September - APNA

Supporting nurses in PRIMARY HEALTH CARE 

Primary Times 

Volume 9 September 2010 

THIS ISSUE 

ISSN 1838-0840 

Nutrition and chronic disease 

Gastroenteritis in children 

Common nutritional deficiencies 

Motivational interviewing

General practice education 

for musculoskeletal conditions 

Osteoarthritis is the 10th 

most commonly managed 

problem in general practice 

and 11% of men and 27% 

of women aged 60 years 

or over are osteoporotic. 

Only 7–20% of patients 

who have sustained 

an osteoporotic fracture 

receive treatment for 

osteoporosis to prevent 

further fractures. * 

These projects are supported by funding from the 

Australian Government Department of Health and 

Ageing through the Better Arthritis and Osteoporosis 

Care Initiative 

* The RACGP Clinical guidelines for the management 

of musculoskeletal diseases 

How can general practice manage 

these conditions better 

The RACGP Clinical guidelines for the management 

of musculoskeletal diseases are now available from 

www.racgp.org.au/guidelines 

To support the practice team implementing these 

guidelines, a range of activities which are specific to these 

conditions have been developed. These include: 

• PDSA activities using the Clinical Audit Tool 

• check Programs on osteoporosis, osteoarthritis, 

and rheumatoid arthritis/juvenile idiopathic arthritis 

• an online learning activity (gplearning) 

• small group learning modules for the practice team 

• a clinical audit 

• a practice nurse guide 

• a GP Network resource. 

QA&CPD points are available for all activities. 

For more information contact qualitycare@racgp.org.au

CONTENTS 

EDITORIAL BOARD 

APNA NEWS 

President and CEO messages 2 

Member questions 3 

Making sense of professional indemnity 6 

FEATURES 

Setting up a PoCT service 10 

Helping patients through 

motivational interviewing 14 

Practice nurse appointments 

for new patients 16 

Gastroenteritis in children 18 

Identifying common nutritional deficiencies 20 

Practice nurses and dietitians 

working together 22 

Nutrition and chronic disease 24 

NEWS 

Greetings from the Editorial Board 

Welcome to the September issue of 

Primary Times. 

With the rising prevalence of chronic and 

complex disease, there is increasing emphasis on 

supporting the self-management and reduction 

of lifestyle risk factors. Accordingly, this issue 

includes articles to assist nurses in identifying 

common nutritional deficiencies, the role of 

nutrition in chronic disease management and 

strategies for working with dietitians. We also 

explore the importance of motivational 

interviewing in assisting patients in behavioural 

change. 

Other articles provide advice about establishing 

point of care testing in general practice and 

managing gastroenteritis in children. We also 

feature PN resourcefulness in setting up nurse 

appointments for new patients. 

We have our first message from the newlyappointed 

APNA President, Julianne Badenoch, 

as well as a brief review of the 2010 APNA 

member satisfaction survey. We also present the 

latest results of the human papillomavirus 

vaccination program. 

In addition, we have selected a number of 

member questions to help you keep up-to-date 

with the latest changes surrounding the new 

national award, national registration, professional 

indemnity and CPD requirements. Information 

about professional indemnity insurance has been 

provided in consultation with Mediprotect and 

Medisure Indemnity Australia. 

We hope you find this issue of Primary Times of 

interest and assistance in your everyday practice. 

We welcome your feedback: editor@apna.asn.au 

Julianne Badenoch 

Early success for HPV vaccination program 8 

APNA Best Practice Nurse Awards now open 8 

APNA Member Satisfaction Survey 2010 12 

Asthma website improved for patients 27 

Role of codeine questioned Malaria 

treatment now on PBS 28 

Primary Times 

The Primary Times is the official publication of the Australian 

Practice Nurses Association (APNA) and is published 4 times 

a year in March, June, September and December. 

APNA is the peak national body for nurses working in primary 

health care, providing representation, professional 

development and support at a local, state and national level. 

AUSTRALIAN PRACTICE NURSES ASSOCIATION INC. 

149 Drummond Street, Carlton, Victoria, 3053 

ABN 30 390 041 210 

T: (03) 9669 7400 F: (03) 9669 7499 

www.apna.asn.au 

APNA CHIEF EXECUTIVE OFFICER 

belinda.caldwell@apna.asn.au 

PRIMARY TIMES CORRESPONDENCE Editor 

editor@apna.asn.au 

Advertising 

advertising@apna.asn.au 

APNA EDITORIAL BOARD 

Carmen Pearce Brown Belinda Caldwell 

Lucy Dear 

Dr Elizabeth Halcomb 

Matt Hall 

Anne Matyear 

Ruth Mursa Meredith Prestwood 

Shirley-Ann Rowley Assoc. Prof. Meredith Temple Smith 

COPY EDITOR 

Mary Petro 

Writer 

Nigel Dear 

DESIGN 

Perry Watson Design 

GENERAL DISCLAIMER 

The views expresses in articles are those of the contributors 

and not necessarily those of APNA. Statements of fact are 

believed to be true, but no legal responsibility is accepted for 

them. Primary Times reserves the right to edit, or not publish, 

any material submitted for publication. APNA takes no 

responsibility for the advertising content in Primary Times and 

does not necessarily endorse any products or services 

advertised. © Australian Practice Nurses Association Inc, 

2010. No part of Primary Times may, in any form, or by any 

means, be reproduced without prior written permission from 

the Chief Executive Officer. 

Platinum partners 

September 2010 Primary Times 

1

PRESIDENT AND CEO MESSAGES 

Reflections from the President 

It’s been a very busy few months for APNA and 

for me as the new President. 

Within hours of being elected as APNA President 

I was off to New Zealand with Belinda Caldwell, 

our dynamic CEO, to visit general practices and Primary 

Health Organisations (PHOs); which have a similar role 

to our Divisions in Australia. We met several amazing 

nurses working in many varied roles. 

Nurse practitioners in NZ are a growing primary 

healthcare workforce, further progressed and entrenched 

in the primary healthcare system than the Australian 

sector and much respected by their colleagues in 

general practice. I was equally impressed by the 

nurses that work on the frontline of general practice. 

Much of their basic day-to-day work is similar to the 

PN role in Australia, in that they run acute clinics daily, 

triage unbooked clients, organise and manage chronic 

disease self management clinics, and plan and run 

preventive health programs. 

What stood out was that the PNs in the PHOs we 

visited are well respected by their clients and colleagues 

and are reasonably renumerated for their contribution 

to the health of the population they serve. They also 

have a well structured career path that allows for 

growth and development in areas of interest. The 

PHOs, in line with the national registration boards, 

run graduate nursing entry to practice programs in 

general practice, based on competencies that are well 

structured and allow for individualised learning plans 

Looking to the future 

and the development of portfolios against knowledge, 

skills and scope of practice. These nurses each have an 

enthusiastic preceptor who is constantly challenged, 

educated and supported to provide a balanced 

educative experience with learning objectives and 

demonstrated outcomes. 

There is a prevalence of PNs at every level in the 

NZ health system. Since the establishment of the NZ 

Primary Health Care Strategy in 2001, there has been 

a business case for the development of a Primary 

Health Care nursing strategic plan in 2010, which has 

nurses on the advisory group. District Health Boards 

(DHB) have Directors of Nursing, nurses are on the 

boards of DHBs and PHOs, and several of the PHOs 

have nursing development teams with nurses employed 

as Nurse Leaders. 

PHOs encourage nurse leaders to run dynamic 

preventive health decision support programs and the 

data from these feed back from the general practice 

to the PHOs — the evidence ensuring funding of 

future projects. 

At the end of our tour we attended the 2010 NZ 

Primary Health Care Nurses Conference in Auckland. 

It provided a wonderful opportunity to hear more about 

the inspiring work of nurses in primary healthcare in 

NZ. The culmination of the conference was the official 

launch of the NZ College of Primary Health Care Nurses. 

The College is a merger of three colleges and sections, 

and is made up of members from the former New 

Zealand Nurses Organisation (NZNO) District Nurses 

Section, Public Health Nurses Section (NZNO) and NZ 

College of Practice Nurses (NZNO). 

We are delighted to hear that our NZ colleague 

Rosemary Minto was recently elected as the chair of 

the NZNO’s 2000-strong College of Primary Health 

Care Nurses. Debbie Davies and Rachel Calverley are 

also on the executive committee of the College. These 

three amazing primary healthcare nurses attended the 

APNA 2010 conference and shared their stories of 

hard work, growth and development of nursing. They 

have been instrumental in the development of nursing 

into a respected and well structured career path for 

primary healthcare nurses. 

We look forward to continuing our friendship with our 

NZ colleagues and extending our international links to 

further value add to APNA’s growth and development. 

Finally, I would like to thank our immediate past 

president Anne Matyear who has led us so well and 

continues to support and mentor me on my journey as 

APNA President for 2010. Thanks so much Anne. 

Julianne Badenoch 

President 

Australian Practice Nurses 

Association 

We finally know what the future holds, or have 

a better idea of its general direction, now that 

the Australian government has been formed. 

delayed writing this message until the announcement, 

I as the policy differences between a Coalition and 

Labor government has significant ramifications for 

primary care nurses and for APNA. 

It was a busy period while we attempted to have a 

voice in the election campaign and provide members 

with an overview of the different policies proposed in 

general practice and health. It has been great to see 

members engaged in the process, putting their 

tuppence worth in and at times holding us to account. 

Member engagement is a key achievement for which 

we aim and encourage. 

Now we know what lies ahead, we can get down to 

the task of advocating for nurses on primary 

healthcare reform, including the practice nurse funding 

incentive, formation of primary healthcare organisations 

(Medicare Locals), after hours telephone triage, 

telehealth consultations and patient controlled electronic 

health records. It will be a busy time and I look forward 

to engaging with members over their experiences and 

views of the challenges and opportunities for nursing 

in each of the proposed reforms. 

The conference committee 2011 has met and 

developed a very exciting and robust program for next 

year’s conference, to be held in Sydney (see ad on 

page 5). Members of the committee range from ENs, 

RNs and a NP candidate, and also have an academic 

and public health nurse in the mix. Rural and city 

locations are also well represented. I cannot speak 

more highly of the value of grass roots members 

taking full ownership of the conference program. 

Finally, in response to the APNA member survey, 

you may have noticed we have ramped up the 

member rewards program. The intention is to provide 

value to members and, in some cases, revenue to 

the association, so that we can limit the need for 

membership subscription increases. However, we are 

monitoring for impact and suitability and welcome 

any feedback as to level of benefit of such programs. 

We also welcome suggestions of other companies 

we could approach. 

Belinda Caldwell, MPH 

Chief Executive Officer 

Australian Practice Nurses Association 

belinda.caldwell@apna.asn.au 

2 

Primary Times September 2010

PROFESSIONAL ISSUES 

Member questions 

It’s been a busy year, with many industry changes. As expected, lots of questions have been raised. 

Do you have a list of the mandatory indemnity 

requirements/competencies for practice nurses 

To remain registered, you are required to undertake 

20 hours (not points) of learning a year. National 

registration does not require you to do anything 

other than that which will ensure you remain 

competent to continue to work in your role — this 

is up to you to decide as a professional. You will 

need to prepare a learning plan looking at your 

role and determine what you need to undertake 

over the year. 

APNA has developed an online CPD portal that 

allows nurses to develop learning plans and record 

CPD activity. APNA is also endorsing learning 

activities, so that learning providers display 

how many hours certain activities are worth. 

(Check out the APNA website: www.apna.asn.au) 

As for professional indemnity, there are new 

standards in national registration around indemnity. 

You will be required to either present evidence of 

your employer’s cover or have your own (see 

article on page 6). The Mediprotect policy covers 

you for full scope of practice and does not have 

specific requirements. So, again it is up to you to 

determine your own scope of practice and ensure 

you are appropriately qualified and trained, 

competent and confident. 

Colleagues who attended the PNCE legal issues 

session in Sydney have said we need to have our 

own professional indemnity insurance even if 

covered by our employer’s insurance. However, I 

have received information from GP NSW and the 

NSW Nurses Association that there is no need to 

have your own insurance policy if you are 

covered by your employer’s insurance. 

You do not need to have your own professional 

indemnity insurance. However, if you are relying 

on your employer’s indemnity insurance, you need 

to make sure that your employer has practice 

indemnity insurance and that you have sighted it. 

The new national board can require you to 

submit evidence of your employer’s insurance. 

You need to also make sure the practice has 

practice indemnity insurance, not GP professional 

indemnity insurance only. If you are relying on 

your practice indemnity insurance, you need to 

look at it and check what nursing care is covered. 

Some policies cover specific nursing activities 

and others cover scope of practice. 

We still recommend having your own 

professional indemnity insurance even though it 

is not a requirement under national registration. 

Relying on your practice indemnity insurance will 

not cover you for the three years after you have 

left the practice, during which a patient is entitled 

to make a claim. Having your own insurance 

means that you know what you are covered for 

and it will travel with you to a new employer. 

I am keen to find out more about the removal of 

MBS item numbers. How does the Government 

find out what nurses are being used for 

The ‘for and on behalf of’ nurse item numbers had 

significant issues in terms of being focused on a task, 

paying insufficiently, and implying a medicolegal 

liability that did not exist. The proposed new 

funding changes are intended to expand the scope 

of practice of nurses in general practice, as well as 

increase the funding going to general practice for 

nurses. 

The new funding is a significant increase on 

the funding provided by the PIP incentive and the 

nurse item numbers. The intent is to not change 

what you do, only how it is funded. This is a big 

change, however, and we expect there to be a lot 

of work and consultation to get the business rules 

correct. This funding provides a greater 

acknowledgment of the autonomous nurse role 

than the current item numbers, which imply 

nurses only work at the direction or under the 

supervision of the GP. 

How will we know what nurses are doing 

We suspect we will see more sophisticated use 

of medical software being uploaded to two local 

networks. The GP analogy is that we only have 

evidence of what they are doing through the 

BEACH study — their item numbers do not 

indicate the clinical care provided. We will 

certainly be arguing that a similar annual 

study is undertaken for the nursing role. 

Nurse practitioners will be funded differently 

from November with access to generic attendance 

item numbers in a similar way to the GP. 

We will keep members up-to-date with the 

changes, and will be seeking input as the 

consultation progresses. 

We have conflicting ideas with some of our GPs 

at the moment regarding nurses undertaking 

cryotherapy treatment, mainly for warts. Are 

there standards for this or education we can 

undertake 

Cryotherapy needs to be considered in the same 

way as any extension to scope of practice — are 

you authorised (probably no restriction here), are 

you educated to do it (is there training available) 

and are you competent/confident And, finally, 

does the practice/organisation have a suitable 

clinical policy and procedure If no training exists 

in this area, you can do research, reading, etc. 

If you are confident that GPs are undertaking 

current best practice, they can teach you. Or, you 

can organise a deemed expert to teach you, such 

as a dermatologist. 

Would you please clarify the hourly rate for 

a Registered Nurse NO2 as a practice nurse 

From what I understand, practice nurses are now 

under the same award as nurses working in the 

hospitals. When I checked out the hourly rate, it 

was significantly less per hour. I have thought 

this would be a great career move, but I can’t 

justify the loss of income. Do you think wages 

will increase in the near future 

It is true that from January all nurses were placed 

under the same award. However, what nurses in 

the hospital get paid will continue to vary, as the 

hourly rate they are paid is part of an enterprise 

bargaining agreement negotiated by the union. 

The average hourly rate for nurses in general 

practice is around $30.50, but can vary depending 

on your negotiations with your employer. Every 

practice is different. We hope you continue to 

consider general practice nursing as a great career 

move, as nurses in general practice a very satisfied 

group with their role and the pay and conditions 

will continue to improve. 

I understand the 20% casual loading will increase 

1% each year, as part of the Modern Awards that 

commenced from 1 July. Can you confirm if this 

should be paid to casual practice nurses from the 

first full pay after 1 July 

The casual loading applies on and from 1 July and 

is adjusted by 1% each year until it reaches 25%: 

• 01/07/2010: 21% 

• 01/07/2011: 22% 

September 2010 Primary Times 3


Member questions – continued 

• 01/07/2012: 23% 

• 01/07/2013: 24% 

• 01/07/2010: 25% 

You can contact the ANF for further advice on 

pay and conditions. 

I have a keen interest in Well Women’s Health 

and, more specifically, incontinence. I have been 

furthering my education in this field by completing 

the Benchmarque course in Continence 

Management and a Pauline Chiarelli Workshop. 

As a result, I feel confident in promoting, 

discussing and educating women on this health 

condition. The practice GPs refer women to me 

for consultation. The issue is what do we ‘bill’ 

them to still be ‘legal’ How can we work it out 

so it is of benefit to everyone 

This is exactly the issue we have been arguing 

for in the restriction of the current MBS PN 

item numbers. The only way you can ‘bill’ for 

incontinence services is by including the GP in 

the consult so that he/she can bill through a 

normal GP consult or you can privately bill for 

this service — which is uncommon, but quite 

OK (frequently done in New Zealand). 

The intention of the new PN funding incentive 

coming in 2012 is to allow a flexible funding 

model through which nurses can provide a range 

of clinical services without having to involve GPs 

for the purpose of billing. There is a high degree 

of opposition to this model of funding from the 

GPs and there will be a lot of working out to do 

in its implementation. 

You must not get ‘legal’ and ‘billing’ confused. 

You are legally able to provide the care in which 

you have been trained and are competent to do. 

Whether it can be funded is a different matter — 

the ‘for and on behalf of’ type of language in the 

MBS is not a legal ruling for the GPs. 

As a PN, I can see a huge advantage in the removal 

of ‘task based’ item numbers. Unfortunately, the 

majority of GPs only see the bottom line. Our GPs 

have already starting talking about reducing 

nursing hours as this has also come at the same 

time as when they are getting significantly less 

income due to the changes in health assessment 

funding. Are larger practices going to be 

disadvantaged financially from the proposed 

changes 

Larger practices are potentially going be 

disadvantaged under the new proposal due to 

the capping at 5 EFT GPs. However, we will have 

the opportunity to argue for increasing the cap 

through the advisory group process and both the 

medical and nursing groups agree on this point. 

In addition there is a commitment that if the 

practice can demonstrate that it will be 

disadvantaged under the new system, it can be 

grandfathered into the scheme over three years. 

This would provide plenty of time to assess the 

operational benefits and disadvantages. GPs who 

currently receive a percentage of the PN item 

numbers as income (contractor or employee GPs) 

will have a reduction in income. However, if the 

overall income to the practice is increased, the 

practice can revisit their contracts with those GPs 

and amend these to ensure no loss of income. 

There will be grandfathering arrangements for 

the first three years of the program to ensure 

that practices are not adversely impacted by the 

restructure of the Practice Incentive Program 

practice nurse incentive and the MBS practice 

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APNA NATIONAL CONFERENCE 2011 

Great Expectations 

After the outstanding success of its first two conferences (The Right Stuff and Golden Opportunities), 

APNA will be holding a third inspiring conference, in 2011. The conference ‘Roadmap for the future 

- great expectations’ will feature renowned keynote speakers, interactive Masterclasses, extensive 

opportunities to network with practice nurses from around Australia, and much more. All topics and 

sessions have been designed to meet the needs of nurses working in general practice and primary 

health care. Learn and network over 2.5 exciting days. 

When: Thursday 7th - Saturday 9th April 2011 

Where: Hilton Hotel Sydney, 488 George Street, Sydney 

CPD Hours: 13-20hrs 

Earlybird: APNA Members - Conference + Workshops: 

$645 (tbc*); Conference only $495 (tbc*) 

Non-members - Conference + Workshops: 

$845 (tbc*); Conference only $695 (tbc*) 

* indicative pricing, to be confirmed shortly 

Don’t miss this outstanding opportunity to network 

with general practice nurses from all around Australia 

while contributing to your professional development. 

Attendance at the APNA National Conference meets 

mandatory CPD requirements under National Registration. 

Program: A fantastic program will include Workshops, 

Masterclasses, Learning on the Move sessions, abstract 

presentations and inspiring plenary sessions including 

panel discussions. 

Social functions include: Welcome cocktail party for all 

delegates plus a Gala dinner featuring the presentation 

of the 2010 APNA Best Practice Nurse Award winners. 

Earn CPD: Under the new National Registration CPD 

requirements, nurses must undertake at least 20 hours 

of Continuing Professional Development each registration 

year, starting from 1 June 2010. Attendance at both 

days of the APNA National Conference will give nurses 

at least 13 hours of CPD, and more if you attend optional 

Workshops and lunch or breakfast sessions, helping you 

meet the majority of your CPD requirements for the year. 

Registrations will be open soon. 

Email events@apna.asn.au with your full name and email 

address to be notified as soon as registrations are open. 

Scholarships now available! 

The Nursing and Allied Health Scholarship and Support 

Scheme (NAHSSS), funded by Australian Government 

Department of Health and Ageing is now open for 

scholarship applications. The scheme is an Australian 

Government initiative supporting nurses and midwives 

to undertake continuing professional education activities, 

short courses and conferences. This scheme is now open 

and closes on 1 October 2010. Please note late applications 

will not be accepted. 

The NAHSSS Scholarships (which include the former 

Practice Nurse scholarship program) are open to all 

currently registered nurses who are Australian citizens 

or permanent residents. The scholarship program is 

administered by the RCNA for the Commonwealth 

Department of Health and Ageing. 

Visit www.rcna.org.au for more information.


Making sense of 

professional indemnity 

As a general practice nurse, you may have a 

‘personal exposure’ for the healthcare you provide. 

personal exposure might mean a civil 

A liability claim for damages or compensation 

being brought against the individual. This is 

regardless of whether you are an employee or not. 

Employers are not responsible for claims made 

directly against a nurse. 

Professional indemnity insurance (PII) 

generally covers civil liability claims made against 

you as a result of your professional services. 

Examples of civil liability claims include (but are 

not limited to): an adverse or unexpected 

outcome for a patient, or an error or omission 

on your part while providing your professional 

services; and a breach of patient confidentiality, 

or libel and slander. Professional indemnity 

insurance also covers: an unintentional breach 

of Trade Practices legislation, or unintentional 

infringement of rights to intellectual property; 

and claims arising from rending, or failing to 

render, emergency first aid and assistance 

(Good Samaritan acts). 

The role of a general practice nurse has 

expanded to the point that, in certain situations, 

the nurse is the only healthcare provider seen by 

the patient. While GPs are responsible for making 

sure current insurance is in place for themselves, 

it is up to the practice or the individual person to 

ensure they are covered sufficiently. Accordingly, 

national registration states that nurses and 

midwives must not practise their professions 

unless they are covered in the conduct of their 

practice by appropriate PII arrangements. 

A copy of the Professional Indemnity Insurance 

Arrangements Registration Standard can be 

downloaded from the Nursing and Midwifery 

Board of Australia and APNA websites. 

The APNA has appointed Mediprotect and 

Medisure Indemnity Australia (MIA), a leading 

health industry insurance intermediary and 

underwriting agency, to provide members with an 

individual professional indemnity product. They 

have provided answers to some common queries 

or situations: 

Q. Does the doctor’s malpractice insurance 

cover me 

This is a difficult one to advise on in a general 

context, as each doctor and each practice has 

its own set of circumstances. In general, most 

medical defence organisations only cover a nurse 

when the doctor has given specific instructions 

and/or is supervising the procedure, i.e. is in the 

room with you and the patient. As this is not 

always the case, it is possible for the doctor’s 

insurance cover to not extend cover in the event 

of an incident, leaving you responsible for your 

own defence and possible costs. While a general 

query may lead to a positive response, each claim 

is taken on its own merits, leaving this possible 

gap in cover. 

Consideration needs to be given as to whether 

the supervising doctor is your employer or not, 

as well. Many practices employ nurses and other 

staff to provide services to contracted doctors. 

It is likely that, if you are being ‘instructed’ or 

‘supervised’ by a contractor, their insurance will 

not extent to cover you as they are a separate 

entity to you and your employer. This onus falls 

on the employer. 

Q. I perform ‘certain’ procedures/activities. 

Am I covered for this 

In general, you are most likely covered for the 

duties and activities of a general practice nurse; 

meaning that all of the common nursing activities 

that you are trained in are included. Further 

training, for example in Pap smears or 

immunisations, can allow you to perform other 

activities. These will be covered as long as you 

hold current and accepted training and/or 

certification (if required). 

The insurance policy is very broad. If you do 

something MIA deems to be outside of these 

activities (e.g. Botox injections), we can evaluate 

your circumstances and make alterations to your 

policy or advise you on alternatives. If you are 

ever unsure, call David at MIA on (07) 3426 0440 

to discuss your situation. 

Q. But I already have public liability insurance. 

Public liability and professional indemnity are 

the two different types of insurance and are 

often confused, or are often perceived to be 

overlapping. The two policies, however, cover 

very different circumstances. 

Public liability insurance will cover a physical 

mishap, for example turning a corner and 

knocking over a patient, causing them injury. 

Professional indemnity covers you for an omission 

or breach of professional duties, such as giving the 

wrong vaccine, also causing harm or an ‘injury’ to 

a patient. 

These are very simple examples of the two 

covers, and employees of a practice are generally 

covered by the public liability of the practice. 

If you are a contractor it is imperative you seek 

advice on your own public liability cover, as 

contractors are seen as separate legal entities. 

Q. How do I know if I’m adequately covered 

How do you ask the tough question Consider 

the following example: Kate has been a practice 

nurse for five years and has been employed at 

her practice for three of those years. Following 

attendance at a PNCE event, where Kate 

participated in a session on legal issues and 

indemnity for general practice, she asked her 

employer about her indemnity cover. The 

employer’s response was ‘you’re covered’ and 

Kate, not wanting to seem difficult by asking 

lots of questions, left it at that. 

Many practice nurses can probably relate to 

Kate’s experience, but the question remains: is 

Kate adequately covered Perhaps she is, but most 

importantly Kate doesn’t know if she is — and as 

an accountable health professional she should 

be 100% confident in her indemnity cover. 

So what should Kate have done differently 

in this scenario She did the right thing in 

approaching her employer and asking about her 

coverage. However, after being informed she was 

covered, Kate should have requested to sight the 

policy and obtained a copy for her records. 

6 



All practice nurses, whether covered by an 

individual policy or a practice policy, should have 

a copy of the indemnity policy for their own peace 

of mind and for nurses board registration 

compliance records. As soon as she obtained a 

copy of the policy, Kate should have checked the 

following criteria: 

1. Is the policy appropriate for you and your 

activities Check that none of YOUR activities 

are excluded. You will need a copy of the policy 

wording to do this effectively. This document 

is often referred to (by name and document 

version/number) on the schedule of insurance. 

2. Are you comfortable with the level and type of 

cover that is in place Is the indemnity level 

high enough — does it have vicarious liability 

for medical practitioners 

3. Can you control and ensure that the cover is 

maintained should you move on 

Professional indemnity needs to be kept in 

place year after year. If you leave your current 

employer you will be relying on this policy, should 

a claim happen at some future date. 

And finally, provided Kate was happy with the 

coverage she had under her employer, she should 

mention to her employer that she will require a 

copy of the policy (for her own registration 

purposes) each time it is updated or renewed (this 

is generally on an annual basis). By forewarning 

her employer, Kate will find asking for a copy of 

the policy easier next time. 

So, for those who think you are covered by your 

practice, follow in Kate’s footsteps and obtain a 

copy of your policy and check that you are 

adequately covered. 

Q. If my practice has a policy why should I look 

at having my own 

Even if your practice does have a policy that 

covers you, there are several benefits to having 

your own indemnity insurance cover. 

The policy is yours to control and take with you 

wherever you go in Australia. You do not need to 

rely on a current or past employer to maintain 

their insurance in order to ensure you are covered. 

The policy offers a range of covers and 

categories to cover all employment arrangements, 

with a standard excess on the policy being $500 

(the displayed premium prices do not include 

APNA membership). 

The policy will cover you, as an individual, for 

civil liability claims, i.e. claims for compensation 

and expenses made against you resulting from the 

provision of your professional duty — general 

practice nursing. The policy also has cover for 

Good Samaritan acts and enquiry costs. 

The policy will not cover you 

for activities that you are not 

qualified to perform ... 

Cover on the policy is limited to you practising 

your professional duty in a general practice 

environment — that is to say that you must be 

working in a GP clinic or medical centre, but we 

have included off site activities such as aged care 

assessment. 

You will also need to bear in mind your ‘scope 

of practice’. The policy will not cover you for 

activities that you are not qualified to perform 

— even if instructed to do so by your employer. 

For example pap smears are becoming a common 

activity for nurses in general practice. However, it 

is advised that you complete a certified Pap Smear 

provider course, even if you currently perform or 

have been performing this activity for some time 

without having completed a relevant course. As a 

general rule of thumb, if a certificate or course is 

available for a particular activity, then you should 

complete the qualification and hold the relevant 

certificate/qualification to ensure coverage under 

your professional indemnity policy. 

The policy will cover what is considered to be 

‘normal nursing activities associated with general 

practice’. We understand that these change 

frequently and the list of practice nursing 

activities is growing. 

So, for those of you out there who think you are 

covered by your practice, follow in Kate’s 

footsteps and obtain a copy of your policy and 

check you are adequately covered. 

The APNA recommends that members seek 

appropriate advice concerning PII for their 

individual needs and requirements. If you would 

like more information on how to apply for the 

Mediprotect General Practice Nurse Professional 

Indemnity product, please call the APNA on 

(03) 9669 7400 or (Free Call) 1300 303 184. 

Application details are also available on the APNA 

website: www.apna.asn.au 

You can also call David from MIA on (07) 3426 

0440 to discuss your individual needs or if you 

have any questions about the Mediprotect/MIA 

General Practice Nurse Professional Indemnity 

product. 

This information is provided by Insurance Marketing Group 

of Australia as a service to APNA members. APNA does not 

offer any advice on professional indemnity insurance. 


NEWS 

Early success for HPV 

vaccination program 

Australia is the first country to rollout a human papillomavirus (HPV) immunisation program, and has achieved a high level of coverage 

across the catch-up cohorts of 12 to 26-year-olds. Two new studies suggest that the impact of the program is already being felt. 

When the national program commenced, the 

Federal Government funded a two-year 

catch-up program to cover 13 to 18-year-old girls, 

with vaccinations delivered through schools, as 

well as 18 to 26-year-old women, who received 

vaccinations through general practice and 

community-based programs. 

The Gardasil HPV vaccine works by preventing 

the transmission the four main cancer-causing 

strains of the HPV — two of which cause cervical 

cancer and two which cause genital warts. The 

vaccine is the most effective when it is given before 

sexual activity begins and exposure to HPV occurs. 

A recent study carried out by The University 

of New South Wales National Centre in HIV 

Epidemiology and Clinical Research showed 

that rates of new genital wart infections have 

significantly dropped by 60% in women under 

27 years of age since the program was launched 

in mid-2007. 

The data also showed a 30% reduction in new 

genital warts cases in heterosexual men, which 

researchers have attributed to reductions in 

transmission from their partners — herd immunity 

benefits. (Herd immunity theory suggests that, in 

diseases passed from person to person, it is more 

difficult to maintain a chain of infection when large 

numbers of a population are immune.) 

In another recent study, Victorian Cytology 

Services demonstrated the world’s first drop in 

precancerous lesions since the introduction of an 

HPV vaccination program. The study showed the 

number of cases of high grade cervical lesions has 

fallen in women aged less than 20 years, suggesting 

that the program is starting to reduce the 

burden of cervical cancer. 

Without the high level of coverage achieved in 

the catch-up program these reductions in warts 

and cervical abnormalities would not have been 

realised as early they have been. 

As a group we should all take great pride in our 

role in the success of the program. Practice nurses 

played a significant role targeting 18 to 26-yearold 

women to participate in the HPV vaccination 

program and getting them back for second and 

third doses. We are aware of many of the efforts 

in actively recalling and opportunistically 

vaccinating eligible women and many APNA 

members have been awarded for initiatives they 

have put in place to support the HPV vaccination 

program. It is fantastic to see the impact of the 

program already being demonstrated. 

APNA Best Practice Nurse Awards now open 

The Australian Practice Nurses Association is 

proud to announce that nominations for the 

2010 APNA Best Practice Nurse Awards are 

now open! With five award categories, the 

APNA Best Practice Nurse Awards aim to 

recognise and reward outstanding nurses 

working in general practice. 

In 2010 five awards are on offer, with prizes of 

$5,000 for each winner to use in enhancing 

their continuing professional development. 

Previous recipients have used their monetary 

prize to undertake work experience and education 

in both local and international locations. 

When considering whether to nominate, 

remember that while what you do in your practice 

might seem normal to you, it may be novel or new 

to someone else. Please refer the 2009 Best 

Practice Nurse Awards page on the APNA website 

to read examples of what the past Best Practice 

Nurse Award winners had done in their practices. 

Nominations for the Best Practice Nurse Awards will close at 5.00 p.m. on Friday, 14 January 2011, 

so make sure you send your nomination in soon! 

Visit www.apna.asn.au then click through to ‘Best Practice Nurse Awards’ under the Events tab. 

The categories open for nomination are: 

Sponsor 

Award Category 

CSL Biotherapies Best Practice Nurse Award for Immunisation 

TENA Best Practice Nurse Award for Continence Care 

MSD Best Practice Nurse Award for Chronic Disease Management 

Royal Australian College of General Practitioners Quality Care 

Musculoskeletal Best Practice Nurse Award 

Pfizer Best Practice Nurse Award for Innovation 

AGPAL Best Practice Nurse Award for Quality Improvement 

8 


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If you are a new customer or wish to 

order now visit www.csldirect.com.au 

to register or phone customer service 

today on 1800 008 275. 

PBS Information: This product is listed on the National Immunisation Program (NIP) Schedule. Refer to the NIP Schedule. 

Please review product information before prescribing. 

Product information is available from CSL Biotherapies Pty Ltd. 

MINIMUM PRODUCT INFORMATION: Fluvax ® Inactivated infl uenza vaccine (split virion). For winter 2010, antigens representative of types: *A/California/7/2009 (NYMC X-181) 

(A/California/7/2009 (H1N1) - like), *A/Wisconsin/15/2009 (NYMC X-183)(A/Perth/16/2009 (H3N2) - like) and *B/Brisbane/60/2008 (B/Brisbane/60/2008 - like); 15 µg haemagglutinin 

of each per 0.5mL dose. INDICATION: Prevention of infl uenza caused by Infl uenza Virus, Types A and B. CONTRAINDICATIONS: Anaphylactic hypersensitivity to previous infl uenza vaccination 

or to eggs, neomycin, polymixin B sulphate or any of the constituents or trace residues of the vaccine. Postpone immunisation in people with febrile illness or acute infection. PRECAUTIONS: 

Treatment for anaphylactic reactions should be available; in immunocompromised patients antibody response may be lower; history of Guillain-Barré Syndrome within 6 weeks of previous 

infl uenza vaccination. *During the 2010 Southern Hemisphere infl uenza season, there was an unexpected increase in reports of fever and febrile convulsions in children aged less than 5 

years following seasonal infl uenza vaccination. In children ≥ 6 months to < 5 years of age with conditions predisposing to severe infl uenza, or who may transmit infl uenza to those at risk of 

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*Please note change(s) in Product Information. 

CSL Biotherapies Pty Ltd. ABN 66 120 398 067. 45 Poplar Road,Parkville, VIC 3052, Australia. FLUVAX ® and ® Thinking Australia are registered trademarks of CSL Ltd. 8748.

PRACTICE MATTERS 

Setting up a PoCT service 

Point of care testing (PoCT) is 

laboratory diagnostic testing 

performed at or near the site where 

clinical care is delivered. 1 It is 

gaining popularity in general 

practice as it provides pathology 

results during patient consultation, 

resulting in faster patient treatment 

and reducing the need for the 

patient to come back to the surgery 

for pathology results. Although it 

offers an illusion of simplicity, it can 

cause significant risk to patient care 

if not performed properly. 

The goal of POCT 

implementation should be to 

improve patient short term and long 

term outcomes. The decision to 

adopt POCT requires careful 

thought to ensure the correct 

decisions are made for the practice. 

Three important areas should be 

considered before developing a 

POCT service: 

1. Establishing a clinical need. 

2. Equipment requirements and 

selection. 

3. Implementation process, training 

and technical support. 

Generally health professionals 

considering PoCT and vendors of 

PoCT equipment tend to focus on 

the advantages of PoCT and often 

overlook potential disadvantages. 

The fundamental question is ‘will 

Advantages 

Simpler sample collection. 

Reduced pre-analytical errors. 

Faster test results available leading 

to more timely treatment. 

Removes pathology access barriers 

in rural and remote areas. 

Increased patient satisfaction. 

Improved medical outcomes. 

Table 1. The advantages and disadvantages of PoCT. 

the improvement in outcomes for 

the patient and practice outweigh 

the costs of PoCT in terms of 

resources (staff time) and money’ 

If you are interested in PoCT, it 

is advisable to identify an individual 

in the practice who will take the 

responsibility of the clinical needs 

assessment, instrument selection, 

training and implementation. This 

person would be identified as the 

PoCT co-ordinator for the practice. 

Before implementing PoCT, the 

following action should be taken to 

ensure decisions made best fit the 

purpose intended by the practice. 

Establishing a clinical need 

If you are considering PoCT, it is 

highly likely you have identified a 

clinical need within your practice. 

If not, you need to consider to the 

following questions: 

• What are you trying to achieve 

by introducing PoCT 

• What are the benefits you are 

expecting to achieve by 

introducing PoCT 

• How will PoCT integrate into the 

clinical management of your 

patients (see Table 2). 

Primary care will most likely 

consider PoCT implementation to 

improve patient quality of care, 

health outcomes and the financial 

Disadvantages 

Increased workload. 

Potential errors due to poor analytical 

performance. 

Potentially incompatible to local 

laboratory method. 

Increased costs. 

Wastage due to consumable short 

expiry. 

Inadequate quality control (QC), quality 

assurance (QA) and documentation. 

feasibility of their practice. 2 

Implementation of PoCT has the 

potential to help manage the 

increasing burden of chronic disease 

that practices have to face. (See 

Figure 1.) 

Equipment requirements and 

selection 

A wide variety of PoCT equipment 

is available in Australia for selection. 

Diversity of equipment is confusing 

and can result in incorrect costly 

decisions, which may not achieve 

the improved clinical outcomes 

planned. 

The Australasian Association of 

Clinical Biochemists (AACB) PoCT 

Patient 

questions 

PoCT test 

performed in 

presence of 

patient 

Outcome 

Faster decision making. 

Starting treatment earlier. 

Improved adherence to treatment. 

Reduced incidence of complications. 

Quicker optimisation of treatment. 

Patient satisfaction. 

• Space requirements 

• Consumable storage 

requirements/expiry date 

• Availability of QC material 

• Portability 

• Maintenance requirements 

• Cost per test 

• Capital cost — is it affordable 

• Connectivity — can it 

electronically download results to 

your patient information system 

Does the manufacturer supply 

training and/or training materials 

Does the manufacturer provide a 

technical support hotline 

It is important to check that the 

device you are considering is suitable 

for the intended clinical use. This 

Decision 

made by 

clinician 

Outocme 

action 

initiated 

Figure 1. Key objectives of introducing PoCT to generate a result quickly so that appropriate treatment 

can be implemented, leading to an improved clinical or economic outcome. 

Working Party has produced a PoCT 

Implementation Guide, which is a 

useful resource for anyone interested 

in setting up a PoCT service in their 

practice. 3 The implementation guide 

outlines PoCT characteristics that 

should be considered before 

deciding on a piece of equipment for 

your practice. 

These include: 

• Sample requirements — type and 

volume (whole blood preferred 

for PoCT) 

• Turnaround time 

• Is it user friendly 

includes accuracy and precision 

required and patient population. 

You will also need to consider any 

drugs that may interfere with the 

method and whether these are 

common substances for the 

population you intend to be testing. 

Implementation process, training 

and technical support 

Introduction of PoCT into your 

practice should follow a systematic 

approach and be implemented 

within a quality framework. 

Currently, there are no mandatory 

Example 

Chest pain, heart failure, drug overdose. 

Chest pain, heart failure, drug overdose. 

Diabetes. 

Diabetes, anticoagulation. 

Anticoagulation 

Fewer journeys, ownership of disease. 

Table 2. Examples of improved clinical outcomes that can be achieved from introducing PoCT. 

10 


PRACTICE MATTERS 

standards or guidelines written 

specifically for PoCT in Australia. 

Responsibility lies with individual 

organisations running PoCT to 

develop their own quality 

framework. 

The Australian Government 

recently funded a multi-centre trial 

to determine the safety, clinical 

effectiveness and satisfaction of 

PoCT in general practice 4 . The 

Quality framework for the trial was 

developed around the Interim 

Standards for PoCT 5 , which were 

developed by the PoCT Implementation 

Subcommittee of the Quality 

Use of Pathology Committee of the 

Federal Department of Health and 

Ageing. These standards take into 

consideration resources in nonlaboratory 

environments, to ensure 

the quality of test outputs is the same 

as for tests performed by pathology 

laboratories. They are a useful 

resource for PoCT co-ordinators. 

PoCT Operator Training is a 

critical element in achieving quality 

results. Implementation of PoCT 

into your surgery should include the 

following minimum requirements: 

• PoCT operators should undergo 

appropriate training and be 

certified as competent. 

• Practices should have written 

policies for all PoCT tests. This 

should include sample collection 

and storage requirements, testing 

procedures, safety/waste disposal, 

quality testing, maintenance and 

reporting of results. 

• It is important that all users of 

PoCT equipment should follow 

manufacturers’ instructions. 

• There should be a process in place 

for routinely monitoring 

instrument performance, 

including quality. 

• Medical alert/critical/panic values 

must be defined. 

• Complete, accurate and timely 

records of patient results should 

be maintained. 

• In addition to the test minimum 

requirements, there are surgery 

requirements to consider. 

These include: 

• Sufficient space availability 

• Power/network requirements 

• Connectivity — can results be 

transferred electronically to 

patient records 

• Portability — is this required 

• Capital cost 

• Warranty 

• Service contract 

• Running costs 

Once you have selected the device 

that suits your clinical need, you 

should explore what support is 

available from the device supplier. 

Most companies offer training and 

training materials that will assist you 

in the implementation process. You 

should also explore what technical 

support is offered after purchase. 

These two important points should 

be considered before purchasing the 

device. If no training or support is 

offered, implementation could be 

problematic. 

Quality control and external quality 

assurance testing 

Quality control is a set of procedures 

designed to monitor test results to 

ensure the test system is performing 

correctly. This involves testing 

control materials, document ing 

results and taking remedial action 

if appropriate. External quality 

assurance (EQA) is run externally 

from the practice and allows the 

practice to check the quality of its 

results to other sites by testing an 

identical sample with an unknown 

value 6 . The EQA provider issues 

reports on results which show how 

the practice performs compared to 

other sites performing the particular 

test. 

Quality testing involves running 

QC and EQA tests to ensure the 

PoCT test is performing as expected. 

The AACB PoCT position 

statement sets minimum requirements 

for QC as at least one QC 

sample to be run each month. A QC 

sample should also be run with 

every new shipment of consumables. 

Although EQA testing is highly 

desirable, it is only mandatory if a 

rebate is being sought from the 

Australian Government 7 . 

Where can I get help 

Local pathology laboratories are a 

huge source of knowledge and 

support for health centres performing 

PoCT and may be a useful 

resource if you require help with 

training, QC/QA or management 

of results. 

The AACB recognises the 

importance of PoCT in Australasia 

and through its PoCT working party 

is committed to developing 

educational materials for healthcare 

providers with an interest in PoCT. 

The PoCT working party will work 

closely with the Australian Point of 

Care Practitioner’s Network (APPN). 

Recently funded by the Federal 

Department of Health and Ageing, 

the APPN will be developed to 

provide a professional effective 

program for training, certification 

and professional development for all 

PoCT operators. The APPN will 

bring together all stakeholders 

involved in PoCT, including doctors, 

nurses, scientists, pathologists, 

industry and consumers. The project 

will also provide educational content 

of the training, competency 

standards and assessment, and 

ongoing education for PoCT device 

operators. The APPN site will also 

provide forums. Technical assistance 

can be sought from APPN scientific 

and nursing staff with extensive 

experience in PoCT. The website 

www.appn.net.au is currently under 

construction and has an operational 

forum for health professionals to 

express what resources they would 

like to see developed to assist them 

with implementation of a quality 

PoCT service in their practice. 

References 

1. Nichols J. Point of Care Testing. 

Clin Lab Med. 2007;27:893–908. 

2. Price C, Kricka L. Improving healthcare 

accessibility through point-of-care 

technologies. Clinical Chemistry. 

2007;53:1665–1675. 

3. Australasian Association of Clinical 

Biochemists. Point of Care Testing 

Implementation Guide. 2008. Accessed 

12 August 2010: www.aacb.asn.au/ 

admin/getfile=1902 

4. Laurence C, Gialamas A, Yelland L, 

Bubner T, Ryan P, Willson K et al. A 

pragmatic cluster randomised controlled 

trial to evaluate the safety, clinical 

effectiveness, cost effectiveness and 

satisfaction with point of care testing 

in a general practice setting — rationale, 

design and baseline characteristics. Trials. 

2008; 9:50. 

5. Australian Government Department of 

Health and Ageing. Interim standards for 

point of care testing in general practice. 

Incorporating POCT trial guidelines. 

Canberra: DoHA, 2004. 


Biochemists. Guidelines for conducting 

quality control and quality assurance for 

PoCT. Accessed 2 August 2010: 

www.aacb.asn.au/web/POCT/ 


Biochemists. Point of Care Testing 

Position Statement. January 2007. 

Accessed 2 August 2010: www.aacb.asn.au 

Rosy Tirimacco 

Rosy is the Operations and Research Manager of the 

Integrated Cardiovascular Clinical Network SA (iCCnet SA), 

funded by Country Health SA. Rosy has extensive experience 

in implementing and running point of care testing (PoCT) 

in hospitals and general practice. She is heavily involved in 

PoCT education of rural doctors and nurses across SA. 

She is currently the chair of the AACB Point of Care Testing 

Working Party and the IFCC Glucose POCT working group. 


SURVEY HIGHLIGHTS 

APNA Member 

Satisfaction Survey 2010 

Many members took part in this year’s APNA Member Satisfaction Survey, conducted in June. The survey provides valuable insight into how 

members view APNA services, as well as areas of improvement. This information will allow the Association to direct its time and resources 

over the coming year to areas members value most. 

Participants were asked to share 

their thoughts on APNA events, 

publications, learning and training 

opportunities, commercial benefits 

and customer service, and the 

Association’s role. Additional 

feedback was also gathered on how 

patients and other medical 

professionals perceive the nursing 

role in general practice. 

Member profile 

The year’s results have shown that 

the growth in practice nursing is 

continuing. Four in five respondents 

have been nursing for more than 20 

years, with under half employed as 

practice nurses for six years or 

longer. This represents a 4% increase 

on the 2009 results. 

Our members cite a variety of 

reasons for joining APNA. The most 

common reasons relate to APNA 

representation for the practice 

nursing profession, networking 

opportunities with other colleagues 

and up-to-date industry news and 

information. 

APNA role 

We asked respondents to consider 

the effectiveness of the APNA role in: 

• developing the practice nursing 

profession; 

• representing member interests; 

• influencing policy; and 

• maintaining a suitable image. 

The results can be seen in the 

accompanying chart. 

Member satisfaction with each of 

these fundamental areas was rated 

highly; with each category scoring a 

satisfaction rate of 80% or higher. 

The Association’s greatest 

100 

90 

80 

% 

70 

Considered 

importance 

Satisfaction 

60 

50 

Developing your profession 

opportunity for improvement was 

its ability to influence policy, with a 

13% difference between those who 

considered it important and those 

who were satisfied with APNA 

progress in this area to date. 

APNA services and benefits 

Respondents were asked to rate 

APNA services. These encompassed 

APNA events, training opportunities, 

the member rewards program and 

publications, such as the e-News, 

Primary Times and the website. 

When comparing the considered 

relevance of each service with 

respondents’ levels of satisfaction, the 

results suggest the most prominent 

areas for improvement are APNA 

education and online learning 

resources and discounts for events. 

We also gathered feedback on 

some of the general services that 

APNA provides. These include 

customer service, the scholarship 

program and information provided 

APNA's roles 

Representing nurses' interests 

Influencing policy 

Our image 

on education and training 

opportunities. The survey results 

showed an increasing recognition of 

the importance of responsive and 

helpful communication with 

members. This suggests that many 

members value improvements in 

APNA staff responses to enquiries 

and the support provided. 

Website 

Primary Times 

Online learning 

Member rewards 

Medical Observer Practice Nurse 

Access to education 

e-News 

Discounts to events 

Conference 

Member services 

Member satisfaction and areas 

for improvement 

The majority of members are 

generally satisfied with their 

membership. More than 99% 

provided an overall satisfaction 

rating of ‘average’ or above and 85% 

gave an overall rating of ‘satisfied’ or 

‘very satisfied’. Three quarters of the 

respondents ‘agree’ or ‘strongly 

agree’ that their membership 

represents good value for money. 

While this is a pleasing result, 

many respondents provided useful 

and pertinent comments about 

areas of improvement. Some of the 

most frequently cited needs include: 

• Continuing development of training 

opportunities, with an emphasis 

on a redeveloped CPD program. 

• Continuing lobbying for wages 

and improved working conditions 

for nurses in primary healthcare. 

• Minimisation of membership 

costs by increasing membership 

numbers. 

The APNA would like to thank all 

members who participated in this 

year’s survey and the valuable input 

provided. 

0 1 2 3 4 5 

Average rating (1-5) 

Considered importance 

Satisfaction 

12 


CLINICAL CARE 

Helping patients through 

motivational interviewing 

It has become commonplace to link the phrase ‘the chronic disease epidemic’ with the 

changing face of general practice and primary care reform. 

The National Primary Health 

Care Strategy 1 emphasises the 

important role practice nurses have 

in delivering effective prevention 

and management of chronic disease. 

In its response to the National 

Preventative Health Taskforce 

report 2 , the Commonwealth 

Government promised $390.3m 

over four years to boost support for 

nurse positions in general practice 

— to support nurses to undertake a 

broad range of prevention activities, 

such as health assessments, health 

promotion and patient education on 

lifestyle issues. 

Chronic disease accounts for a 

third of all problems managed in 

Australian general practice. 

Hypertension, diabetes, depression, 

cholesterol and lipid disorders, 

arthritis and asthma account for a 

half of these problems 3 . Interestingly, 

behavioural risk factors (smoking, 

nutrition, alcohol consumption and 

physical activity 4 ) are key to 

prevention and management for 

many of these conditions. 

Lifestyle counselling remains an 

important part of general practice 

and nurses are taking a prominent 

role in this work 5 . The way nurses 

and doctors interact with patients 

in lifestyle counselling is critical to 

their effectiveness, particularly given 

the busy, time-limited nature of 

general practice. 

Motivational interviewing (MI), 

originally developed by psychologists 

in the field of smoking 

cessation, is a theoretically based 

framework that has been shown to 

be effective in the provision of brief 

lifestyle counselling in general 

practice 6–8 , and helping patients 

make behavioural change. It can 

be adapted for use in routine 

consultations between nurse and 

patient or used as a planned strategy 

over a number of consultations 

specifically targeting lifestyle risk 

factors. It is particularly useful in 

getting away from the sort of tussle 

and wrestle that can come to 

characterise consultations where the 

GP or nurse is frustrated that the 

patient does not seem to follow their 

advice about a healthier lifestyle. 

This sort of conflict tends not to 

result in change. More often it leads 

each party to dig their heels in to 

resist change. 

The key concept of MI is 

‘ambivalence’. In this context, 

ambivalence means conflicting 

thoughts and feelings that the 

patient may have towards the 

behaviour they are trying to change. 

Ambivalence is normal. Of course 

people would not keep smoking if 

they did not continue to enjoy it at 

least in some way. The result is that 

patients come to feel stuck and 

unable to change. Ambivalence is 

also a powerful tool. Mobilising and 

helping patients to talk about their 

ambivalence is the aim of MI. 

One way to initiate this sort of 

dialogue with a patient is to ask 

about ‘importance and confidence’. 

For example, when talking with a 

patient about smoking, you can 

gauge a patient’s readiness to make a 

change (see Figure 1) with questions 

such as: How important would you 

say it is for you to stop smoking, on 

14 


CLINICAL CARE 

1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support Self-Efficacy 

Accept where the patient is at Use decisional balance Avoid argument Acceptance 

Use reflective listening Confidence and importance ratings Reframe Positive reinforcement and encouragement 

Work with ambivalence Direct the intentiontowards change Reflect Acknowldege past successes (even part-success) 

Elaboratewith the patient 

Involve the patient in problem solving 

Table 1. Principles and Strategies of Motivational interviewing. 

Confidence 

10 

9 

8 

7 

6 

5 

4 

3 

2 

1 

0 

1 2 3 4 5 6 7 8 9 10 

Figure 1. Importance, confidence and readiness to change. 

a scale from 1 to 10 How confident 

would you say you are that you could 

stop smoking on the same scale 

from 1 to 10 It also builds on the 

patient’s sense of autonomy, keeping 

the focus on what they believe and 

feel, not what the nurse or GP 

believes. If the patient scores low, a 

follow-up question could be asked 

about what they believe would help 

move them further along the scale. 

These questions can also open up 

the space for a ‘patient centred’ yet 

directive dialogue between nurse 

and patient, exploring the patient’s 

ambivalence and helping build 

motivation for change. The aim is 

to work collaboratively with the 

patient, avoiding direct confrontation. 

Miller and Rollnick 9 describe 

four principles of MI, each of which 

is supported by a range of strategies 

(see Table 1). 

Expressing empathy involves 

using all our previous training in 

good basic communication skills. 

Attending well to the patient, using 

an open posture, employing skilful 

and reflective listening and 

summarising back what the patient 

said will all help build a sense of 

empathy and understanding with 

the patient. Similar skills are used in 

affirming the patient’s efforts and 

Importance 

building his/her self-efficacy and 

confidence about the future. 

Developing discrepancy means 

building on the dialogue that starts 

with the importance and confidence 

questions. The aim is to help 

patients clarify important goals 

for themselves and to explore the 

consequences of their current 

behaviour, pointing out that there 

may be a discrepancy between these 

consequences and the goals they 

may have. Exploring both sides of 

the equation is what is meant by a 

‘decisional balance’. Again, talking 

about smoking is a good example. 

Key open questions can be: What 

are all the good things you enjoy 

about smoking What are some 

of the less good things about your 

smoking Helping the patient to 

make this an extensive list can 

give you a chance to weave in 

information about the known harms 

and health damaging effects of 

smoking. If the patient can’t identify 

many negatives, additional questions 

could be: What is there about your 

smoking that other people might see 

as reasons for concern What are 

some of the hassles that your 

smoking may have caused How 

does your smoking fit in with your 

diabetes/asthma/hypertension 

Generating positive talk from the 

patient about the possibility of 

change can be useful, with questions 

such as: What are the things that 

you would like to have in your life 

instead of tobacco If you did make a 

change to your lifestyle, how would 

you like things to turn out Who are 

the people in your life that would 

support you in quitting 

Rolling with resistance means 

reframing barriers that the patient 

may raise. ‘I couldn’t get through all 

the stress at work without smoking!’ 

might be reframed as ‘It’s good that 

you have managed to identify some 

of the triggers that keep you 

smoking. Let’s think about how we 

could help you deal with that stress’. 

Motivational interviewing will 

not be suitable for all people or all 

situations. But it can be a useful 

strategy to employ when you have 

reached a block with a patient 

around a lifestyle behaviour that 

seems to be a problem. It can help 

you get beyond assumptions you may 

be making subconsciously that this 

patient is being ‘difficult’ and should 

take your advice now and change his/ 

her lifestyle. It can generate new 

ideas for both you and the patient. 

The skill is to weave it into the 

complex ongoing relationship that 

develops between a practice nurse 

and a patient over time. 

References 

1. Commonwealth Department of Health 

and Aged Care. Building a 21st Century 

Primary Health Care System: Australia’s 

First National Primary Health Care 

Strategy. Canberra: Commonwealth 

Department of Health and Aged 

Care; 2010. 

2. Commonwealth Department of Health 

and Aged Care. Taking Preventative 

Action — A Response to Australia: 

The Healthiest Country by 2020 — 

The Report of the National Preventative 

Health Taskforce. Canberra: 

Commonwealth Department of Health 

and Aged Care; 2010. 

3. Britt H, Miller G, Charles J, Henderson J, 

Bayram C, Pan Y, et al. General practice 

activity in Australia, 2008–09. Canberra: 

AIHW; 2009. 

4. The Royal Australian College of General 

Practitioners National Standing 

Committee — Quality Care. Smoking, 

Nutrition, Alcohol and Physical activity 

(SNAP): A population health guide to 

behavioural risk factors in general 

practice. Melbourne: RACGP; 2004. 

5. Halcomb E, Moujalli S, Griffiths R, 

Davidson P. Effectiveness of general 

practice nurse interventions in cardiac 

risk factor reduction amongst adults: 

A systematic review. International 

Journal of Evidence-Based Healthcare. 

2007;5(3):269–295. 

6. Ashenden R, Silagy C, Weller D. 

A systematic review of the effectiveness 

of promoting lifestyle change in general 

practice. Fam Pract. 1997;14(2):160–176. 

7. Lai D, Cahill K, Qin Y, Tang J. 

Motivational interviewing for smoking 

cessation. Cochrane Database of 

Systematic Reviews. 2009(1). 

8. Rubak S, Sandboek A, Lauritzen T, 

Christensen B. Motivational interviewing: 

a systematic review and meta-analysis. 

Br J Gen Pract. 2005;55(513):305–312. 

9. Miller WR, Rollnick S. Motivational 

interviewing: preparing people for 

change. 2nd ed. New York: Guilford 

Press; 2002. 

Dr John Furler MBBS, FRACGP, PhD 

Senior Research Fellow Primary Care Research Unit 

Department of General Practice The University of 

Melbourne 


PRACTICE NURSE PROFILE 

Practice nurse appointments 

for new patients 

East Brunswick Medical Centre is 

a general practice located in the 

inner suburbs of Melbourne with 

four doctors and two nurses. Like 

many practices, we have experienced 

a growing demand to accommodate 

new patients due to population 

growth, the retirement of older solo 

practitioners and closure of their 

practices. 

While most local practices have 

‘closed their books’ to new patients, 

we have always kept our doors open 

to these patients. Our policy was to 

provide all new patients with a 

30-minute appointment with a 

doctor to take a full medical history. 

Our dilemma, however, was that in 

most cases patients were waiting up 

to six weeks for a ‘new patient’ 

appointment. 

We reviewed the structure of 

these appointments and realised 

that time-intensive medical history 

taking and recording of data in the 

electronic medical record was well 

within the scope of our practice 

nurses. In addition, feedback from 

our receptionists informed us that 

many patients wanted to be on our 

books to access a doctor when the 

need arose. 

Over a few weekly clinical 

meeting sessions, involving all the 

doctors and nurses, an agreed 

protocol was established for all new 

patients to be offered a ‘nurse 

registration appointment’. Patients 

do not see a doctor at this 

registration visit, unless an 

abnormality is noted, and the 

appointment is generally available 

within five working days. Patients 

could still choose to see a doctor for 

their initial appointment, but they 

will need to wait longer. 

Consultation was held with the 

practice medical indemnity insurers, 

who were satisfied that the 

specifications set down for the 

‘nurse registration appointment’ 

would not in any way breach the 

cover provided under the practice 

insurance policy. 

The nurse registration 

appointments were launched. 

Nurses are responsible for taking 

a thorough history from the patient, 

including conditions, operations, 

medications, allergies and immunisations. 

Clinical assessment includes 

blood pressure, weight, height, waist 

measurement, urinalysis and 

random glucose. 

All details are recorded into the 

patient’s electronic medical record. 

If appropriate, a transfer of previous 

medical records is instigated. If the 

nurse detects an immediate clinical 

problem, there is a duty doctor 

allocated from each week day who 

can be accessed to provide a clinical 

assessment of the patient. Patients 

are charged a non-rebatable fee for 

the appointment, as it requires 

30–45 minutes of the nurse’s time 

— the fee is $56.00, payable 

on the day. 

As a practice, we believe that this 

process has had several positive 

outcomes. Patients see the nurses 

as part of the clinical team; initial 

records are established in line with 

accreditation standards; doctors 

feels they have excellent information 

available to them when they consult 

with the patient; and, patients 

express satisfaction with the process 

as it enables them to be registered 

with a practice of their choosing. 

Importantly, nurses’ professional 

satisfaction is enhanced by their 

independent and responsible role. 

Since commencing this new 

process in August 2008, we have 

welcomed 1128 new patients to our 

Roslyn O’Reilly 

Roz has worked extensively in both public and private 

hospitals, and also worked as a supervisor in a 

regional laboratory of Melbourne Pathology. She made 

the move into general practice as a practice nurse 

approximately five years ago. Roz has been a member 

of the GP working party through St Vincent’s Hospital 

in Melbourne and is part of a research project with 

The University of Melbourne, Department of General 

Practice, focusing on introducing diabetic patients 

to and educating them about insulin. 

Teresa Reid 

Teresa has extensive nursing experience in the UK and 

Australia. She has worked in general practice since 

2004 and at East Brunswick Medical Centre for the 

last three years. She is an immunisation provider and 

Pap test provider and has completed a Postgraduate 

Certificate in Women Centred Clinical Care. 

practice — 357 (32%) of these via a 

nurse registration appointment. One 

of our receptionists is the designated 

new patient co-ordinator. Initially, 

she had to encourage patients to 

accept the nurse registration option, 

but many new patients now ask to 

be booked for a nurse registration 

visit. Almost $20 000 in income has 

been generated from this initiative, 

which covers nurses’ wages for this 

service and generates income back 

to the practice. In addition, doctor 

time is available to see existing 

practice patients, and of course our 

new patients. 

Feedback is obtained monthly via 

a questionnaire sent out to a random 

sample of these patients. Feedback 

has been positive, with patients 

expressing satisfaction with their 

visit and the nurse’s thorough 

explanation about the centre and 

what it can offer patients. 

16 


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CLINICAL CARE 

Gastroenteritis in children 

Each year around 20 000 children suffering dehydration, as a result of 

gastroenteritis, are admitted to Australian hospitals and over a million 

more consult a general practitioner 1 . 

Gastroenteritis in infants 

and children is a common 

intestinal infection, which causes 

vomiting, diarrhoea and fever and 

can usually be managed at home 

by encouraging oral rehydration 

therapy (ORT). 

Acute gastroenteritis is the most 

frequent diagnosis in paediatric 

emergency departments across 

Australia and New Zealand 2 . 

Gastrointestinal conditions 

accounted for the highest number of 

calls to the Kidsnet helpline service 3 , 

emphasising that managing 

vomiting and diarrhoea at home is 

still a great concern to parents. 

What is gastro 

Diagnosis of gastroenteritis evolves 

from the exclusion of other causes of 

vomiting and diarrhoea, such as 

infective, surgical and metabolic. 

Although it can sometimes be 

bacterial or parasitic, the majority of 

cases are viral — the most common 

of which is rotavirus. 

Gastroenteritis is seasonal and 

usually presents in autumn and 

winter, with rotavirus peaking in 

spring. As there are no indications 

for anti motility or anti diarrheal 

drugs in children, and antiemetics 

are avoided due to the high risk of 

Degree of Dehydration 

Very mild (3%) 

Mild (5%) 

Moderate (7-8%) 

Severe (>10%) 

Table 1. An overview of the signs and symptoms of dehydration. 

side effects, the key to managing 

gastroenteritis is achieving and 

maintaining adequate hydration 4 . 

How to determine dehydration 

Determining if a child is dehydrated 

and to what extent is difficult, as 

individual signs of dehydration 

are imprecise. The following 

combination of three clinical signs 

has been shown to be the most 

accurate for assessing dehydration 5 . 

1. Increased capillary refill 

>2 seconds 

2. Abnormal skin turgor 

3. Abnormal respiratory patterns 

(deep acidotic breathing) 

What next 

The use of ORT for mild and 

moderate dehydration can prevent 

or reduce hospitalisation and aid in 

a child’s recovery. Oral rehydration 

therapy has become the therapy of 

choice as it has been shown to be 

as effective as intravenous therapy, 

with fewer adverse effects 6 . 

As dehydration is a deficiency 

in both fluids and electrolytes, 

introducing oral rehydration 

solutions such as Hydralyte is 

extremely beneficial as early 

intervention. Oral rehydration 

solutions use the principle of glucose 

Symptoms and Signs 

Reduced urine output, thirst, no clinical signs 

Dry mucous membranes 

Mild tachycardia 

Lethargy, tachycardia, reduced skin turgor, 

sunken fontanelle, sunken eyes 

Above + poor perfusion, shock 

facilitated sodium transport in the 

small intestine, to facilitate intestinal 

water absorption 6 . Drinks with high 

sugar content have a high osmolarity 

and therefore may increase 

diarrhoea and the risk of dehydration. 

For this reason, sports drinks 

are unsuitable for rehydration 7 . 

Breastfed babies should continue 

with frequent feeds, and may be 

supplemented with oral rehydration 

solutions. 

It is imperative to give small 

amounts of oral rehydration 

solutions fluid via syringe, spoon, 

cup or bottle as the child will 

tolerate this better than larger 

volumes at once. 

Commencing a trial of fluid form 

(Table 1) when the child and family 

are seen will simultaneously educate 

the families in the methods of ORT 

and give staff a more accurate 

account of the fluid intake and 

output of the child with 

gastroenteritis. 

Early reintroduction of the child’s 

normal diet has been shown to 

improve the child’s weight gain, and 

reduce the duration of diarrhoea 6,4 . 

When dealing with children with 

gastroenteritis it is essential to 

educate the families on infection 

control, and the importance of hand 

washing. 

Five tips for managing rehydration 

1. Early intervention with oral 

rehydration solutions 

2. Offer small frequent sips of oral 

rehydration solutions, 0.5ml/kg 

every 5 min or a Hydralyte 

iceblock. 

3. Strict hand washing to prevent 

spread. 

4. Engage parents as partners in 

the therapeutic process. 

5. Utilise trial of fluid form. 

Introducing ORT with an oral 

rehydration solution and trial of 

fluid forms into your practice will 

ensure early intervention and 

education of families, leading to 

more effective and successful 

ongoing management of 

gastroenteritis. 

18 


CLINICAL CARE 

References 

1. Carlin J, Chondros P, Masendycz P, 

Bugg H, Bishop R, Barnes G. Rotavirus 

infection and rates of hospitalisation for 

acute gastroenteritis in young children 

in Australia, 1993–1996. Med J Aust. 

1998;169:252–256. 

2. Acworth J, Babl F, Borland M, Ngo P, 

Kriesser D, Schutz J, et al. Patterns of 

presentation to the Australian and New 

Zealand Paediatric Emergency Research 

Network. Emergency Medicine 

Australasia 2009;21:59–66. 

3. Harris C, Wilkinson F, Mazza D, Turner 

T. Evidence based guideline for the 

management of diarrhoea with or 

without vomiting in children. Special 

Issue. 2008;37:22–29. 

4. Steiner M, DeWalt D, Byerley J. 

Is this child dehydrated JAMA. 

2004;291:2746–2754. 

5. NSW Health Department. Infants and 

children: Acute Management of 

Gastroenteritis. 3rd Ed. Clinical practice 

guidelines for the treatment of infants 

and children with gastroenteritis. 2010. 

6. Hanson R, Exley B, Ngo P, Fitzpatrick M, 

Petering E, Matthews S, et al. Paediatric 

telephone triage and advice: the demand 

continues. MJA. 2004;180:333–335. 

7. Schultz J, Babl F, Sheriff N, Borland M. 

Paediatric Research in Emergency 

Departments International Collective 

(PREDICT). Journal of Paediatrics and 

Child Health. 2008;44: 560–563. 

Resources 

1. Paediatric clinical practice 

guidelines are available on the 

Clinical Information Access 

Program website: www.ciap. 

health.nsw.gov.au 

2. The Royal Children’s Hospital 

Melbourne website has 

information sheets for health 

professionals and parents: 

www.rch.org.au 

3. Parent fact sheets are also 

downloadable on the following 

websites: 

- Children’s Hospital at 

Westmead: www.chw.edu.au 

- Sydney Children’s Hospital: 

www.sch.edu.au 

Peta Dewar, RN, Master of 

Nursing Paediatrics and 

Neonates 

Peta has over 12 years of general 

and emergency paediatric 

experience. She worked as the 

Paediatric Emergency Clinical 

Nurse Consultant for Northern 

Sydney Central Coast Area 

Health Service for six years 

and is consulting for Hydration 

Pharmaceuticals. 

Coming soon 

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Want to know more about assessing absolute cardiovascular disease risk 

The National Vascular Disease Prevention Alliance* has collaborated with leading experts in the field to develop 

five vodcasts on absolute cardiovascular disease risk. These vodcasts are short video interviews that cover: 

• what absolute risk means in practice 

• overcoming barriers to using an absolute risk approach 

• engaging patients to think about absolute risk 

• assessing absolute risk in Aboriginal and Torres Strait Islander people 

• assessing absolute risk in younger people. 

For more information, visit www.heartfoundation.org.au/absoluterisk 

* The National Vascular Disease Prevention Alliance is a group of four leading 

and well-known Australian charities: Diabetes Australia, Kidney Health Australia, the 

National Heart Foundation of Australia and the National Stroke Foundation. It was 

established in 2000 and aims to reduce cardiovascular disease in Australia.

CLINICAL CARE 

Identifying common 

nutritional deficiencies 

Practice nurses are in a unique position to identify nutritional deficiencies 

in patients, and to motivate beneficial dietary changes. 

patient’s willingness to change 

A diet is paramount to successful 

treatment and requires sufficient 

education and confidence in the 

recommendations. The importance 

of good nutrition is widely 

recognised, and by understanding 

key demographic inadequacies 

nurses can provide recommendations 

for improved quality of life. 

Children and 

adolescents 

Children and teenagers have specific 

nutritional requirements to support 

rapid growth and development. 

Unfortunately, many Australian 

children are getting less than their 

recommended daily intake of 

essential vitamins and minerals. 

It is more important than ever to 

be aware of what kids are eating to 

identify possible deficiencies. 

Key nutrients for children and 

adolescents: 

• Calcium is essential for growing 

bones and teeth. 

• Vitamins A and C, zinc and iron 

help build a strong immune 

system. 

• B group vitamins to convert food 

into energy. 

• Iron, folate and vitamin B12 for 

growth and development. 

• Vitamin A is essential for eye 

health. 

• Iron deficiency can be associated 

with impaired physical 

performance as well as affecting 

memory, concentration and 

performance. 

Iodine 

Iodine is a trace mineral, essential 

for the synthesis of thyroid 

hormones that influence normal 

growth and development, 

particularly of the brain. The thyroid 

hormones T3 and T4 facilitate brain 

maturation from the womb through 

to our 20s, so it is vital that infants, 

children and teenagers receive 

adequate iodine to support 

development of advancing cognitive 

abilities for school performance, 

achievement and IQ. Iodine was 

once plentiful in the diet through 

dairy and iodised salt. However, 

changes in the diary industry and 

the decreased popularity of iodised 

salt have led to a widespread 

deficiency in our population. 

The iodine status of Australian 

children was studied in The 

Australian National Iodine Nutrition 

Study, published in The Medical 

Journal of Australia in 2006. This 

study investigated the iodine levels 

of 1709 children aged 8–10 years of 

age, and found that almost half the 

children may be deficient in iodine. 

However, it was not until the 

University of Otageo in New 

Zealand conducted a ground 

breaking study, investigating iodine 

supplementation in 184 school aged 

children, that the full benefit of 

iodine supplementation was 

realised. 

The study, published in The 

American Journal of Clinical 

Nutrition, assessed cognitive 

performance in children 

supplemented with iodine. The 

iodine tablets developed for the 

study were supplied by Blackmores. 

The children who received iodine 

displayed significantly improved 

performance in tests of perceptual 

reasoning, a high level intellectual 

function. This is the first time iodine 

supplementation was shown to 

benefit average mildly deficient 

children. Sheila Skeaff, study author 

and Senior Lecturer, University of 

Otago, New Zealand, said that 

supplementing with iodine can help 

to ensure children are not iodine 

deficient, and help them to reach 

their full intellectual potential. 

Food sources of iodine are kelp, 

seafood, iodised salt and more 

recently fortified bread. The 

recommended daily intake for 

children 1–18 years is 90–150 mcg. 

Preconception, 

pregnancy and 

breastfeeding 

Good health and nutrition provides 

a solid foundation for healthy 

conception, pregnancy and 

breastfeeding. Optimal nutrition 

provides key nutrients to support 

the parents’ fertility, the baby’s 

development, and maternal health 

throughout pregnancy and lactation. 

Parents should be encouraged to eat 

a varied diet of seasonal fresh, whole 

foods to support the increased 

nutritional requirements and to 

establish healthy eating patterns for 

the growing family. 

Prospective parents share the 

opportunity to prepare for healthy 

conception by maximising 

nutritional intake. It is ideal to start 

preconception care 3–4 months 

before a planned pregnancy to allow 

for healthy sperm production, 

establish healthy ovulation 

(particularly following the use of the 

oral contraceptive pill) and replenish 

existing nutritional deficiencies. 

Key nutrients for maternal 

preconception, pregnancy and 

breastfeeding: 

• Iron requirements increase during 

pregnancy due to accelerated red 

blood cell formation, immune 

function and thyroid function. 

Supports foetal brain, blood, eye 

and bone development. 

• Zinc is important for healthy 

growth and development 

especially during first and second 

trimesters. It is important for the 

mother as it can help to 

facilitating labour and prevent 

cracked nipples during 

breastfeeding. 

• Folic acid reduces the risk of 

neural tube defects if taken 

pre-conceptually and in the early 

stages of pregnancy. The majority 

of women have below 

recommended intakes of folate 

prior to conception. 

• Vitamin D is involved in healthy 

bone building. Maternal vitamin 

D status during pregnancy and 

lactation directly affects the baby 

for the first few months of life, and 

later influences the child’s height 

and bone strength. A recent study 

published in The Journal of 

Nutrition (American Society of 

Nutrition) found that 66.1% of 

newborn babies were born 

deficient in vitamin D. CoQ10, a 

powerful antioxidant, is linked to 

healthy conception and 

pregnancy, particularly the first 

trimester and labour. The normal 

curve of plasma CoQ10 rises with 

each trimester of pregnancy. 

Key nutrients for male 

preconception health: 

Zinc is involved in cellular 

reproduction, so is very important 

for healthy sperm count and 

motility, testosterone levels and 

facilitating a healthy conception. 

Selenium, a potent antioxidant, 

20 


CLINICAL CARE 

is important for healthy sperm 

production and motility. 

B group vitamins particularly B5 

for testicular health and B12 to 

increase sperm count and motility. 

Omega 3 essential fatty acids 

Research has highlighted the 

importance of omega 3 essential 

fatty acids (EFA) for conception, 

pregnancy and breastfeeding. These 

‘good fats’ must be obtained in 

sufficient quantities in the diet for 

healthy fertility, pregnancy and 

breastfeeding. 

Inadequate maternal and paternal 

EFA levels have been associated with 

infertility, particularly for men, as a 

strong negative correlation has been 

established with low omega 3 levels 

and total sperm count, motility 

and morphology. This is a strong 

recommendation for increasing 

consumption as part of 

preconception preparations. 

The metabolic demand for omega 

3s, particularly docosahexaenoic 

acid (DHA) increases in pregnancy 

and during lactation. The benefits of 

meeting requirements are many and 

varied. A recent meta-analysis of 

studies showed that 

supplementation with fish oil in the 

second half of the pregnancy 

resulted in increased length of 

gestation and slightly greater birth 

weight. Higher maternal intake in 

DHA has also been shown to have 

beneficial effects on visual acuity, 

cognitive function, hand-eye 

co-ordination and maturity of sleep 

patterns in infants. Supplementation 

continuing through lactation 

ensured higher concentrations of 

DHA in breast milk, in order to 

provide for the rapid growth of the 

baby, particularly the brain. Human 

milk DHA levels have been 

positively correlated to visual 

development in breastfed infants, 

and investigations are continuing 

into other areas, such as language 

production, comprehension and 

cognitive function. 

It is recommended that pregnant 

and breastfeeding mothers consume 

2–3 servings of most types of fish 

weekly. Blackmores Conceive Well 

Gold and Pregnancy & Breastfeeding 

Gold contain a range of 

nutrients to support preconception 

and pregnancy such as those 

mentioned above. 

Seniors 

There is no doubt that Australia is 

faced with an ageing population, and 

this demographic has been identified 

at a disproportionate risk of 

nutritional deficiencies. Ageing is 

associated with a decline in a 

number of physiological functions 

that can impact nutritional status in 

addition to medication, 

hospitalisation and other social 

realities. The nutritional status of 

older people is an important 

determinant of quality of life. 

A study published in the Journal of 

the American Dietetic Association 

suggested a significant proportion 

of people over 50 do not receive 

sufficient nutrients from diet alone 

and therefore may benefit from 

supplementation. Those that did 

supplement were more likely to 

receive adequate levels of essential 

nutrients. Many members of this age 

group are motivated to maintain 

health and vitality through good 

nutrition and are open to nutritional 

education. 

Key nutrients for seniors: 

• Calcium is well recognised for 

building strong healthy bones and 

preventing osteoporosis, but is 

also involved in cardiovascular 

health particularly regulation of 

healthy blood pressure. 

• Co enzyme Q10 is a naturally 

occurring nutrient; unfortunately, 

human tissue concentrations 

decrease with advancing age. This 

potent antioxidant is concentrated 

in metabolically active tissues and 

supports cardiovascular health, 

immune function, and energy 

levels. 

• Increasing evidence supports the 

multifactor benefits of optimal 

omega 3 EFA consumption, 

including a protective role in 

cardiovascular health, cognitive 

function, visual acuity and 

reduction of inflammatory states 

such as arthritis. 

• Vitamin B12 deficiency is 

estimated to affect 10–15% of the 

population aged over 60; however, 

this can be difficult to diagnose 

as the elderly do not frequently 

display the classical signs and 

symptoms. B12 deficiency may 

be a result of atrophic gastritis, 

hypochlorhydria and resulting 

gastrointestinal dysbiosis binding 

B12 and preventing absorption. 

Adequate levels are necessary 

for cognitive and psychiatric 

performance and cardiovascular 

health. Food fortification with 

folate may further complicate 

diagnosis of this deficiency. 

• Antioxidants such as vitamin A, 

E, carotenes and zinc may be 

lowered resulting in lowered 

immune resistance to infection, 

delayed recovery and poor tissue 

healing. Maximising consumption 

of these nutrients may support 

healthy immune resistance, 

recovery from infection and 

healthy tissue healing. 

Vitamin D 

Vitamin D has been identified as a 

major deficiency in the ageing 

Australian population — possibly 

affecting up to 75% of this segment. 

Older people are prone to deficiency 

due to low dietary intake, 

diminished exposure to sunlight, 

poor intestinal absorption and 

impaired hydroxylation in the 

kidneys and liver (conversion of D3 

into its metabolically active forms). 

One of the most recognised 

functions of vitamin D is to mediate 

calcium homoeostasis to reduce 

likelihood of osteoporosis. This is 

achieved via stimulation of intestinal 

calcium absorption, reabsorption of 

calcium from the kidneys and 

regulation of parathyroid hormone 

influence on skeletal calcium stores. 

Vitamin D supplementation has 

been investigated for preservation 

of muscle strength and functional 

ability. Successful treatment with 

vitamin D resulted in clinical 

improvement in muscle strength, 

walking distance, functional ability 

and body sway; therefore identifying 

vitamin D as an important nutrient 

to reduce risk of bone fracture. 

Higher concentrations of vitamin 

D have been shown to have a 

protective affect on age related 

diseases, marking vitamin D as an 

‘anti ageing’ vitamin. The American 

Journal of Clinical Nutrition 

published a study that identified 

higher concentrations of vitamin D 

with increased telomere length — 

a chromosomal marker of ageing. 

Researchers conclude that higher 

levels of vitamin D may age more 

slowly than those with low levels. 

The National Health and Medical 

Research Council has set the AI 

(adequate intake) for vitamin D at 

5–15 mcg for adult women and men. 

There are two forms of vitamin D. 

One is produced by the action of 

sunlight on skin (D3 or cholecalciferol) 

and the other is found in a 

limited range of foods (D2 or 

ergocalciferol). With current food 

supplies and patterns of eating, 

it is almost impossible to obtain 

sufficient vitamin D from the diet 

alone. Vitamin D in foods is fat 

soluble and is biologically less active. 

Supplementation provides a reliable 

and convenient method to maintain 

intake. 

Danielle Steedman B. Hlth Sc, Ad Dip NAt, 

DBM, DRM, MATMS 

Danielle is a naturopath with over 10 years of 

experience in clinical practice and the natural 

supplement industry. Her interests are women’s 

and children’s health, utilising dietary, nutritional 

and herbal medicines to educate and motivate 

patients to achieve optimal health. 


SPECIALIST INTERVENTION 

Practice nurses and dietitians 

working together 

Health professionals, such as practice nurses and dietitians, must work 

together to help Australians be healthier. 

In order to effectively partner with 

dietitians, practice nurses need a 

good understanding of the services 

dietitians provide, when to refer and 

how to find a suitable practitioner. 

Medical nutrition therapy: a 

dietitian’s ‘bread and butter’ 

Dietitians translate scientific 

nutrition information into practical 

advice to help people make the right 

decisions about what to eat. Medical 

nutrition therapy involves nutrition 

assessment, dietary advice, 

knowledge and skill development, 

and behavioural counselling. The 

aim is to facilitate long-term 

behaviour change by encouraging 

patients to self-manage their health 

through nutrition, diet and other 

lifestyle changes. 

Accredited Practising Dietitians: 

who are they and what do they do 

In Australia there are no rules 

governing the use of the terms 

‘dietitian’ and ‘nutritionist’. These 

titles may be used by dietitians, 

nutrition scientists, and nutrition 

graduates — or people with very 

limited nutrition qualifications! The 

Dietitians Association of Australia 

(DAA) recommends looking for the 

APD credential when choosing a 

dietitian. 

Accredited Practising Dietitians 

(APDs) have either completed a 

DAA-accredited university degree, 

comprising a minimum of four 

years full-time training, or have 

successfully sat the DAA 

examination for overseas-trained 

dietitians. They must also take part 

in ongoing continuing professional 

development, and are bound by 

DAA Code of Professional Conduct. 

Most Australian health funds 

have levels of cover that give a rebate 

for visits to private practice APDs. 

Patients may also get a rebate 

through Medicare if they are under 

a care plan for a chronic health 

condition (such as type 2 diabetes) 

that is being co-ordinated by a GP. 

Medicare rebates are also available 

for people with type 2 diabetes 

attending group sessions run by 

an APD. 

APDs advise patients on the 

nutritional management of many 

conditions, such as diabetes, 

cardiovascular disease, 

gastrointestinal disorders, cancer, 

physical and mental disabilities, 

food allergy and intolerance, and 

overweight and obesity. 

Practice nurses and dietitians: 

working together 

Practice nurses will differ in their 

interest in the area of nutrition. 

Some may choose to discuss general 

nutrition guidelines on healthy 

eating (based on the Dietary 

Guidelines for Australian Adults) 

with their patients, while others 

will refer patients for all nutrition 

counselling to a specialist — an 

APD. 

Finding an Accredited Practising 

Dietitian 

Finding an APD is easy. Go to www. 

daa.asn.au and click on the ‘Find an 

APD’ tab or call the toll free APD 

hotline on 1800 812 942 and ask for 

the contact details of APDs in your 

local area. Look in the Yellow Pages 

under ‘Dietitian’ for an APD or call 

your local public or private hospital 

or community health centre and ask 

to speak to an APD. 

Summary points 

• Nutrition intervention can 

improve patient outcomes. 

• APDs modify diets to treat a wide 

range of nutrition-related health 

conditions. 

• APDs are university-qualified 

nutrition and dietetic 

professionals, and are the experts 

in food and nutrition. 

• Medicare provides rebates for 

visits to an APD for patients 

under a care plan for a chronic 

health condition co-ordinated by 

a GP. 

• Most private health funds provide 

rebates for visits to APDs in 

private practice. 

• By working together, PNs and 

APDs can improve the nutritional 

status of patients. 

• Visit www.daa.asn.au to find an 

APD in your local area, or to visit 

‘Smart Eating for You’ for 

nutrition information for your 

patients. 

Claire Hewat 

CEO Dietitians Association of Australia 

The aim is to facilitate 

long-term behaviour 

change by encouraging 

patients to self-manage 

their health through 

nutrition, diet and other 

lifestyle changes. 

Did you know 

Reading and reflecting 

on the content in 

Primary Times is worth 

one hour of CPD. 

22 


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FEATURE 

Nutrition and chronic disease 

The Australian Institute of Health and Welfare report Australia’s Health 

2010 shows deaths from stroke and heart attack have decreased by 

76 per cent since the 1960s — and cancer deaths have also fallen 1 . 

The report, however, reveals a worrying upwards trend in rates of 

diabetes and obesity. 

In 2007–2008 one in four children 

aged five to 17 and 61 per cent of 

adults in Australia were deemed 

overweight or obese. The rates of 

type 2 diabetes have increased in 

parallel with rates of overweight and 

obesity in Australia 2 . More than 

800 000 Australians have been 

diagnosed with diabetes, making the 

disease three times more common 

than it was two decades ago. 

We have all heard the phrase ‘You 

are what you eat’. Poor nutrition and 

physical inactivity are known risk 

factors for lifestyle-related chronic 

diseases, such as type 2 diabetes, 

cardiovascular disease and cancer. 

Nutrition intervention can help 

prevent and better manage some 

chronic health conditions and can 

greatly improve quality of life in 

both the short and long term. 

An Accredited Practising 

Dietitian (APD) is best-placed to 

provide tailored, evidence-based 

nutrition advice to patients. But 

practice nurses are now more often 

carrying out health assessments to 

detect chronic diseases and are 

increasingly at the forefront of 

delivering health information to 

patients. This presents an 

opportunity for practice nurses to 

discuss general nutrition principles 

and basic healthy eating guidelines 

with patients, and to refer them to 

an APD for further advice. 

Ten ways to help improve patients’ 

health 

1. Encourage patients to start a 

food diary. This will help them 

see what they are eating and 

drinking, and where there may 

be any problem areas. A food 

diary is also useful to take to 

any appointment with an APD. 

2. Encourage patients who are 

overweight or obese to lose 

weight. No one likes to be told 

they need to lose weight, but 

there are many benefits — such 

as improved blood lipids, 

reduced blood pressure and 

decreased insulin resistance. 

Modest weight loss of 5–10% of 

starting weight can be beneficial 

to health. And focussing on 

‘waist loss’ must be a priority. 

Ideally, women should have a 

waist circumference of under 80 

cm and men less than 94 cm. 

3. Recommend patients eat more 

fruit and vegetables. For many 

people, adding one more piece 

of fruit and one more serve of 

vegetables to their day is a good 

goal. Encourage patients to build 

up to the recommended two 

pieces of fruit and five serves of 

vegetables (around three cups) 

every day. Visit www.gofor2and5. 

com.au for patient resources and 

fact sheets on improving fruit 

and vegetable intake. 

4. Eat less energy-dense foods 

and drinks. Foods rich in fat 

and added sugar provide ‘empty 

calories’ and often not many 

nutrients. Cakes, biscuits, 

pastries and chocolates fall into 

this category. One small square 

of chocolate provides 120 kJ — 

the same as 10 strawberries, but 

24 


Important to demonstrate, easy to use. 1,2 

SIMPLE 

TWO 

STEP 

OPERATION 

Practice nurses play a critical role in making certain 

EpiPens are used correctly in life-threatening allergic 

reactions. By ensuring your patients regularly 

re-familiarise themselves with EpiPen encourages 

correct use in an emergency situation. 3 

Encourage your patients to join EpiClub. 

EpiClub is an online educational resource that also 

offers a FREE reminder service which reminds people 

that their EpiPen is about to expire and needs to be 

replaced. ‘How to use EpiPen’ videos are also available 

to download. 

PBS Information: Authority Required. Refer to PBS Schedule for full authority information. 

† After administration of EpiPen ® always seek medical attention 

References: 1. EpiPen ® Approved Product Information. 2008. 2. Kemp SF, et al. Allergy. 2008;63:1061-1070. 3. NPS RADAR. Adrenaline (EpiPen) auto injector for acute allergic anaphylaxis. 

www.npsradar.com.au Accessed June 2009. 

Before prescribing, please review approved Product Information. Product Information is available on request 

from Alphapharm. MINIMUM PRODUCT INFORMATION EpiPen ® . Adrenaline Auto-Injector 300mcg / 0.3mL EpiPen ® Jr. Adrenaline 

Auto-Injector 150mcg / 0.3mL. The following are not a complete listing: Indication: For the emergency treatment of anaphylaxis 

(acute severe allergic reactions) due to insect stings, drugs or other allergens. Contraindications: Contraindications are relative, 

as this product is intended for use in life-threatening emergencies. Cardiac dilation, certain arrhythmias, cerebral arteriosclerosis, 

vasopressor drug contraindication, maternal blood pressure > 130/80, shock (except anaphylactic shock), organic brain damage, 

general anaesthesia. Precautions: sulfite allergy, intravenous administration, ventricular fibrillation, prefibrillatory rhythm, tachycardia, 

myocardial infarction, phenothiazine-induced circulatory collapse, prostatic hypertrophy, anginal pain in coronary insufficiency, elderly, 

individuals with diabetes, cardiovascular disease, hypertension, narrow angle glaucoma, hyperthyroidism, psychoneurosis, Parkinsonism. 

Injection into hands, feet, ears, nose, buttocks, genitalia. Pregnancy Category A. Excreted in breast milk. Adverse Effects: anxiety, 

restlessness, tachycardia, respiratory difficulty, tremor, weakness, dizziness, headache, dyspnoea, cold extremities, pallor, sweating, 

nausea, vomiting, sleeplessness, hallucinations, flushing of face and skin. Psychomotor agitation, disorientation, impaired memory, 

potentially fatal ventricular arrhythmias, severe hypertension which may lead to cerebral haemorrhage and pulmonary oedema. 

Dosage: Single intramuscular injection into anterolateral aspect of thigh, repeat every 5 to 15 minutes if symptoms recur or have not 

subsided. Adults > 30kg: EpiPen ® auto-injector (300mcg Adrenaline) Children 15 – 30kg: EpiPen ® Jr auto-injector (150mcg Adrenaline). 

PBS Dispensed Price: EpiPen & EpiPen Jr $106. EpiPen ® is a registered trademark of Mylan, Inc. EpiPen ® and EpiPen ® Jr. are 

distributed in Australia by Alphapharm Pty. Limited. ABN 93 002 359 739, Cnr Wentworth Park Road 

& Bay Street, Glebe NSW 2037, Australia, Phone (02) 9298 3999, Medical Information Phone: 1800 028 365, 

www.alphapharm.com.au ALPH2456/PT EPI038 8/09

FEATURE 

without the nutrients. Patients 

should be encouraged to swap 

soft drinks and cordials for diet 

versions or, better still, to choose 

water and reduced-fat milk 

instead. Swapping a can of soft 

drink for water will save 694 kJ. 

5. Ask patients to choose lower 

fat versions of three foods they 

eat regularly. Lower fat versions 

will reduce kilojoule intake 

enough to shed some kilos. 

Suggest patients look at the 

nutrition labels of two similar 

products and choose the one 

with the lowest total energy 

(kilojoule) and fat content. A 

good goal is to look for less than 

10 g total fat per 100 g, with an 

emphasis on choosing the 

product with the lowest 

saturated fat content. 

6. Suggest throwing out the salt 

shaker and looking for 

salt-reduced foods. A high salt 

diet can contribute to the risk 

of hypertension, heart disease 

and kidney disease. Research 

suggests that cutting back salt 

intake will reduce the risk of 

coronary heart disease and 

stroke. Encourage patients to 

reduce processed foods, as these 

contribute to around 75 per cent 

of most people’s total sodium 

intake. 

7. Be aware of alcohol. If a patient 

drinks alcohol, they should be 

encouraged to adhere to the 

National Health and Medical 

Research Council’s guidelines 3 . 

Healthy men and women should 

drink no more than two standard 

drinks on any day and aim for at 

least two alcohol free days each 

week. A standard drink provides 

10 g of alcohol (the amount in 

100 mL wine or 285 mL full 

strength beer). Some patients 

may choose wine spritzers (wine 

diluted with plain mineral water) 

or light beers. 

8. Suggest a low glycaemic index 

(GI) diet, rich in whole grains 

and fibre. Examples of low GI 

foods include wholegrain bread, 

pasta, oats, legumes, some fruit 

(such as apples, oranges and 

pears) and dairy foods (such as 

milk and yoghurt). Carbohydrate 

foods with a low glycaemic index 

release glucose into the 

bloodstream more gradually and 

are generally more filling, 

compared with higher GI foods. 

9. Watch ‘portion distortion’. 

Before eating or drinking, 

patients should be encouraged 

to look at the amount in front of 

them. Is it enough for one — or 

two people It’s often easy to 

indulge in big plates or bowls of 

food, but overeating can result 

in feeling sluggish and can add 

centimetres to a person’s 

waistline. 

10. Encourage patients to move 

more. They should start slowly 

and work up to being active (at a 

moderate intensity) for at least 

30 to 60 minutes each day. Some 

patients may benefit from using 

a pedometer, and should aim to 

build up to 10 000 steps a day. 

Suggest patients take the steps at 

work or walk to their local 

shops. An Accredited Exercise 

Physiologist can provide tailored 

exercise advice. 

Nutrition advice from an APD 

There are some patients who will 

require specific medical nutrition 

therapy and will benefit from a 

referral to an APD. An APD is the 

most suitably qualified health 

professional to provide tailored 

nutrition intervention and support 

in preventing and managing chronic 

diseases. Involving an APD in your 

practice can further improve the 

holistic care of patients and is a great 

selling point for your practice. 

Triggers for referring to an APD 

There are many situations indicating 

the need for a referral to an APD, 

including: 

• A new diagnosis requiring specific 

dietary modification (for example, 

diabetes, abnormal blood lipids). 

• Poor understanding of dietary 

management (for example, a 

patient who has had diabetes for 

years, but has poor blood glucose 

control). 

• Significant unintentional weight 

change (either weight loss or 

gain). 

• Any nutritional deficiencies (such 

as anaemia or iodine deficiency). 

• Changes in medication prescribed 

that may affect dietary intake. 

• Periodic review of chronic 

conditions. 

Medicare rebates for dietetics 

services 

Chronically ill people who are being 

managed by their GP under the 

Medicare Benefit Schedule (MSB) 

Chronic Disease Management items 

Carbohydrate foods 

with a low glycaemic 

index release glucose 

into the bloodstream 

more gradually and are 

generally more filling ... 

program can get rebates for allied 

health services, including APDs. 

Eligible patients are those with a 

chronic condition, defined as one 

that is likely to be present for at least 

six months and who require care 

from their GP and two other health 

professionals. This includes 

conditions such as asthma, cancer, 

cardiovascular disease and diabetes. 

Patients can access a maximum of 

five visits per calendar year. 

Medicare rebates are now also 

payable for group services provided 

by APDs for people with type 2 

diabetes, on referral from a GP. 

References 

1. Australian Institute of Health and 

Welfare. Australia’s Health 2010. 

Accessed 8 August 2010: www.aihw.gov. 

au/publications/index.cfm/title/11689 

2. Australian Bureau of Statistics. National 

Healthy Survey: Summary of Results 

2007–2008. Accessed 8 August 2010: 

www.abs.gov.au/ausstats/abs@.nsf/ 

mf/4364.0/ 

3. National Health and Medical Research 

Council. Australian guidelines to reduce 

health risks from drinking alcohol. 

Accessed 8 August 2010: www.nhmrc. 

gov.au/publications/synopses/ds10syn. 

htm 

Resources 

1. To find an APD in your local area, 

go to www.daa.asn.au and click on 

the ‘Find an APD’ tab or call the 

toll free APD hotline on 1800 812 

942 and ask for the contact details 

of APDs in your area. 

2. The ‘Smart eating for you’ section 

of the Dietitians Association of 

Australia (DAA) website (www. 

daa.asn.au) contains practical 

nutrition information for patients, 

including healthy recipes and tips, 

nutrition from A to Z, a healthy 

eating self-assessment quiz, a 

virtual supermarket tour and 

more. 

3. Australia’s Healthy Weight Week 

(AHWW) is an annual initiative of 

the DAA. Held in late January each 

year the program aims to encourage 

Australians to achieve or maintain a 

healthy weight and lifestyle. 

Visit the AHWW website at: 

www.healthyweightweek.com.au 

Claire Hewat 

CEO of the Dietitians 

Association of Australia 

26 


RESOURCES 

Asthma website improved for patients 

Asthma Foundation NSW 

provides the community with 

evidence-based, user-friendly 

information to help people better 

understand and manage their 

asthma. The Foundation offers a 

comprehensive range of free 

information services including: 

• an improved content-rich 

website: www.asthmafoundation. 

org.au; 

• a telephone support line staffed 

by health professionals with 

asthma expertise–1800 645 130; 

• asthma information packs; and 

• an onAIR bi-monthly 

e-newsletter. 

The new website was developed 

after extensive consultations with 

the community, and benchmarked 

against best practice websites, to: 

1. Make it easy for users to find the 

specific asthma information they 

are seeking. Users were 

consulted during the 

development to identify 

important topics and where they 

would expect this to be located 

on the website. 

2. Ensure all information is based 

on evidence and easy to 

understand. The website 

platform supports the processes 

needed for the development, 

review, editing and publication 

of content. 

3. Promote greater user interaction. 

Many people stated they would 

value the opportunity to share 

their asthma experiences with 

others facing the same 

challenges. 

4. Provide better functionality so 

users can book courses and 

make payments online. 

Patients are encouraged to visit the 

website to better understand and 

manage their asthma. On the 

website, patients can: 

• Join the Asthma Assist 

information service to receive a 

free Asthma Control Pack and 

the onAIR e-newsletter. 

• Register for an asthma course. 

• Send an enquiry to a health 

professional on the Asthma 

Information Line. 

• Discover what can trigger 

asthma. 

• Download the popular ‘Ten 

questions to ask your GP’. 

• Review what to do in an asthma 

emergency. 

• Download some quick tips to 

control asthma. 

• Better understand their asthma 

medication. 

• Check if they are using their 

inhaler correctly by comparing 

their technique with the online 

videos. 

Visit the Asthma Foundation 

NSW website at: 

www.asthmafoundation.org.au 

Continuing Professional Development 

now even easier! 

WHAT The College of Nursing Online Continuing 

Professional Development courses. 

WHY Because you can manage your continuing professional 

development in your time, at your pace and in your space. 

The College 

of Nursing 

CPD 

hours! 

WHEN Available now. 

WHERE They’re online! You undertake the course wherever 

you are! Go to: http://cnnectcpd.nursing.edu.au 

Courses available 

A range of online courses is available, with more on the way, including: 

• Respiratory assessment • Abdominal assessment 

• Cardiac assessment • Wound assessment 

• Neurological assessment: Using the Glasgow Coma Scale 

• Neurological assessment: Cranial nerve, motor and sensory 

Course fee: $99.00 per online course 

Contact us now for your free Continuing 

Professional Development Handbook. 

Phone: 02 9745 7500 

Email: csc@nursing.edu.au 

Web: www.nursing.edu.au 

When phoning please quote APNA1007

NEWS 

Role of codeine questioned 

The role of codeine in managing 

acute pain has been questioned in 

this month’s edition of Australian 

Prescriber. 

In the article, Dr Bridin 

Murnion, from the Drug Health 

Service at Royal Prince Alfred 

Hospital, Sydney, reviews the 

evidence around combinations of 

different painkillers in the same 

tablet (e.g. ibuprofen or 

paracetamol with codeine). She 

explains in many cases pain relief is 

not increased by using two 

different painkillers. 

Dr Murnion said: ’Codeine is 

often an ingredient in combination 

painkillers, however there is not 

much evidence for its effectiveness 

and the role of codeine in 

managing acute pain is unclear.’ 

A review of evidence by the 

National Prescribing Service (NPS) 

shows that studies in acute pain 

suggest only modest additional 

pain relief is achieved when 

codeine is added to paracetamol, 

and the risk of side effects increases 

after repeated doses. 

As an opioid, codeine can be 

addictive. When people take it in 

higher doses than recommended, 

they are also taking high doses of 

the other pain relief ingredients, 

such as paracetamol or ibuprofen. 

When misused, these ingredients 

can cause serious adverse events 

such as stomach and liver damage. 

A National Health and Medical 

Research Council review found 

insufficient evidence to 

recommend the use of 

paracetamol/codeine combinations 

in acute low back pain, acute neck 

pain, acute shoulder pain or acute 

knee pain. While there is a 

significant body of evidence 

identifying the efficacy of NSAIDs 

(e.g. ibuprofen, aspirin, diclofenac) 

in acute pain, there are limited data 

on combining them with opioids. 

These findings are in line with 

NPS reviews of evidence that show 

when treating acute pain, only 

modest additional pain relief is 

achieved when codeine is added to 

other analgesics. 

Karen Kaye, NPS acting CEO, 

said: ’As a weak opioid, codeine can 

be addictive but because it can’t be 

purchased without either 

paracetamol, aspirin or ibuprofen, 

people end up consuming more 

than they need of these products 

too. 

’Taking more than the 

recommended maximum amount 

of these products can result in 

serious side effects. Overuse or 

misuse of products containing 

aspirin or ibuprofen can result in 

gastric ulcer perforation, or in 

products containing paracetamol, 

liver toxicity or death.’ 

Dr Murnion said the recent 

rescheduling of these products is 

unlikely to impact significantly on 

people’s pain relief options but may 

reduce the harms from overuse. 

The full article can be viewed at: 

www.australianprescriber.com 

Malaria treatment now on PBS 

Patients with malaria due to 

Plasmodium falciparum can receive 

subsidised medical treatment via the 

Pharmaceutical Benefits Scheme 

(PBS). 

Riamet® (artemether 20mg with 

lumefantrine 120mg) combines two 

anti-malarials to treat acute, 

uncomplicated malaria caused by 

the parasite Plasmodium 

falciparum. In clinical studies, the 

28-day cure rate was 96 per cent 1 . 

The World Health Organization 

(WHO) has certified Australia as 

free of malaria; however, returning 

travellers and refugees from malariaendemic 

countries require 

treatment. PBS listing will allow 

those who are not ill enough to 

warrant hospitalisation, to be 

effectively managed in the 

community. 

Approximately half of the 

600–700 cases of malaria reported 

each year in Australia are due to 

Plasmodium falciparum 2 . 

Riamet® tablets are indicated for 

patients 12 years and older, weighing 

at least 35 kg 1 . The medication, 

manufactured by Novartis, is available 

at the dispensed price of $96.90 for a 

24 tablet pack. Registration and 

reimbursement of a dispersible tablet 

for infants and children has recently 

been approved and PBS listing is 

expected later this year. 

References 

1. Riamet Approved Product Information. 

2. Liu C, Begg K, Johansen C , Whelan P, 

Kurucz N, Melville L and the National 

Arbovirus and Malaria Advisory 

Committee. Communicable Diseases 

Network Australia National Arbovirus 

and Malaria Advisory Committee Annual 

Report, 2006–07. Communicable 

Diseases Intelligence. 2008; 32: 31–47. 

PBS information: Authority 

required Treatment of suspected or 

confirmed malaria due to 

Plasmodium falciparum. 

Note: Artemether with lumefantrine 

is not PBS-subsidised for 

prophylaxis of malaria. 

Minimum Product Information 

• RIAMET® 20 mg/120 mg tablets 

(artemether/lumefantrine) 

• RIAMET® 20 mg/120 mg 

dispersible tablets (artemether/ 

lumefantrine) 

See approved Product 

Information before prescribing. 

Approved Product Information 

available on request. 

Worked 

overseas 

Have you worked overseas 

as a nurse in general practice 

If so, we would like to hear 

from you. Our December 

issue of the Primary Times will 

look at practice nursing around 

the world. 

The issue will explore the 

major differences between each 

country’s use of nurses in 

general practice. 

If you would like to be part 

of this issue, please email 

some basic details of your 

experience in working overseas 

to: editor@apna.asn.au 

28 


Think all infant formulas are the same 

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If a mother decides to mix feed or move on from breast feeding, the choice of formula matters. 

Only Karicare Immunocare ® nutritionally supports the infant’s developing immune system through a patented blend of 

prebiotic oligosaccharides inspired by breast milk, helping to provide long-term protection against allergy and infection. 

Compared to a standard formula, this provides: 

• 51% less incidence of atopic dermatitis (p

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September - APNA

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