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Community Affairs References Committee
Palliative care in Australia

BRYCE, Ms Julianne, Senior Federal Professional Officer, Australian Nursing Federation

COULTHARD, Ms Robyn, Member, Australian Nursing Federation

FOLEY, Ms Elizabeth, Federal Professional Officer, Australian Nursing Federation

MALONE, Ms Geri Malone, National Professional Officer, CRANAplus

PIGOTT, Ms Catherine, Member, Australian Nursing Federation


CHAIR: Welcome. I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. Do you have any comments to make on the capacity in which you appear?

Ms Pigott : I also have a palliative care and nursing education background.

Ms Malone : I am here at the invitation of the ANF. I work for CRANAplus, which is the organisation for remote health. I am based here in Canberra.

Ms Coulthard : I also work as the Policy Officer for the Congress of Aboriginal and Torres Strait Islander Nurses.

CHAIR: Thank you. We have your submission. It is No. 85. I invite anyone to make an opening statement. I realise you have a range of expertise at the table in front of us. We will then ask you some questions.

Ms Bryce : I will make the opening statement. With the nursing and midwifery professions constituting over 50 per cent of the healthcare and aged-care workforce, they are delivering the greater proportion of palliative care in this country. As the union representing the professional industrial interests of nurses, midwives and assistants in nursing, the ANF has a very real concern with palliative care policies, service delivery models, access and equity issues, research, innovation, education, continuing professional development, and outcomes of models of care for recipients of palliation.

We welcome the opportunity to appear before this committee in its inquiry into palliative care in Australia to clarify any issues raised in our written submission and expand on issues raised. In order to provide you with the information we believe you need, our team consists of registered nurses with expertise in palliative care, aged care, Indigenous Australian Aboriginal and Torres Strait Islander issues, rural and remote settings of care, and policy. Palliative care models and services have improved in quality and have increased in number over the past years, and we know that palliative care specialist nurses have been at the forefront of these advances. As there is still much work to be done, we are requesting that the committee take heed of advice received through witnesses to make recommendations for funding investment which can enable further enhancements to care delivery, health profession education and research endeavours to achieve better outcomes in palliative care for our community.

Senator MOORE: Thank you for your submission. The role of nursing in the whole area of palliative care has been raised in a number of submissions. One of the things that has come out is the need for specialised training. In most areas where people seek medical support, it is often the nurse who is the person there for them, just by the nature of what happens in local communities. In terms of the access, availability and cost of specialised training in palliative care at the moment for people in your profession, can you give us some ideas about what is available, the cost and the availability of women and men in the profession to attend?

Ms Pigott : For undergraduate nursing courses it is a very full curriculum. It is hard to get a place for palliative care within that curriculum. But there is a PCC4U program for an option for palliative care. It is a Palliative Care Curriculum for Undergraduates—that is PCC4U. That has been a program that has run quite successfully for a while. Then postgraduate, so for the specialist palliative care nurse, there are a number of graduate certificates, graduate diplomas and masters degrees in palliative care nursing that can be accessed through a number of different universities, such as the Australian Catholic University, Edith Cowan and La Trobe and University of Melbourne as well. Some of these are on distance, some of these are face to face. Some of these involve clinical assessment and assessment to assess changes in clinical practice. Some of these are more online and call for assessment of clinical practice in their own area. The cost of them ranges. For a graduate certificate you are talking between $5,000 and $10,000. Around $6,000 and $7,000 is the average mark for a graduate certificate in university. For a graduate diploma it would be double that. For masters it is variable depending on whether it is masters by research or masters by coursework.

CHAIR: It is expensive, in other words.

Ms Pigott : For nurses, yes.

Senator MOORE: And time consuming.

Ms Pigott : Time consuming, yes.

Senator MOORE: Scholarship options?

Ms Pigott : There are a number of scholarship options available. Some are through the state that people can apply for. But, again, it is trying to get the people to then have backfill so that they can actually have the time to study.

Senator MOORE: You raised that a number of times in your submission that, if you are working, the availability of attending and getting relief is very low, particularly as you get into regional areas.

Ms Pigott : Absolutely, and difficult because it can be quite intense study to become a specialist palliative care nurse.

Ms Foley : The Australian government does fund postgraduate scholarships for people to undertake postgraduate studies but the numbers are fairly limited. We have recently made representation to the Department of Health and Ageing to have the funding increased. We do not have much hope that that will happen, but we have made representation that there is a very great need for additional funding for nurses undertaking postgraduate programs. The scholarships are a contribution to the cost that Cathy has been talking about. It does not fund the whole program.

Senator MOORE: What does it fund?

Ms Foley : For example, with a $6,000 course they might get about $3,000 towards it.

Senator MOORE: So it is a contribution. Is that similar to all scholarships or is it particularly in this one?

Ms Foley : That is for all of the postgraduate and continuing professional scholarships.

Senator MOORE: So any other specialist scholarship programs are the same so it is not particular to this one.

Ms Foley : Yes.

CHAIR: Ms Malone wanted to make a comment.

Ms Malone : I just wanted to add to that. A lot of the education for nurses, particularly in rural and remote, is not so much postgraduate for qualifications but continuous professional development, which are short courses but we know they are accessed more the further away you are. Whilst there has been some great advances in online education, it is still a challenge for that generalist nursing workforce—which a lot are in rural and remote—to factor that in. Again, opportunities, certainly face to face education are very limited the further out from metropolitan areas you go.

Senator MOORE: Do you have any idea what the numbers are for people with qualification in the Australia workforce at the moment?

Ms Bryce : In palliative care?

Senator MOORE: In palliative care.

Ms Pigott : It is a very difficult thing to estimate because, as there are different nurses involved in palliative care from generalist nurses to specialist nurses, it is a really a difficult thing to estimate. It is a similar thing to cancer nursing in that people can say that they are a specialist palliative care nurse, but that does not necessarily mean they have the education completed. I know you are getting representatives from the Palliative Care Nurses Australia later. With the people who are members of that—of which I am one—you would expect they are specialist palliative care nurses and would have some education. In trying to get numbers it is difficult for the general nursing health workforce.

Ms Bryce : Some obviously have experience from having done further education in continuing professional development. Others have a formal postgraduate qualification up to master's level. So there is quite a variance in the preparation for working in the area of palliative care. There is no regulatory requirement to have a palliative care qualification in order to be able to work in palliative care, because there is such a range of care that is provided.

Ms Coulthard : Good basic general nursing care is palliative care, so the specialist add-on of knowledge of medications and knowledge of specific clinical care for palliative care does not deny that most nurses are already able to provide good palliative care. There is also a range of nurses who have developed good clinical skills through clinical work and who have had very little extra training or education.

Senator MOORE: But there is no regulation.

Ms Coulthard : No.

Senator MOORE: Your submission says that you think there needs to be a change to allow a more formal statement about nurses' ability to do work in this area, particularly around medication. That is an area where this committee has had recommendations over a number of years about widening the basis of the professional accreditation of different people working within the health space. Specifically, when working in a palliative care environment now, what can an experienced nurse do and not do for their patient? I am particularly interested in the issue of medication, because we know that pain control is a core aspect for people who are working through this stage. So, in terms of what you are able to do without supervision and what you have to have supervision to do, what is the current situation and what would you like it to be?

Ms Bryce : Registered nurses, within their scope of practice, can provide palliative care and are able to provide medicines as they are prescribed; they can administer medicines. Where specialist palliative care nurses come into their area of expertise is around some of the palliative requirements that people have as they are progressing through their illness. So they are involved in medication administration and understanding of specific medicines that may be able to assist in the care of someone, particularly towards the end of their life. That is where their specialty expertise comes into play. Nurse practitioners obviously are able to prescribe, and they not only prescribe for medicines administration but can administer the medicines. So, as far as scope of practice goes, all nurses can provide palliative care and they determine their own scope of practice. They are responsible and accountable for the care that they provide, and they would only provide care to their level of competence. So they look for support and expertise from other health practitioners where they determine that that is not their scope of practice any further. Where we have nurses who have qualifications in palliative care, they are providing a greater level of care according to their competence, right up to the point where they are a nurse practitioner. I will hand to Cathy.

Ms Pigott : Some of the things that we would be doing around medication in particular would be providing information to the patient and the family about why that medication has been started—particularly around morphine; people have a number of different myths about morphine, so it gives them information about why they might be on morphine—what we are doing, why we have changed it from perhaps oral medication to syringe driver medication, what is happening with the person, why things might be changing and why we might be having a different type of medication or perhaps no medication. We would add an adjuvant medication if they have a different type of pain. That is what the nurse's role is: to talk to the patient, and particularly the family, about what is happening with the person, why things are changing, where we are going, what to expect and what sort of side effects to look for when we administer the medication—because people might be a little bit nervous if we give them some morphine, but in fact what is happening, of course, is that their body is deteriorating and that is what they are dying from, not from an overdose of morphine. So it takes a lot of education, a lot of information provision and a lot of family support for us to be able to do that, and that is where your specialty nurse knowledge comes in particularly.

Ms Bryce : So the issue is symptom management, really. It is the expertise that the nurse brings, and they bring that to varying levels depending on their qualification and their scope of practice.

Senator MOORE: And the availability under the Medicare system is linked to their nurse practitioner status as opposed to their palliative care training.

Ms Bryce : Correct. Access to the PBS—

Senator MOORE: Yes. Widening the availability of people to work with medication is under nurse practitioner status. The qualification in palliative care is not to do with that; it is to do with the skills in working with patient and family.

Ms Bryce : That is correct. That is the general qualification in palliative care. Where nurses have gone on to become endorsed as nurse practitioners is where they are able to prescribe and have an even greater understanding of medicines as they are administered in relation to palliative care. They are a specialist palliative care nurse/practitioner.

Senator MOORE: I have one more question in relation to your submission and the two people who are here today who are from an Aboriginal-Islander background. Is there a particular issue with Aboriginal-Islander nursing that you would like to have on the record?

CHAIR: Who will go first?

Ms Coulthard : I will not talk about remote areas; I will leave that for Geri. We have said in our submission that there is a common myth, a widely held belief, that Aboriginal and Torres Strait Islander people only live in remote areas. That is a myth. Certainly a large proportion of very remote populations are Aboriginal people but that does not mean that they all live there. A lot of Aboriginal and Torres Strait Islander people who live in rural, inner rural, urban and metropolitan places do not have their health care needs particularly well looked after because mainstream health services tend to have this view that only rural and remote practitioners need to learn about Aboriginal and Torres Strait Islander health. So our submission states the obvious, which is to ask the community to become involved and to be respectful of each community's culture and spiritual beliefs and processes during the palliative care process.

Senator MOORE: What evidence do you have that they are not? That is the kind of statement we all support but the fact that you have made that statement indicates that you think that they do not. What has led you to make that statement?

Ms Coulthard : We do not have a lot of evidence, save that not many Aboriginal and Torres Strait Islander people who access palliative care services.

Senator MOORE: So they do not use the services.

Ms Coulthard : They do not use them—we can assume—possibly because they do not cater for people's needs. We also know that there are some cancer specific hospitals dotted about the country and that they are not heavily used by Aboriginal people. Empirically, we find out that people do not use services. So where are they?

Senator MOORE: Yet we know that Aboriginal and islander people have got cancer—

Ms Coulthard : Yes. And we know that they live in urban centres.

CHAIR: They have particular forms of cancer and high rates of cancer.

Ms Coulthard : Yes. And we know that they die a lot younger. We know all of those things, but we do not know where they are.

Ms Malone : Can I make a comment from the remote perspective.

Senator FIERRAVANTI-WELLS: Before you comment, Ms Malone, can I just follow on with Ms Coulthard. Do I read into your comment that it is general health services? We happen to be talking about palliative care today but I read into your comment and what you have said in your submission that it is general health services and the misconception is that it is basically Aboriginal and Torres Strait Islanders who only go to those services, whereas you are actually saying the complete opposite of that. The fact is that they—

Ms Coulthard : I am saying that they have the right to choose—

Senator FIERRAVANTI-WELLS: In practice, what is actually happening is that in metropolitan areas there are mainstream health services that they are not accessing, which they would otherwise or should otherwise access, and you are saying that what is precluding them or perhaps what is one of the impediments is the lack of proper sensitivity and those sorts of issues. I just wanted to make sure that I understood what you were saying.

Ms Coulthard : And be welcome.

Senator FIERRAVANTI-WELLS: And welcome, yes. Sorry, Ms Malone, I just wanted to clarify that.

Ms Malone : I just wanted to make the comment that when it comes to the Aboriginal and Torres Strait Islander population in the remote and very remote areas it is just reflective of the lack of service generally; therefore, they do not get access to services that we take for granted because they live in those areas.

CHAIR: I notice in your submission you made the point that that was a glaring omission in the terms of reference. Given that it has been raised and we have paid a lot of attention to it, it will be addressed in our report.

Ms Bryce : There might be an opportunity to talk about examples that we have.

Ms Malone : Yes, if you have a couple of case studies. We canvassed a couple of our members and from the perspective of a very remote Aboriginal community in the corner country in the Northern Territory and South Australia the feedback I have from the staff out there—and they gave me a couple of examples of women in their community in end-of-life care—reflected that people want to stay in their community to die. There are a lot of complexities around that. It is not just around the health services available. Like anywhere, it is about family supporting that decision. All the care is coordinated from Alice Springs, which is 700 kilometres away by road—and not very good roads—or a two-hour flight if you can get one.

One example was that they have come to an arrangement for one of these women that she goes to Alice Springs for three weeks and comes back out to the community for one week. That is the cycle. That involves a road trip every time she does that. That seems in some ways to be working, but in terms of being able to do that better in the community they just do not have the resources to support them in their homes. It comes back on the remote area staff, who are remote area nurses and Aboriginal health workers. Whilst they might say it is certainly within their remit to provide all sorts of care for people, they are not resourced well enough, as you would know, to provide that for someone in their home. End-of-life care requires a lot of resources, time and commitment. That was just an example of how when people have to go and access things there is a distance factor. Things like HACC services and those other things that have been talked about are just not available in those communities and it comes down to a very small amount of health resources to provide that additional care. It just seems that people are then disadvantaged because they cannot die in their own home as they would choose to.

Senator FIERRAVANTI-WELLS: I will just take the opportunity to ask about the diversity in your profession. I know this is a more general question, but have you got some statistics in relation to particularly cultural diversity amongst the profession? Obviously when you are dealing with palliative care there are those sensitivities. We have heard about the Aboriginal and Torres Strait Islander community and the broader community and the larger, culturally diverse community. Can you just expand on that a little bit for me.

Ms Bryce : We have slightly in excess of 330,000 nurses and midwives in this country. Like you said, they come from a wide range of culturally diverse backgrounds. We have been doing a considerable amount of work with Health Workforce Australia around some of the data that we have on that workforce. It is not great. We know that. We are working to improve that data collection. In the undergraduate program there is considerable content that deals with transcultural issues. Now we have a requirement for a discrete core unit on Aboriginal and Torres Strait Islander health, history and culture as part of the undergraduate nursing curriculum.

Certainly cultural issues come to the fore when you are dealing with palliative care. We do have quite a broad workforce that we bring to the table in relation to providing that care. As far as that goes, it is not necessarily a matching process between people's cultural understandings of a particular culture in the care they are providing, but we are working quite hard in palliative care to provide resources for culturally and linguistically diverse communities. But there is not enough of those resources. It is quite an intensive process to provide all the support across the spectrum not just from qualified nursing staff but from carers and volunteers and support for family members.

Senator FIERRAVANTI-WELLS: Ms Bryce, how do you deal with many of the language barriers that you must on a daily basis face? That was a smile, so I think she means that it is a very difficult one.

Ms Bryce : It is a very difficult one. Certainly, when people are unwell, one of the first things that goes is their second, third, fourth, fifth language. They will go back to their first language and then, if they are very unwell, not even that. It is a constant challenge from a nursing perspective to provide care to people where there are communication issues. It is very much part and parcel of the role and very important in palliative care and end-of-life care. Did you want to talk to that?

Ms Pigott : The other part of it is that every family, every patient brings their own culture. Certainly part of the role of the nurse is to talk to the family and develop a relationship with that family and understand the culture of that particular family, understand who is the decision maker, who would help support that person in their dying phase. Certainly it is part of the nursing role, a nursing specialty. As part of palliative care we do have cultural units to try and help support nurses in that area. But, definitely you need to also consider each individual family and patient's culture as well.

Senator FIERRAVANTI-WELLS: They must, obviously, from a language perspective assist as well. I do not know if you heard my example earlier. I was in Western Australia and there was a gentleman from a Chinese background in the aged-care facility that I visited. It had taken them a month to find somebody who spoke his dialect because, of course, the issue of reversion, not just to the native language, but often to a remote dialect that compounds the problem even more so.

Ms Bryce : It is obviously a daily challenge from a nursing perspective to deal with those issues and is extremely time consuming, resource intensive and incredibly important to the care that you are providing. Working sensitively with family around and how you go about that is part and parcel of the nursing role, not just in palliative care, but in the everyday care that we are providing.

Ms Coulthard : In aged care I have a fairly long history in residential aged care. An aged-care facility is a small community, or a large family or a big household. What tends to happen is that there is usually somebody there who is a nurse or an enrolled nurse or a care worker, sometimes other types of workers, who can help and assist with language. Nurses, generally, are a cross-section of the community. There are many nurses and they come from all parts of the community.

Senator FIERRAVANTI-WELLS: I have met some nurses who as I have travelled around who often have three or four languages. That goes without saying, Ms Coulthard.

Ms Coulthard : I think that the humanity of nurses and the humanity of people who work in health often overtakes the formalised role. In aged care there is certainly a propensity for that household to stick together. When the chips are down people will work together. The shame of that is that to formalise that knowledge is very difficult because nurses in aged care cannot leave their post either for very long to go off to study because there is a shortage of RNs in aged care.

CHAIR: Can I just pick up on that point because it was one of the issues in your submission. Obviously with the announcement on Friday, which dates some of the submissions already, I would not mind giving you a question on notice, if that is okay, for you to look at what you think of the announcements that were made on Friday and how they meet some of your concerns and also subsequent to that what else needs to be addressed.

Ms Bryce : We will take that one on notice because we are still working on that.

CHAIR: Join the club. That is why I am asking you to take it on notice.

Senator FIERRAVANTI-WELLS: I think we all spent the weekend sitting there with this mountain of paper.

Senator MOORE: I have to admit I did not.

Ms Bryce : We are certainly working with the government around the compact and, in particular, the workforce aspect of that announcement, and we can get back to you in relation to those questions.

CHAIR: That would be really appreciated. You did make some important points in your submission. Thank you. Sorry, Senator Fierravanti-Wells, I wanted to get that in.

Senator FIERRAVANTI-WELLS: I think it was Senator Moore who we originally interrupted.

Senator MOORE: On the topic of the advanced care directive you made a couple of comments in your submission about the need for consistency. I am interested in your perspective about the training that is given to members in their workplaces about this. I would have thought it was training that was on the job for people working particularly in aged care or in palliative care. Is there an understanding that there is training about the role of an advanced care directive and is it something that is raised with you as a concern by members?

Ms Bryce : There is quite a variance in what is available and it varies considerably from state to state. There are some programs that are quite well understood and taken up in certain states—Respecting Patients Choices obviously has quite a large profile nationally but particularly in Victoria. There are a range of advanced care directives. It is not a nationally coordinated process. It is a really important conversation that needs to happen. What we are emphasising in our submission is the importance of the coordination of that with the legal issues around guardianship and power of attorney so that you have a really good understanding of what that person would actually like to happen in their care. It is important to have that conversation as early as possible so that you know what is going to happen into the future and can deal with things before you get to that stage where it is incredibly difficult to make those kinds of decisions on someone else's behalf even where they are able to contribute to that discussion. It is quite varied and it is important to have national consistency and a better understanding. More and more we are seeing it incorporated into undergraduate curricula. It is part and parcel of postgraduate curricula. Cathy can talk more about that but it is a varied model across the states and territories. It is not well coordinated nationally.

Senator FIERRAVANTI-WELLS: My question is about the frequency of where you have a person in a palliative care setting and you have discord in relation to these very issues because they have not been resolved beforehand. Is that frequent, infrequent, relatively common—just anecdotally, I know there are no stats on this, but you understand the gist of my question.

Ms Bryce : It would depend on your area of practice. A lot of people think about palliation as cancer services. In actual fact, palliative care is much broader than that as you well know. It would depend on the area of practice that you were working in as to what the demand would be. I can speak from a Victorian perspective to say that a number of units have started to work more proactively around advanced care directives, for example, renal units where they know that when people become a renal patient they are immediately to some extent on a palliative journey. They are working with particular members of staff so that they were prepared to be able to have those discussions with patients.

What is really important about advanced care directives is that the person makes the decision about who they want to talk to. To some extent we need to have a workforce that is prepared to have that conversation so to be able to direct people where it is not the scope of practice or to be competent in that area of practice. It is a broad education that we all need to have around being able to work with people to set up an advanced care directive and then to build on that with some specialist expertise for people who are quite wholly and solely devoted to that role in helping people to have those difficult conversations.

Ms Coulthard : The setting in which nurses work makes a huge difference to the way that they manage advanced care directives. In aged care there has been a lot of training for nursing and care staff at all levels about advanced care directives. The problem is that advanced care directives have no legal standing in many states and are often contrary to the wishes of the enduring guardian or the enduring power of attorney for medical treatment, so issues erupt daily, not every day, but they are common.

Senator FIERRAVANTI-WELLS: It is quite common, yes.

Ms Coulthard : They commonly erupt and there are issues then culturally and I do not mean in Aboriginal culture I mean in other cultures with head of family and who makes the decisions.

Senator FIERRAVANTI-WELLS: Well, this is the point where I picked up.

Ms Coulthard : It can be in aged care it can be quite a treacherous path for the staff and for the nurse. In the end it is often managed by negotiation and mediation rather than a legal document. The biggest issue in residential aged care is the advanced nature of dementia. People are often not able to say what they want themselves.

CHAIR: Part of that then goes back to that we have been talking about staff training. We also need to be talking about that conversation that families need to have and increased awareness and education around aged-care directives—

Ms Coulthard : That is not about—

CHAIR: power of attorney and all of that. Sorry?

Ms Coulthard : That is not about educating nurses or health workers; that is about educating the community.

CHAIR: That is what I mean. There are two separate things that we are talking about. We are talking about a completely separate set of focus of resources. A community discussion, education and staffing across the board is separate to that.

Ms Malone : As Robyn said, it depends entirely on the setting where nurses work. Perhaps some of those who are in aged care in specific units might be a little bit more prepared for it, but it has been my experience in a generalist sense that it might well come up anywhere and not just nurses but health staff generally are not well prepared for it. So, yes, it is certainly about the community but it is where people go when they want advice about these things, particularly in the smaller communities. As we know, the health service staff are called upon for advice on a whole lot of things. So I would agree that it is across-the-board. But certainly in some areas, probably outside of aged care and palliative care, generally their workforce is very badly prepared for this.

Ms Pigott : It is often the transition from an acute or chronic disease such as cancer or kidney disease to then saying that the aim of the treatment now is palliative care. It is that transition period that is difficult for people to talk about, and that is often when the advanced care directives might hopefully be discussed. It is those permissions and it is the need for a multidisciplinary approach: to having that discussion about what the goals of care are now, what we are expecting to do with the treatment and what the patient actually expects to have as the result of the treatment. Are they expecting to be healed or are they expecting that there will be no further cure offered? There are certainly a lot of palliative care treatments offered that would keep them comfortable and they would understand that. It is that transition period that is difficult for advanced care directives.

Senator MOORE: I would like to follow up on something on education. Ms Pigott, you talked about the access to specialised palliative care options in the undergraduate course. Were they options that people could choose amongst other options, or were they set programs within some schools?

Ms Pigott : Within some schools it is set, but in other schools it is an option that they do palliative care.

Senator MOORE: Is there a list of those anywhere that say where they are offered and where they are not? Of the large number of schools of nursing across the country at the moment, we do have evidence somewhere about the few medical schools that offer palliative care, and it is quite low. In the government submission they actually said which ones were offering it in medical schools. There was not anything about the nursing schools. If we could find out where they were, it would give us some indication of just how widely spread the training is. Also really important is the information you have about where the postgraduate availability is. We have done work with aged care and there is a similar issue with aged care and also with attracting nurse trainees, students, to see this as a very valuable place to practise. I have a horror story about one nursing school I went to, which I know well. I was there while the head of nursing was actually putting on her academic hat because some young students had determined that their placement in aged care was not a real nursing placement and they did not think that was an appropriate placement. With her full academic rigour she was making it clear to them about their inaccurate assessment, but it shows what the students thought. I would be interested to see whether that was something that they thought about palliative care as well.

Ms Bryce : Certainly we have the Australian Nursing and Midwifery Accreditation Council being responsible for the national accreditation standards for courses leading to registration as a nurse and within those national standards there are core curricula articulated. So it is across the lifespan and the core curricula deal with a lot of the national health priority areas like aged care, mental health and Aboriginal and Torres Strait Islander health. It is a quite lengthy list. We can provide you with that information. As far as specific palliative care units within a curriculum, as Cathy said before it is a very full curriculum that they have and it is about drawing out the theory that they have undertaken while they are on clinical practice and are putting that into practice. I think the example that you have given is a good example of where nurses in the workplace and clinical supervisors—nurses who are undertaking the role of clinical supervisors—have a really important role in helping students to understand how the theory that they have learnt and the clinical skills that they have can be applied in practice settings and how that is appropriate to the care that they are providing. As far as palliative care is concerned and determining which undergraduate courses offer a palliative care unit, as either core or elective, you could certainly have a discussion with the Council of Deans of Nursing and Midwifery.

Senator MOORE: We are happy to do that. It is just that you mentioned in your evidence the number that did. I am very interested to see how many do offer it as a stand-alone component in their training, but we can get onto that. There must be a central spot to talk with them.

Ms Pigott : Another issue, as Julianne was just saying, is that palliative care can be part of, as you say, a focus of a clinical practice and so it is difficult to say that it is a stand-alone unit. The palliative care for undergraduates project is a particular example of that where the idea of the use of that palliative care program is that lecturers use part of that and they will use that as a case study and then they can incorporate palliative care in sections of their teaching. So some of it might not be a discrete palliative care unit but it might be incorporated into the whole of the curriculum as they go along.

Senator MOORE: It gives us a start to see how many people actually itemise it amongst the other clearly important areas of practice, so how many schools actually have it clearly up there that this is a discipline for a trained professional.

Ms Foley : We can give you the contact for the council.

Senator MOORE: That would be great, Ms Foley, and then we could follow it up. It is about this whole question: where does the issue of palliative care fit in our priorities of health care? That is what we are struggling with. I have got one more quick question and you can take this on notice. We have been talking a lot about the case manager role. With previous witnesses we have talked about that and Senator Fierravanti-Wells has been following it up. With any individual, particularly someone who is staying at home and working through the care process, having a case manager to whom they can turn and who can give them help about the range of help they require would be a good idea. Who would do that job and where would they fit? Without pre-empting your response, it seems to me that trained nurses would be one area where that could fit. So it is just to get some thoughts from you about this whole concept of a case manager that would work with someone and their family—because it is about working with the whole family group. I will leave that with you and if you would care to give us any information back that would be great. We are working through this, because that does not exist now. If you are lucky enough to have a GP who is working with you, that is one thing but it is not part of the structure.

Ms Bryce : To a large extent it is part and parcel of the nurse's role. That is what we have been doing for a very long time, to pull all of the resources together and to be the go-to person in relation to the care that is provided. Obviously, where we have a nurse practitioner working in that area then they can be a really important person as far as case management goes. But they are also providing a level of expertise to assist other nurses to be in that case management role and providing the resources for them. There are a range of ways that they can be doing that. Certainly, using telehealth facilities to assist with that process, whether it is the nurse who is the case coordinator or nurse practitioner who is case-coordinating or assisting those case coordinators, and then using those resources that we already have that are rolled out from the government in a way that can provide mentorship and support, as well as direct patient clinical care.

Ms Coulthard : The only thing I would add to that is that it seems, after a long time in practice, that nurses are the one group of people who do understand what all of the other health practitioners do and who know where they are, how to get hold of them and when to get hold of them. That seems to be unique to nursing—that we have a much better understanding of all of the other clinicians' roles in relation to our own and separately.

Ms Malone : I would state that it is absolutely imperative, particularly when there is distance involved, that there is someone who can really pull that together. I am sure you have heard lots of times about the different agencies involved and what a nightmare it is. Often, again, it is about who is in the community. I know that in some instances it might be the allied health person. It is about who has a good, permanent—and I underline the word 'permanent'—relationship with the individual in the community. We go on about fly-in fly-out, but that is another issue.

Senator MOORE: Yes, increasingly an issue.

CHAIR: If you want to build on those comments, that would be really great, in particular the community care—how you coordinate the community care. We had a really good example from Ms Jackman this morning about how a case management situation would have greatly helped her when she was caring for her husband in the home. We have given you quite a bit of homework. I want to add a little bit more. When you are responding on the residential care or the new aged-care package, could you also touch on ACFI—about needing to adjust ACFI.

Ms Bryce : According to the union model?

CHAIR: Yes, looking at that in light of the aged-care reforms that were announced on Friday. That would be appreciated. Thank you for your time. It is really, really valuable to us when we get people who work at the coalface, so to speak, presenting evidence to us. It is really valuable for case studies. Thank you very much. Your efforts are much appreciated. We will suspend now for lunch.

Proceedings suspended from 12 : 32 to 13 : 25