if allowing this avenue can bring relief then I am all for it.

As for the rest of us, I still don’t know. I will state for the record I have never used marijuana. I can see both sides of the debate, and I guess as I have gotten older my views have become more complex. While once very much against the idea now I am leaning toward society’s choice. There are some distinct advantages to legalizing marijuana.

  • Once legal safe limits on consumption can be placed.
  • Regulations on growing, processing, and distribution can be instated and ensure a safe product.
  • There will be a decreased demand from law enforcement agents in going after marijuana users and dealers.
  • Marijuana use can be taxed leading to revenue.
  • Legalization may also spark increased interest in investigating other medicinal properties.

So I guess I am on the legalizing side of the debate. I also can see the arguments with those who wish to uphold the laws against marijuana use. However, I do feel that they will be fighting a loosing battle in years to come.

References

Herb.com: Marijuana Deaths: How Many Are There?

Huff post: Here’s How Many People Fatally Overdosed On Marijuana Last Year

New Health Guide: Can You Overdose On Marijuana?

Family Council: Number of Deaths Caused by Marijuana Much More than 0

National Institute on Drug Abuse: What is marijuana?

 

 

 

Nursing is the most trusted profession, and here is an example of why.

 

An article in the Business Insider Australia has announced that for the 23rd year in a row nursing is seen by the Australian public as the most trusted profession! Australian healthcare enlarge takes out the top three spots with doctors being ranked as number two while pharmacists bring up third. However, the Australian public is not alone feeling in good hands with nurses around.

Roy-Morgan-image-survey-2017

Roy Morgan Research- Source: https://www.businessinsider.com.au/healthcare-remains-australias-most-trusted-profession-and-union-leaders-now-rank-higher-than-politicians-2017-6?r=US&IR=T

In 2016 Nurses and doctors ranked number one and two respectively in Brittan. A yearly Gallup poll conducted in the United States has had nurses ranked as the most respected in honesty and ethics since being added to the list since 1999, barring one year. In light of the September 11th attacks in New York that year firefighters took out the top spot. However, nurses were back in the number one position in 2002. According to GFK Vertrauen in 2013 both Japan and South Korea also ranked nurses as the most trusted profession.

But why is that? Look at a wonderful example of selfless commitment to society- Kristy Boden. An Australian who graduated from Flinders University nursing program and was working in London as a theatre nurse. She was killed not running away from the carnage that was happening during the attack, but towards it to try and help others. What she was trained to do, without fear for her safety. As nurses we know that we are trained to put others first in order to maintain health and well-being.

All of us in the healthcare profession: nurses, doctors, care assistants (AINs), radiologists etc. work tirelessly to maintain and promote optimal health in our society. We take those run-down and broken and mend them as best we can. I have always said that true nursing is not just a profession, it is a calling. And once you heed that call you are always a nurse or a doctor or a physio. And no matter where we may be in our daily lives should someone need our help we will be there to assist, whether we are in uniform or not. I have rendered assistance in a few cases in my career, however no where near the bravery that Kristy showed.

It makes me proud to know that my fellow nurses and I have gained the trust of the Australian people, and many others around the world. I am proud to say that I am a registered nurse.

References

Business Insider Australia: Healthcare remains Australia’s most trusted profession – and union leaders now rank higher than politicians- https://www.businessinsider.com.au/healthcare-remains-australias-most-trusted-profession-and-union-leaders-now-rank-higher-than-politicians-2017-6#Jduov1jC4UHu1Utb.99

Quartz Cannes Daily Brief: Nurses are some of the most trusted workers across the world, while politicians still languish at the bottom- https://qz.com/853048/nurses-are-the-most-trusted-profession-across-the-world-and-politicians-are-the-least/

Gallup poll: Americans faith honesty and ethics for police rebounds- http://www.gallup.com/poll/187874/americans-faith-honesty-ethics-police-rebounds.aspx?g_source=Social%20Issues&g_medium=newsfeed&g_campaign=tiles

GFK Verein: Trust in Professions- http://www.gfk-verein.org/sites/default/files/medien/1/dokumente/1403_vertrauen_in_berufe_downloadcharts_english_2.pdf

The Advertiser: South Australian woman Kirsty Boden killed in London Bridge terror attack-  http://www.adelaidenow.com.au/news/south-australia/south-australian-woman-kirsty-boden-feared-killed-in-london-bridge-terror-attack/news-story/07c8f1fbe255ee056aa7f36dab7f3fec

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

Are we taking care of our new nurses?

As I sit at my computer I ponder what to write. Then I think to the new graduate nurses who I work with every day. In a previous life I was a university lecturer, and the same statements I hear each day from my new graduate nurses I heard from those students: “I can’t find a new graduate position”. So I wonder, what is the current state of new graduate registered nursing uptake in 2017?

This question should be an easy one to answer. The Australian Health Practitioner Association (AHPRA) agency is requiring all student nurses to be registered with them in order to fulfill clinical placements. So finding out the number of students enrolled in accredited nursing programs in Australia should be easy, right? Not so fast. I search of the AHPRA website revealed NO data on the number of student nursing registrations. Despite this AHPRA quite easily detailed a report about the number of nurses registered in Australia all the way back to 2012, along with pertinent demographic data which I used in an earlier post. So why has AHPRA not bothered to reveal student nursing numbers?

So why does this matter?

Because nursing is a profession which cannot be automated and is increasing in demand! You cannot simply create a machine to do what a nurse does, despite some attempts otherwise. In our most vulnerable state nurses provide the personal care we need. And nurses need the complexity of thought needed to provide intricate assessment of a patient’s needs and identify problems before they cause serious life-and-death situations such as those of Vanessa Anderson.

And let’s face it, the Australian public is becoming older and needing more healthcare. Modern healthcare is allowing for longer life expectancy, and with that older adults will utilize more healthcare. Additionally, the baby boomer generation will expect greater results in terms of customer care which will require adequate numbers of appropriately trained and attentive nurses. So where will these registered nurses come from?

Will there be a nursing ‘shortage’?

Last year Monash business school did a study on on the climate of the nursing and midwifery workforce. The Monash report determined that an occupation which is demanding, such as nursing, should likely see between three to six percent of its workforce intending to leave. However, this study showed that 32% were considering leaving the profession, with 25% determined to do so. Even the Department of Health in a report filed in 2013 stated their figures indicated Australia had adequate numbers of nursing staff only up to 2016. Another poll found that 100% of nurses surveyed stated that the government undervalued their role.

Ah, but overseas nurses can fill the void? It is true that a significant number of nurses are overseas-trained? The Australian Bureau of Statistics reported in 2013 that one-third of nurses (33%) were overseas-trained, up from 25% in 2001. This fact has been highlighted as a reason why Australian new graduate nurses cannot find post-registration employment. But with 33% of the 342,221 nurses registered in Australia overseas-trained in 2016 is the overseas nurse a threat to our domestic nursing cohort? Some may think so. The Australian Nursing and Midwifery Federation feels that the 457 visa program for overseas nurses is “… being taken as a shortcut and that employers see it as a quick fix.”

Troubles post-study for nurses

Publicity around newly registered nurse employment seemed to peak in 2014-2015. ABC news reported that ” thousands of nursing graduates are unable to find work in Australian hospitals.” Even in 2016 the rumbling of underemployment of nursing graduates continued. In West Australia a WA Today article reported that only 500 of about 1500 (33%) newly graduated nursing students secured a nursing role. The Health Times reported that of the new graduate nurses in 2007 97.4% were able to secure full-time employment; however, in 2014 that figure dropped to 80.5%.

So where do we go from here?

Firstly, we need to have clear evidence as to the extent of the problem. I would call on AHPRA as the registration body to release statistical figures about the number of student registrations, just as they have done for registered and enrolled nurses. With that information we can clearly see how many students we have in nursing programs in Australia. Additionally, I would call on AHPRA to include a statistical figure on the number of overseas-trained nurses registered in Australia. As they are the governing body and provide the certification that overseas nurses are able to work in this country they would be able to provide figures as-such.

Secondly I would suggest the Department of Health re-visit their strategy paper on nursing retention and recruitment. This report is from 2013 and stated the nursing workforce was only adequate until 2016. If the government does care about the potential nursing workforce into the future reviewing their strategies and making a future policy framework would be necessary. It would also be helpful for the Council of Australian Governments to convene on this issue as they are the primary employer of a large number of nurses through the public health hospital system.

Without adequate statistical data there can be no informative discussion regarding the debate over new graduate nurses in Australia. One thing is certain, without adequate places for these energetic and qualified nurses to go the profession will continue to struggle in providing adequate healthcare to the increasing ageing population of Australia. Policy makers and statisticians need to act now in preventing a healthcare crisis in the future.

References

AHPRA: Student registration-  https://www.ahpra.gov.au/Registration/Student-Registrations.aspx

Advantech: Industry 4.0: It’s happening – Nurses are replaced by Robots- http://www.advantech.com/machine-automation/industry%20focus/206d0919-7a6f-4c80-9caa-cdfd662bd712/

The Australian: Coroner blames hospital for death- http://www.theaustralian.com.au/archive/news/coroner-blames-hospital-for-death/news-story/3d9318ea30f206211774e7931bd6526e

Sydney Morning Herald: Healthcare is a booming industry and Australia is in the box seat-  http://www.smh.com.au/comment/the-care-boom-20160928-grqqzv.html

Sydney Morning Herald: With an ageing population is healthcare sustainable?-  http://www.smh.com.au/comment/with-an-ageing-population-is-healthcare-sustainable-20160319-gnm98t.html

Monash University: What Nurses & Midwives Want: Findings from the National

Survey on Workplace Climate and Well-being-  https://business.monash.edu/__data/assets/pdf_file/0004/624127/What-Nurses-And-Midwives-Want-Findings-from-the-National-Survey-on-Workplace-Climate-and-Well-being-2016.pdf

Department of Health: 7.2 Nursing and midwifery retention-  http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review-australian-government-health-workforce-programs-toc~chapter-7-nursing-midwifery-workforce%E2%80%93education-retention-sustainability~chapter-7-nursing-midwifery-retention

Australian Bureau of Statistics: 4102.0 – Australian Social Trends, April 2013-  http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features20April+2013

Sydney Morning Herald: Nurse graduates ‘locked out’ of workforce as migrants get jobs-  http://www.smh.com.au/business/workplace-relations/nurse-graduates-locked-out-of-workforce-as-migrants-get-jobs-20150606-ghi9c8.html

Health Times: Generation Next – Helping Graduate Nurses and Midwives Find Jobs-  https://healthtimes.com.au/hub/nursing-careers/6/news/nc1/generation-next-helping-graduate-nurses-and-midwives-find-jobs/1422/

ABC News: Thousands of nursing graduates unable to find work in Australian hospitals: union-  http://www.abc.net.au/news/2014-05-24/thousands-of-nursing-graduates-unable-to-find-work/5475320

NSW Nursing and Midwifery Association: Nurse graduates unemployed or underemployed-  http://www.nswnma.asn.au/nurse-graduates-unemployed-or-underemployed/

Health Times: Nursing shortage expected to worsen-  https://healthtimes.com.au/hub/workplace-conditions/60/news/nc1/nursing-shortage-expected-to-worsen/490/

WA Today: All trained up with nowhere to go: WA’s hundreds of unemployed graduate nurses-  http://www.watoday.com.au/wa-news/all-trained-up-with-nowhere-to-go-was-hundreds-of-unemployed-graduate-nurses-20161211-gt8qkz.html