IN NEW ZEALAND Journal of Professional Nursing
INSIDE THIS ISSUE... Phase II cardiac rehabilitation in rural Northland Inpatient hypoglycaemia: A study of nursing management Primary healthcare NZ nurses’ experiences of advance directives: Understanding their potential role
Volume 29. No. 2
JULY 2013
Praxis: “The action and reflection of people upon their world in order to transform it.” (FREIRE, 1972)
E D IT O RIAL BO ARD EDITOR-IN-CHIEF: Denise Wilson RN, PhD, FCNA (NZ) Norma Chick Willem Fourie Thomas Harding Dean Whitehead Stephen Neville Michelle Honey Jean Gilmour
RN, RN, RN, RN, RN, RN, RN,
RM, PhD PhD, FCNA PhD PhD, FCNA PhD, FCNA PhD, FCNA PhD
(NZ) (NZ) (NZ) (NZ)
COVER: Crimson was deliberately chosen by the Editorial Group as the colour for this journal as it represents, for us, imagination, intuition, potentiality, struggle and transformation. KORU: Designed for this journal by artist, Sam Rolleston: The central Koru indicates growth, activity and action. The mirrored lateral Koru branches indicate reflection. Transformation is shown by the change of the initial plain Koru design to a more elaborate one.
PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org ISSN 0112-7438 HANNAH & YOUNG PRINTERS
CO NTE NTS EDITORIAL .......................................................................................................................................... 2
ARTICLES: Phase II cardiac rehabilitation in rural Northland Catherine Beasley, sz Robyn Dixon ..................................................................................................... 4 @
Inpatient hypoglycaemia: A study of nursing management Adrienne Coats, Dianne Marshall .............................................................................................. 15 Primary healthcare NZ nurses’ experiences of advance directives: Understanding their potential role Raewyn Davidson, Elisabeth Bannister, Kay de Vries ................................................................. 26 NOTES FOR CONTRIBUTORS............................................................................................................. 34
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand EDITORIAL With awareness comes choice: Only part of the picture
Open for Better Care (http://www.open.hqsc.govt.ns/) creates a compelling case for using knowledge transfer to actively reduce patient harm. The requirement for evidence based nursing management of patient care and
With awareness comes choice – is this really as easy
scholarly practice is clearly articulated in Domain Two
as it sounds? A key assumption in the often heard
of the Nursing Council’s competencies (Nursing Council
exhortation to publish nursing research is that practice
of New Zealand, 2007). This level of practice is evident
can be developed by the transfer of new knowledge into
in the articles presented in this issue of Nursing Praxis.
evidence based health care. I would argue that the vision of even high quality information seamlessly flowing into
In preparing for this editorial and having been
clinical practice is naive. Knowledge transfer is seldom
asked to write about knowledge transfer I have
a one way process of passive diffusion.
discovered that the concept has many synonyms in the literature which can be confusing (e.g. knowledge
Exploring the concept of knowledge transference
translation or knowledge utilisation). There is often a
also requires an appreciation of what counts as valid
conceptualisation of a hierarchical and linear process
knowledge or evidence and why. Knowledge transfer in
flowing from researcher to practitioner in the literature.
my view therefore requires the application of scholarly nursing. Scholarly nursing builds on Ernest Boyer’s
Knowledge translation is most commonly used in
notion of scholarship and requires appreciation of a
reference to the Canadian Institutes of Health Research
broader construct of knowledge for practice which
(CIHR) definition of a dynamic and iterative process that
incorporates experiential and ethical knowing with
includes the synthesis, dissemination, and exchange
the rigour of an intellectual base and commitment to
along with the ethically-sound application of knowledge
a service base (Riley, Beal, Levi, & McCausland, 2002).
with the aim of improving health outcomes through
Putting this another way, scholarly nursing practice
more effective health services (Canadian Institutes of
requires nurses to exercise rigour when considering
Health Research, 2012). Knowledge translation often
the epistemological assumptions of knowledge
results in the development of tools for application such
development and transfer from a variety of standpoints
as clinical guidelines or care pathways. Knowledge
(practice experience, ethics, intellect and service
utilisation on the other hand can be seen as picking
commitment) before practice development occurs.
up from where translation leaves off. Work in this area includes consideration of the various stakeholders
The imperative for nursing scholarship in the context
in both practice and policy decision making and the
of knowledge transfer is obvious when we consider the
process of diffusion of technology and innovations in
Canadian Institutes of Health Research (2012) assertions
health service organisations (Estabrooks et al., 2008).
that around 30% of patients do not get access to proven effective treatments, 25% get care that is not needed
Knowledge transfer definitions are congruent with these
or is potentially harmful and 75% of patients do not get
concepts but with the valuable addition, in my view,
the information they need for decision making. In New
of a broader non-linear process involving researchers,
Zealand, the recently launched patient safety campaign
educators, clinicians and policy makers right from the
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Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand
agenda setting and idea generation stage through to
In my own work promoting web-based resources to
the implementation of initiatives. From this perspective
provide access to knowledge relevant to scholarly
nurses in all areas of practice have responsibility for
nursing practice, I make the assumption that whilst
generating questions as well as implementing proven
awareness does not guarantee choice, ignorance
solutions. The Canadian Nursing Health Services
certainly limits it. I believe that we owe it to the
Research Unit (NHSRU) (2004) website has a useful
population that we serve to mindfully keep ourselves
definition of knowledge transfer that captures this
as current as possible so as to provide accessible
intent well.
information for others to have a sound awareness of the choices they can make in their own health care.
In summary, knowledge transfer does not occur by passive diffusion but rather a complex dynamic process that can be cyclic or multidimensional. The complexity
Dr Kathryn Holloway, PhD, RN, FCNA(NZ) Dean, Faculty of Health, Whitireia. N.Z.
of the clinical practice environment requires that a comprehensive organising framework is utilised. This requires more than just a practitioner’s ability to critically appraise evidence and make rational decisions. Effective
References
knowledge transfer depends on the achievement and sustainability of significant and planned change involving individuals, teams, and organisations.
Canadian Institutes of Health Research. (2012). Knowledge translation & commercialisation. Retrieved from http:// www.cihr-irsc.gc.ca/
There are a number of models developed to support
Canadian Nursing Health Services Research Unit. (2004). Knowledge transfer. Retrieved from http://nhsru.com/ knowledge-transfer
effective knowledge transfer in the literature, however no single framework provides all the answers. What is clear is the nurse needs to consider multiple facets such as the appraisal of the knowledge for transfer in terms of its worth and fit, the specific context of practice as well as multiple strategies to support implementation. The Promoting Action on Research Implementation in Health Services (PARIHS) framework developed by Rycroft-Malone and colleagues is an often referenced example of scholarly practice. The PARIHS framework focuses on implementing research for evidence-based practice, attending to the characteristics of the elements of evidence (including research, clinical experience, and patient experience), context (covering culture,
Estabrooks, C., Derksen, L., Winther, C., Lavis, J., Scott, S., Wallin, L., & Profetto-McGrath, J. (2008). The intellectual structure and substance of the knowledge utilisation field: A longitudinal author co-citation analysis, 1945 to 2004. Implementation Science, 3(1), 49. doi:10.1186/1748-5908-3-49 Nursing Council of New Zealand. (2007). Competencies for the registered nurse scope of practice. Wellington: Author Retrieved from www.nursingcouncil.org.nz. Riley, J. M., Beal, J., Levi, P., & McCausland, M. P. (2002). Revisioning nursing scholarship. Journal of Nursing Scholarship, 34(4), 383-389. doi:10.1111/j.15475069.2002.00383.x Stetler, C., Damschroder, L., Helfrich, C., & Hagedorn, H. (2011). A guide for applying a revised version of the PARIHS framework for implementation. Implementation Science, 6(1), 99. doi:10.1186/1748-5908-6-99
leadership, and evaluation) and facilitation (clarifying purpose, role, and skills/attributes) and has a recently developed supporting guide for practitioners (Stetler, Damschroder, Helfrich, & Hagedorn, 2011).
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand PHASE II CARDIAC REHABILITATION IN RURAL NORTHLAND z Catherine Beasley, RN, MN (Hons), PG Cert, PG Dip. Hauora Hokianga, Rawene zss Robyn Dixon, PhD, RN, School of Nursing, University of Auckland
Abstract Cardiovascular disease has been identified as a leading cause of mortality in New Zealand. It is therefore of little surprise that the New Zealand Health Strategy has identified cardiovascular health as a target area for improved management. A main contributor to cardiovascular disease is coronary artery disease, which can lead to acute coronary syndromes such as myocardial infarction. Cardiac rehabilitation should be offered to those who have suffered from a coronary event, with the aim of improving quality of life for the client and reducing the incidence of further cardiac episodes. Since hospital stays are, on average, less than one week following a cardiac event such as a myocardial infarction, the majority of such rehabilitation is delivered in the primary care setting. This descriptive, exploratory, qualitative study focused on the perceptions and experiences of nurses involved with the delivery of cardiac rehabilitation in a rural health care setting in a Northland region of New Zealand. The paper draws upon two focus groups the researcher conducted with a total of twelve nurses. A general inductive approach was used to analyse the collected data. Five main themes were identified in relation to cardiac rehabilitation: “foundations of rural cardiac rehabilitation”, “focal points”, “influencing factors”, “here and now”, and “future requirements”. This study provides insight into how cardiac rehabilitation is approached in one rural setting of New Zealand. Furthermore, it identifies some ideas for the further development of cardiac rehabilitation services.
Keywords: cardiac rehabilitation, rural, nurses, experiences
Introduction Cardiovascular disease accounted for almost half of all
in the ability to continue employment and, in some
deaths in New Zealand in 2009, of which coronary artery
instances, a significant emotional impact. Coronary
disease was a core contributor (Ministry of Health,
artery disease is particularly prevalent in males and
2012b). It is therefore of little surprise that the Minister
among people of Māori descent (Riddell, Jackson,
of Health (2012a) identified cardiovascular disease as
Wells, Broad, & Bannink, 2007; Sinclair & Kerr, 2006),
a priority in the New Zealand Health Strategy. The
and is further influenced by socio-economic risk
number of people affected by cardiovascular disease
factors (Best Practice Advisory Committee, 2011).
is expected to continue to rise as a result of longer life expectancy and an ageing population (Alwan, 2011). The effects include reduced quality of life, interruptions
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szs C., & Dixon, R. (2013). Phase II cardiac rehabilitation Beasley, in rural Northland. Nursing Praxis in New Zealand, 29(2), 4-14.
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Cardiac rehabilitation should be offered to clients
and social factors.
In the ideal situation, cardiac
following an acute coronary event such as myocardial
rehabilitation care should adopt a multi-disciplinary
infarction. In the New Zealand Guidelines Group’s
approach. In many rural settings, however, this is
(2002) report, however, uptake rates of cardiac
simply not a realistic option despite the fact that the
rehabilitation were shown to be consistently low, with
incidence rates of coronary artery disease are highest
a wide degree of variation in programme content.
in these locations (Aoun & Rosenberg, 2004; Wachtel
In addition, Valencia, Savage, and Ades (2011) have
et al., 2008a).
suggested that those living rurally exhibit, on average, fewer positive health behaviours than do individuals
Cardiac rehabilitation should be initiated immediately
that reside in urban locales. As such, greater inputs
following a coronary event and consists of three phases.
therefore will be necessary to engage with, and
Phase I, inpatient care, centres on introducing a client
improve the health of, rural clients. Furthermore, in
to the concept of heart disease and preparation for
rural areas additional challenges exist regarding the
discharge from hospital. Phase II, following a client’s
delivery of cardiac rehabilitation care. These limitations
discharge from hospital, is the largest component.
can include: limited access to services (Aude, Hill, &
It consists of a programme that spans several weeks
Anderson, 2006); socioeconomic factors, such as lower
and is based on intensive education, particularly
income and education (Oberg, Fitzpatrick, Lafferty, &
surrounding lifestyle interventions such as smoking
LoGerfo, 2009); and a ‘rural attitude’ of getting on with
cessation, exercise, diet, and aspects of social and
life (De Angelis, Bunker, & Schoo, 2008).
psychological care. Phase III, long-term management, is focused on helping the patient develop the ability to
The primary health care setting has been identified as
continue implementing the changes initiated in Phases
having the ability to improve cardiac rehabilitation care
I and II (New Zealand Guidelines Group, 2002; World
participation rates (Cupples et al., 2010). In most rural
Health Organization, 2007). A cardiac rehabilitation
locations, the nursing staff account for a significant
programme should, in effect, provide support and
proportion of the health workforce and their role in
encouragement to clients as they make modifications
primary health care delivery is, therefore, viewed
to their behaviour, thereby maximising the likelihood
as invaluable (Francis & Mills, 2011; Howie, 2008).
of their recovery.
Nevertheless, Wachtel, Kucia and Greenhill (2008a) claimed that in rural areas cardiac rehabilitation care management is typically approached on an ad
Literature Review
hoc basis; Shepherd, Battye, and Chalmers (2003), however, suggested that rural nurses felt they lacked
A literature search was undertaken in order to
adequate training in cardiac rehabilitation.
explore the available research pertaining to cardiac rehabilitation. An initial search was conducted of the
In New Zealand, evidence-based guidelines are
CINHAL, Pubmed, Medline, Cochrane and EMBASE
available to facilitate health-care professionals’ delivery
databases for articles published between 2001 and
of cardiac rehabilitation (New Zealand Guidelines
2012. In addition, relevant conference abstracts and
Group, 2002).
These guidelines acknowledge that
reference lists in related articles were searched. The
their implementation in rural communities can be
initial key words searched were: cardiac rehabilitation,
difficult for a variety of reasons, including geographic
Phase II, rural and secondary prevention.
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand Cardiac rehabilitation largely focuses on achieving
topic (Saunamaki, Andersson, & Engstrom, 2010).
an optimal quality of life (Aoun & Rosenberg, 2004; Yates, Braklow-Whitton, & Agrawal, 2003) by adopting
Generally, the rural client is believed to have greater
a multi-disciplinary approach to health care (New
health care needs (Australian Institute of Health and
Zealand Guidelines Group, 2002) to prevent further
Welfare, 2008; Howie, 2008), which Humphreys
cardiac related incidents (Centers for Disease Control
and Wakerman (2008) suggested is related to the
and Prevention, 2008; De Angelis et al., 2008). The
increased distances that need to be covered in order
foundations of an effective cardiac rehabilitation
for these clients to access health care services. As a
programme reside in lifestyle modifications, exercise
result, the health service demands – particularly those
and medication management (National Institute for
made of nurses – are also predicted to be higher.
Health and Clinical Excellence, 2007). Despite the
However, Martin Misener et al. (2008) claimed that
apparent focus on lifestyle recommendations, an
little attention had been paid to the point of view of
Australian retrospective analysis of medical records
those nurses working as generalists and providing care
found that such advice was often poorly documented
to rural peoples with a vast range of health needs. In
(Wachtel et al., 2008b). Oberg et al. (2009) arrived at
light of the above, this study was designed to identify
similar findings, noting that lifestyle advice was offered
the experiences and perceptions of nurses working to
in fewer than half of the cases reviewed. Although it is
deliver cardiac rehabilitation in rural communities.
possible that this is the result of a failure to record that lifestyle advice was given in the client’s file as opposed
Aim
to the advice not being provided.
In
addition
to
lifestyle
interventions,
client
This study aimed to explore nurses’ perceptions of
psychological needs require careful consideration.
and experiences with the delivery of Phase II cardiac
According to Strike and Steptoe (2004), those with
rehabilitation in a rural health setting.
coronary artery disease are three times more likely to experience depression, particularly post-myocardial infarction. Furthermore, those with coronary artery
Methodology
disease and depression have at least double the rates of mortality within two years of a cardiac event (Barth,
The foundation of this study was a qualitative,
Schumacher, & Hermann-Lingen, 2004).
descriptive, exploratory design.
This combination
enabled a phenomenon that little is known about One factor that might contribute to depression is
to be studied in its natural setting (Routio, 2007) so
sexual dysfunction, which can occur as a known side
that we could describe it and explore the influencing
effect of medications used to treat those diagnosed
factors. The intention of the study was to enable
with coronary artery disease (Jaarsma et al., 2010). A
nurses to describe their experiences delivering cardiac
survey of cardiac nurses, however, found that although
rehabilitation in a rural setting.
nurses were aware of the presence and impact of sexual dysfunction, few addressed the issue as part of their practice (Jaarsma et al., 2010). This could be
Ethics
a result of inadequate training on how to address the Ethical approval for this study was granted by the Page 6
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Northern X Regional Ethics Committee, reference
Thirteen potential participants consented to participate
number NTX/11/EXP/216. The local Taumata were
in the research; however, one was unavailable during
consulted throughout this study. The Taumata are
the data collection period and so the results presented
a group of senior Maori staff who are able to give
are from the 12 remaining participants. All participants
advice on Maori customs and provide cultural support
were female; the majority were over 50 years of age
(Hokianga Health Enterprises Trust, 2011). All potential
and had been working in the community under study
participants were provided with information sheets;
for at least 5 years.
participation was voluntary and written consent was obtained prior to commencing focus group
Data collection was conducted using focus groups,
discussions. In addition, consent forms were signed by
which are generally associated with good respondent
the organisation manager stating that an individual’s
rates (Burns & Grove, 2001). Focus groups also enable
decision not to participate would have no influence
researchers to explore the question being studied
on their employment. This step was undertaken to
while allowing the stimulation of ideas by listening
assure potential participants that their involvement
to others talk within a group setting (Schneider,
was completely voluntary.
Whitehead, Elliott, Lobiondo-Wood, & Haber, 2007). A semi-structured focus group guide, based on the New Zealand guidelines, was developed and used
Methods
to facilitate group discussions and to ensure that similar questions were presented to both groups.
A descriptive, exploratory, qualitative, focus-group
Two focus groups were conducted within a one-week
study was undertaken using a convenience sample.
period at the central health service site, each lasting
Nurses employed in the rural locale at the centre of
approximately one hour. At the initial recruitment,
the research and who were directly involved with the
potential participants were advised that a member
delivery of care to clients following an acute coronary
of the Taumata may be present at the focus groups
event, were invited to participate. These inclusion
to offer cultural support and guidance.
criteria resulted in all community health nurses and
scheduling conflict a Taumata member was only able
practice nurses being eligible to participate.
to be present at the first group.
Recruitment was performed by attending the monthly
Prior to commencing data collection, participants
community nurses’ meeting.
The researcher first
were reminded that the researcher would be using a
gave a presentation that outlined the study and that
digital recorder and that they could request that it be
included opportunities for the nurses to ask questions.
switched off at any point during the discussion. This
A colleague then coordinated the distribution of
point was also explained clearly in the information
information sheets to participants and the collection
sheets provided to participants. The researcher also
of the signed consent forms. Self-addressed envelopes
requested that any information shared in the group be
were also distributed to allow the return of consent
kept within the group. An open-ended question about
forms at a later date via posted mail. The researcher
what happens when a person who has had a cardiac
did not gain consent directly from potential participants
event is discharged from hospital was used to initiate
in order to minimise the risk of them feeling obligated
discussion for both groups. Further questioning was
to participate due to their knowing the researcher.
guided by the focus group guideline.
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Due to a
Page 7
Nursing Praxis in New Zealand The discussions were transcribed verbatim by the
relationship between your client, the family,
researcher as soon as possible after each focus group.
the community, you, the general practitioner,
A general inductive approach (Thomas, 2006) was then
the health centre, the ward and your, specialist
used to guide the data analysis. This approach relied
doctors and even your cardiac nurses and your
on the processing of raw data to develop meanings
other services — you can wrap these around them
and ideas about the phenomenon under study. A
[the clients]. (FG1)
constant comparative analysis was then adopted, and each piece of raw data was compared with all others to
Although initial cardiac rehabilitation care and
identify points of both variance and similarity. Multiple
guidance was believed to be given during the inpatient
broad categories were developed based on the
period, some felt that community-based care relied
original study question. These were further refined in
on facilitating access to other services – for example,
an effort to identify any areas of overlap and common
doctor, cardiac rehabilitation nurses (out of immediate
phrases, and were then used to form a reduced
locality) – rather than on the actual delivery of cardiac
number of categories. This process of reviewing and
rehabilitation. One nurse spoke of putting resources
reducing categories continued until five main themes
into the local context to ensure that the client received
remained. To organise the collected data, transcripts
practical and achievable advice:
were transcribed and coded using NVivo 9 software.
…sitting down and just talking about what is
The coded transcripts were reviewed by a second
in the brochure [cardiac resource provided in
impartial health care colleague to confirm the validity
hospital] helps because for the people in our
of the defined themes. The five themes and a sample
area sometimes things [in the brochures] are
of quotes were then reviewed by two focus-group
unrealistic. (FG1)
participants to check if they judged the themes to be a fair reflection of the discussion content. The results of
When discussing the services available outside of the
the coding of the discussions were also reviewed with
immediate health service, participants in both focus
a member of the Taumata.
groups agreed that people do not utilise these options: …the idea of rehab services and centres is that you are specialising in it [cardiac rehabilitation]
Results
and you know you are able to give them more comprehensive service, but having our people
The analysis identified five themes relevant to the
actually engaging with that service in [city-south]
study’s aim: what nurses perceive to be the foundations
or [city-north] is…you know… doesn’t happen
of cardiac rehabilitation; awareness of focal points
with so many. (FG2)
in cardiac rehabilitation; experience of influencing factors; active cardiac rehabilitation (the here and
Nurses spoke of making themselves accessible to
now); and, future requirements (where to from here).
clients. However, they also had strong views regarding the benefits of clients having access to other persons
Foundations of cardiac rehabilitation
with similar experiences. They felt this provided a
Nurses emphasised that the foundations for delivering
means of support and understanding:
cardiac rehabilitation in a rural setting rested on a
…the support [of] other people who have
team approach:
experienced the same event as you, and having
…you have got a clinic, you’ve got referrals, that Page 8
that strength, you know, together… (FG2) Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Focal points in cardiac rehabilitation
mean, it is part of our assessment we have got
Participants in both groups touched on all aspects of
inbuilt to us. (FG2)
cardiac rehabilitation (smoking cessation, diet and exercise as part of broader efforts to manage weight,
Furthermore, several nurses reported feeling concern
depression and mental health, medication, sexual
regarding the limited options for clients who could be
dysfunction). However, exercise, depression and sexual
depressed or otherwise in need of emotional support:
dysfunction appeared to be the nurses’ points of focus.
…he almost needs, like, counselling and a bit of mental health support. Yeah, and I can’t give it to
Exercise
him in 15 minutes consultation or half an hour or
Current practice regarding the management of
whatever, you know. He needs something in a big
exercise varies from nurse to nurse. Experiences
way… (FG1)
included examples in which exercise plans were set out for clients as well as referrals for green prescriptions
Sexual dysfunction
offered (an initiative that offers a supported pathway
One focus group included an extended discussion
for people to increase their activity level). The nurses’
surrounding concerns, particularly for male clients,
responses showed some uncertainty regarding the
regarding sexual dysfunction following a myocardial
availability of green prescriptions and their ability to
infarction. The nurses included in this group questioned
make a referral. Furthermore, some nurses believed
whether enough was being done to address this, while
that health interventions, such as exercise classes,
also discussing the effect it can have on a family:
were more inclined to have positive outcomes when
…that [sexual dysfunction] is a strain on the
undertaken by community coalitions rather than when
relationship, for the marital relationship, family
they were coordinated by health professionals:
relationship. (FG1)
…you want the community to initiate those things [exercise/health initiatives], that is how they are
The discussion also acknowledged that encouraging
going to work. (FG2)
males to discuss issues related to sexual dysfunction can be difficult, as some believe it is a private matter:
Depression
…she [the patient’s wife] just said he won’t come
In both focus groups there was discussion about the
in because he knows, if he realises that is why he
fact that the incidence of depression was high following
is going in for [sexual dysfunction]…it is none of
cardiac events. The nurses raised concerns about how
their [doctor/nurses] business. (FG1)
depression was assessed following a cardiac event, and that no official assessment tool was available.
Influencing factors
Several nurses across both groups, however, referred
The nurses identified several factors known to
to personal life experiences and innate instincts
influence attendance at cardiac rehabilitation care,
as strategies for identifying potential instances of
including distance to services, cost, work and family.
depression:
In the opinion of the nurses, however, three additional
I think by the time you have come through as much
factors should be included that influence patients’
nursing as we have, we are actually screening all
involvement in cardiac rehabilitation: client motivation,
the time without using any particular tool… we
role models and local attitudes.
can see and from body language and what they are saying and how they are looking and stuff. I Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Participants in both focus groups shared the perception Page 9
Nursing Praxis in New Zealand that client motivation was a key factor in the patient’s
cracks, isn’t it? (FG2)
participation in a cardiac rehabilitation programme: …the hard bit is getting THEM to be responsible for
The nurses also noted that, on some occasions, they
their health and them wanting to do something
would first hear about a client’s condition through
about it. We can do all the pushing we want. (FG1)
people in the local community: I know in my practice we don’t actually know
A second key influence on participation in cardiac
that someone has come back and had a big MI
rehabilitation was the presence of role models. The
[myocardial infarction] or STEMI [ST elevation
presence of an individual that is able to relate to the
myocardial infarction], CABG [coronary artery
client and provide evidence of positive outcomes was
bypass graft] or whatever because we haven’t had
believed to facilitate change:
referrals; we [community nurses] know because
…a lot of walkers in the [area] and they are
we live in the community and we actually know
motivated. A lot of them are motivated by seeing
the community. (FG1)
someone else doing it. So they get together. (FG2) Furthermore, the majority of nurses saw the doctor as Lastly, the nurses spoke about the local attitude among
a key person in cardiac rehabilitation. The priority was
patients concerning the desire for a return to normalcy,
generally on having clients meet with a doctor, with a
which often contributed to patients opting not to
focus on reviewing the client’s new medications. Little
pursue further treatments. Nurses in both groups
was said that suggested meetings with the nurses
spoke of how clients would often make comments to
occurred as a regular component of this process,
the effect of, “I’m okay” (FG1 and FG2).
despite the recognition that there is a limit to what doctors can achieve in the time allowed for client
Active cardiac rehabilitation – here and now
consultations.
During the discussions, it became apparent that the
…the GPs are really busy, they have not got time
nurses’ experiences of cardiac rehabilitation varied
to sit for an hour or so and talk to people. (FG1)
widely. One nurse commented on this: It is a bit of an ad hoc [process in cardiac
Future requirements
rehabilitation]. (FG2)
Based on the nurses’ experiences of cardiac rehabilitation there was a strong sense that there
It also appears that discharge summary paperwork
exists a need to introduce a pathway of care or a
was not routinely received by the community nurses
cohesive care plan:
upon a client’s discharge from hospital. This seemed
… a really important point [a care pathway],
particularly prevalent in situations in which the primary
that could improve service for a start [cardiac
care was not delivered at the local hospital (i.e., in an
rehabilitation]. (FG1)
urban hospital):
… [having a] sheet that we systematically follow
…the discharge summary hopefully comes…
[for cardiac rehabilitation]… I think that needs to
sooner than later. (FG1)
be [available]. (FG2)
…if you don’t know they’ve had it [the cardiac event], then that [cardiac rehabilitation] doesn’t
Nurses felt this was necessary to provide a structure
happen and that is where they fall through the
to the rehabilitation process in the community setting.
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Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Discussion
therefore is an area that requires further examination within rural communities.
The perceptions of the nurses who participated in this study supported the New Zealand Cardiac
This research highlighted the fact that the nurses felt
Rehabilitation guidelines (New Zealand Guidelines
they knew their communities, and often had rapport
Group, 2002) in part by the belief that success relies
with their clients that had been established prior to
on a team approach. However, unlike urban areas
their cardiac event. This rapport assisted the nurses
where nurses can expect to play an active role in
to quickly identify changes in mood and/or behaviour.
delivering education (Thomas, King, Lui, Oldridge,
It was also noted that no specific screening tool for
Pina & Spertus, 2007), rural-based nurses spoke of
depression is currently being used by the nurses.
their roles in liaison and as facilitators rather than of
Screening for depression has previously been reported
their responsibilities in the direct delivery of cardiac
by Jones (2009) as requiring improved management,
rehabilitation care. In general, the nurses in this study
as a number of cases go undiagnosed. Furthermore,
believed that the majority of lifestyle and medication
Scottish cardiac rehabilitation guidelines indicate
information provided to clients occurred during their
incidences of depression following a cardiac event can
inpatient treatment. However data about information
be one in every two people (Scottish Intercollegiate
provided during inpatient treatment were not
Guidelines
collected as part of the present study. International
management is necessary.
Network,
2002);
as
such,
careful
cardiac rehabilitation care guidelines incorporate the expectation that the majority of lifestyle advice should
The nurses in this study also noted that sexual health,
be disseminated after a patient has been discharged,
and particularly sexual dysfunction, was an area that
given the briefness of hospital stays post cardiac
often went unaddressed. Several studies have claimed
events (Clinical Resource Efficiency Support Team,
that sexual dysfunction is not discussed frequently
2006; Scottish Intercollegiate Guidelines Network,
enough (Farrell & Belza, 2012; Jaarsma et al., 2010),
2002; New Zealand Guidelines Group, 2002). This
which Saunamaki et al. (2010) have suggested that the
could lead to a gap in current services within the rural
latter may be the result of inadequate training. It also
community under study.
might be the case that as a result of living in a small community, clients and nurses know each other well,
The nurses in this study believed that support groups
and this then leads to a reluctance on the part of both
could form an important component of cardiac
parties to address this issue.
rehabilitation. De Angelis et al. (2008) noted that support groups can provide an opportunity for
To initiate cardiac rehabilitation in the community it is
people to share experiences, although some potential
first necessary to plan the transition of care from the
participants can find them daunting. Nonetheless,
hospital to the community. Currently this does not
the current guidelines promote such groups as part
always happen, particularly when clients are treated
of effective strategies for the delivery of cardiac
outside the local area. This gives rise to the possibility
rehabilitation (New Zealand Guidelines Group, 2002).
that clients’ needs are overlooked or not responded
There are currently no support groups available in
to, particularly if no discharge paperwork is filed by the
the immediate area this study was conducted, and
hospital or received by the community health centre.
nurses spoke of clients being reluctant to travel. This
This has previously been identified as a barrier to
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Page 11
Nursing Praxis in New Zealand cardiac rehabilitation care participation (Vandelanotte,
II cardiac rehabilitation care as it is delivered in that
Dwyer, Van Itallie, Hanley, & Mummery, 2010; Walters
particular location. Due to the small sample size and
et al., 2010).
the focus on a single location, the findings reported here cannot be generalised to other settings, although
Lastly, there was a sense among the nurses in this study
the broader themes may have relevance.
that there exists a need to adopt a clear framework or plan of care that would provide structure and guidance for them in the delivery of Phase II cardiac rehabilitation.
Conclusion
The Northern Ireland cardiac rehabilitation guidelines (Clinical Resource Efficiency Support Team, 2006), for
This study has explored the perceptions and beliefs
instance, suggest the adoption of a shared plan of
of nurses working in a rural health service. The
care with the client. Alternatively, The Heart Manual
experiences of the nurses in this study suggest that
is recognised in both the United Kingdom (National
their roles focus on liaison and coordination with
Institute for Health and Clinical Excellence, 2007)
respect to cardiac rehabilitation care, and that the
and Australia (Dollard, Smith, Thompson, & Stewart,
approach adopted is somewhat ad hoc. The nurses felt
2004) as an effective, home-based alternative for the
that there was a need to consider the introduction of a
delivery of cardiac rehabilitation. Both approaches are
more structured approach with regard to the delivery
based in efforts to empower and motivate clients to
of cardiac rehabilitation care. To provide a more in-
take an active role in their treatment, which reflects
depth understanding of the cardiac rehabilitation
the primary aim of the New Zealand Guidelines (New
process in this rural community it is recommended
Zealand Guidelines Group, 2002).
that additional research be undertaken to explore the perceptions and beliefs of other team members,
Strengths and limitations
such as doctors, inpatient nurses and physiotherapist.
This study is based on a small sample of community-
Finally, with regard to future planning, both nurses
based nurses working in a specific location in rural
and clients would benefit from the adoption of a
New Zealand. It provides in-depth insights into these
formal plan of care designed for cardiac rehabilitation
nurses’ beliefs and perceptions surrounding Phase
in the community.
References Alwan, A. (2011). Global status report on noncommunicable diseases 2010. Retrieved from http://www.who.int/nmh/publications/ ncd_report_full_en.pdf Aoun, S., & Rosenberg, M. (2004). Are rural people getting HeartSmart? Australian Journal of Rural Health, 12(2), 81-88. doi:10.1111/ j.1038-5282.2004.00553.x Aude, T., Hill, P. D., & Anderson, M. A. (2006). Quality of life after participation in a rural phase II cardiac rehabilitation program. Journal of Nursing Care Quality, 21(1), 56-62. doi:10.1097/00001786-200601000-00012 Australian Institute of Health and Welfare. (2008). Rural, regional and remote health: Indicators of health status and determinants of health. Rural Health Series Number 9. Retrieved from http://www.aihw.gov.au/publication-detail/?id=6442468076 Barth, J., Schumacher, M., & Hermann-Lingen, C. (2004). Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis. Psychosomatic Medicine, 66(6), 802-813. doi:10.1097/01.psy.0000146332.53619.b2 Best Practice Advisory Committee. (2011). Cardiovascular disease risk assessment. Retrieved from http://www.bpac.org.nz/ magazine/2011/august/cvra.asp
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Nursing Praxis in New Zealand Burns, N., & Grove, S. (2001). The practice of nursing research: Conduct, critique and utilization (5th ed.). Philadelphia, PA: Elsevier Saunders. Centers for Disease Control and Prevention. (2008). Receipt of outpatient cardiac rehabilitation among heart attack survivors – United States 2005. MMWR, 57(04), 89-94. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5704a2.htm Clinical Resource Efficiency Support Team. (2006). Guidelines for cardiac rehabilitation in Northern Ireland. Belfast, Ireland: Author. Retrieved from http://nicardiacnetwork.org/uploads/60d02f36-1cf6-42de-92fe-8c2b5486576b/resources/0c2c927d-e7b6-4aa5a616-4e56c282f916/Crest%20Guidelines%20for%20Cardiac%20Rehabilitation%20May%2006.pdf. Cupples, M. E., Tully, M. A., Dempster, M., Corrigan, M., McCall, D. O., & Downey, B. (2010). Cardiac rehabilitation uptake following myocardial infarction: Cross-sectional study in primary care. British Journal of General Practice, 60, 431-435. doi:10.3399/ bjgp10X502155 De Angelis, C., Bunker, S., & Schoo, A. (2008). Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs. Australian Journal of Rural Health, 16(3), 137-142. doi:10.1111/j.1440-1584.2008.00963.x Dollard, J., Smith, J., Thompson, D. R., & Stewart, S. (2004). Broadening the reach of cardiac rehabilitation to rural and remote Australia. European Journal of Cardiovascular Nursing, 3(1), 27-42. doi:10.1016/j.ejcnurse.2003.10.002 Farrell, J., & Belza, B. (2012). Are older patients comfortable discussing sexual health with nurses? Nursing Research, 61(1), 51-57. doi:10.1097/NNR.0b013e31823a8600 Francis, K. L., & Mills, J. E. (2011). Sustaining and growing the rural nursing and midwifery workforce: Understanding the issues and isolating directions for the future. Collegian, 18(2), 55-60. doi:10.1016/j.colegn.2010.08.003 Hokianga Health Enterprises Trust. (2011). Hauora Hokianga Integrated PHO - Annual report for the year ending 30 June 2011. Hokianga, New Zealand: Author. Howie, L. (2008). Rural society and culture. In J. Ross (Ed.), Rural nursing: Aspects of practice (pp. 3-18). Dunedin, New Zealand: Rural Health Opportunities. Retrieved from http://www.health.govt.nz/publication/rural-nursing-aspects-practice Humphreys, J., & Wakerman, J. (2008). Primary health care in rural and remote Australia: Achieving equity of access and outcomes through national reform. A discussion paper. Retrieved from http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/ 16F7A93D8F578DB4CA2574D7001830E9/$File/Primary%20health%20care%20in%20rural%20and%20remote%20Australia%20 -%20achieving%20equity%20of%20access%20and%20outcomes%20through%20national%20reform%20(J%20Humph.pdf Jaarsma, T., Stromberg, A., Fridlund, B., De Geest, S., Martensson, J., Moons, P., . . . Thompson, D. R. (2010). Sexual counselling of cardiac patients: Nurses’ perceptions of practice, responsibility and confidence. European Journal of Cardiovascular Nursing, 9(1), 24-29. doi:10.1016/j.ejcnurse.2009.11.003 Jones, M. (2009). Using screening tools to identify the risk or presence of depression in older people. Nursing Times.net, 105(49-50), 24-7. Retrieved from www.nursingtimes.net Martin Misener, R. M., Macleod, M. L. P., Banks, K., Morton, A. M., Vogt, C., & Bentham, D. (2008). “There’s rural, and then there’s rural”: Advice from nurses providing primary healthcare in Northern remote communities. Nursing Leadership, 21(3), 54-63. doi:10.12927.cjnl.2008.20062 Minister of Health. (2012a). Implementing the New Zealand health strategy 2011. publication/implementing-new-zealand-health-strategy-2011
Retrieved from http://www.health.govt.nz/
Ministry of Health. (2012b). Mortality and demographic data 2009. Retrieved from http://www.health.govt.nz/publication/mortalityand-demographic-data-2009 National Institute for Health and Clinical Excellence (NICE). (2007). MI: Secondary prevention (CG48). London, United Kingdom: Author. Retrieved from http://www.nice.org.uk/nicemedia/pdf/CG48NICEGuidance.pdf New Zealand Guidelines Group. (2002). Evidence-based best practice guideline: Cardiac rehabilitation. Wellington: Author. Retrieved from http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-group Oberg, E. B., Fitzpatrick, A. L., Lafferty, W. E., & LoGerfo, J. P. (2009). Secondary prevention of myocardial infarction with nonpharmacologic strategies in a Medicaid cohort. Preventing Chronic Disease, 6(2), 1-9. Retrieved from http://www.cdc.gov/pcd/issues/2009/ apr/08_0083.htm Riddell, T., Jackson, R., Wells, S., Broad, J., & Bannink, L. (2007). Assessing Maori/ non-Maori differences in cardiovascular disease risk and risk management in routine primary care practice using web-based clinical decision support: (PREDICT CVD-2). The New Zealand Medical Journal, 120(1250). Retrieved from http://journal.nzma.org.nz/journal/120-1250/2445/ Routio, P. (2007). Models in the research process. Retrieved from http://www2.uiah.fi/projects/metodi/177.htm
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Nursing Praxis in New Zealand Saunamaki, N., Andersson, M., & Engstrom, M. (2010). Discussing sexuality with patients: Nurses’ attitudes and beliefs. Journal of Advanced Nursing, 66, 1308-1316. doi:10.1111/j.1365-2648.2010.05260.x. Schneider, Z., Whitehead, D., Elliott, D., Lobiondo-Wood, G., & Haber, J. (2007). Nursing and midwifery research: Methods and appraisal for evidence-based practice (3rd ed.). Chatswood, New South Wales, Australia: Elsevier. Scottish Intercollegiate Guidelines Network. (2002). Cardiac rehabilitation: A national clinical guideline. Edinburgh, United Kingdom: Author. Shepherd, F., Battye, K., & Chalmers, E. (2003). Improving access to cardiac rehabilitation for remote Indigenous clients. Australian and New Zealand Journal of Public Health, 27(6), 632 - 636. doi:10.1111/j.1467-842X.2003.tb00611.x Sinclair, G., & Kerr, A. (2006). The bold promise project: A system change in primary care to support cardiovascular risk screening. The New Zealand Medical Journal, 119(1245), U2312. Retrieved from http://journal.nzma.org.nz/journal/119-1245/2312/ Strike, P. C., & Steptoe, A. (2004). Psychosocial factors in the development of coronary artery disease. Progress In Cardiovascular Diseases, 46(4), 337-347. doi:10.1016/j.pcad.2003.09.001 Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation data. American Journal Of Evaluation, 27(2), 237-246. doi:10.1177/1098214005283748 Thomas, R. J., King, M., Lui, K., Oldridge, N., Pina, I. L., & Spertus, J. (2007). Performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/ secondary prevention services. Journal of the American Heart Association, 116, 16111642. doi:10.1161/CIRCULATIONAHA.107.185734 Valencia, H. E., Savage, P. D., & Ades, P. A. (2011). Cardiac rehabilitation participation in underserved populations. Journal of Cardiopulmonary Rehabilitation and Prevention, 31, 203-210. doi:10.1097/HCR.0b013e318220a7da Vandelanotte, C., Dwyer, T., Van Itallie, A., Hanley, C., & Mummery, W. K. (2010). The development of an internet-based outpatient cardiac rehabilitation intervention: A Delphi study. BMC Cardiovascular Disorders, 10(27), 1-8. doi:10.1186/1471-2261-10-27 Wachtel, T. M., Kucia, A. M., & Greenhill, J. A. (2008a). Secondary prevention for acute coronary syndrome in rural South Australia: Are drugs best? What about the rest? Rural Remote Health, 8(4), 1-11. Retrieved from http://www.rrh.org.au/articles/subviewnew. asp?ArticleID=967 Wachtel, T., Kucia, A., & Greenhill, J. (2008b). Unstructured cardiac rehabilitation and secondary prevention in rural South Australia: Does it meet best practice guidelines? Contemporary Nurse, 29(2), 195-204. doi:10.5555/conu.673.29.2.195 Walters, D. L., Sarela, A., Fairfull, A., Neighbour, K., Cowen, C., Stephens, B., . . . Karunanithi, M. (2010). A mobile phone-based care model for outpatient cardiac rehabilitation: The care assessment platform (CAP). BMC Cardiovascular Disorders, 10(5), 1-8. doi:10.1186/1471-2261-10-5 World Health Organization. (2007). Prevention of cardiovascular disease: Guidelines for assessment and management of cardiovascular risk. Retrieved from http://www.who.int/cardiovascular_diseases/guidelines/Full%20text.pdf. Yates, B. C., Braklow-Whitton, J. L., & Agrawal, S. (2003). Outcomes of cardiac rehabilitation participants and nonparticipants in a rural area. Rehabilitation Nursing, 28(2), 57-63. doi:10.1002/j.2048-7940.2003.tb02030.x
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Nursing Praxis in New Zealand INPATIENT HYPOGLYCAEMIA: A STUDY OF NURSING MANAGEMENT Adrienne Coats, RN, MN, Clinical Nurse Specialist Diabetes, Northland District Health Board, Whangarei Hospital, NZ. Dianne Marshall, RN, MA, Senior Lecturer, School of Nursing, University of Auckland, NZ.
Abstract Optimised glycaemic management during hospital admission is critical to good patient outcomes. Inpatient hypoglycaemia is associated with increased morbidity and mortality during the hospital stay and post-discharge. To mitigate the deleterious effects of hypoglycaemia, many hospitals have an inpatient protocol to guide clinicians. Earlier research has shown that nurses fail to follow such protocols. This descriptive study used a retrospective audit of inpatients’ treatment and progress notes to examine nursing adherence to a hypoglycaemia protocol. Adult medical and surgical inpatients with Type 1 or Type 2 diabetes mellitus and who had experienced hypoglycaemia during a three month period were included. One hundred and seventeen episodes of hypoglycaemia were identified in 32 patients who met the inclusion criteria. A predominance of these, 29 patients (90.6%), had Type 2 diabetes with 20 (62.5%) of the sample being medical patients. Diabetes medications included the use of insulin only (n=18, 56.2%), oral hypoglycaemic agents only (n=9, 28.1%) and five patients (15.7%) received a combination of these therapies. Three of the 117 episodes were treated with administration of intravenous glucose whilst the remaining 114 episodes were able to be treated with oral therapy. The recommended oral treatment to correct hypoglycaemia is 9-15 grams of glucose only. Adherence to most steps of the hypoglycaemia protocol was low. Initial treatment with glucose was administered in 46 (40.4%) cases. The required repeat capillary blood glucose test in 10-15 minutes was obtained in 35 (30.7 %) cases. Within thirty minutes of detection, only 36.7% of episodes were corrected. A high degree of prolonged and recurrent hypoglycaemia was identified, with 40% of the episodes lasting more than one hour, and 72% of patients having more than one hypoglycaemic episode during their admission. Recommendations from the study include review of the hypoglycaemia protocol, development of strategies to help nurses prioritise the management of hypoglycaemic episodes, ongoing education for nurses, and regular re-audit.
Key words: hypoglycaemia, inpatient, protocol
In New Zealand, diabetes has been described as
Diabetes is the most commonly identified comorbidity
reaching epidemic status (Berkley & Lunt, 2006). The
in people admitted to hospital (Barnabas, Javed, Javed,
prevalence of Type 2 diabetes was predicted to increase
& Kaushal, 2010). In Northland during 2005, 5% of
from 123,944 people (3.2% of population) in 2001
all inpatients had diabetes and they used 21% of all
to 194,380 (4.5% of population) in 2011 (Ministry Of
the bed days (Northland District Health Board, 2006).
Health, 2007). By 2012, 200,000 (5%) of New Zealand
Patients with diabetes have complex health care needs
adults had been diagnosed with diabetes (Ministry
in the hospital setting and may experience prolonged
of Health, 2012a). Diabetes is a significant cause of
lengths of stay and increased rates of inpatient infection,
mortality in New Zealanders, and resulted in 869 deaths per 100,000 people during 2009 (Ministry of Health, 2012b). Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Coats, A., Marshall, D., (2013). Inpatient hypoglycaemia: A study of nursing management. Nursing Praxis in New Zealand, 29(2), 15-24.
Page 15
Nursing Praxis in New Zealand disability and mortality (Moghissi et al., 2009). Whilst
hospital were experiencing hypoglycaemia and that
tight glycaemic control has been advocated for the
the hospital protocol for its management was not
Intensive Care Unit (ICU) patient for some time, good
consistently followed was the catalyst for this study.
metabolic control is now also recommended for all patients with diabetes in the non-ICU context as a means to improve clinical outcomes (American Diabetes
Study Design and Method
Association, 2006; Turchin et al., 2009). A retrospective audit of the treatment and progress Hypoglycaemia is known to be common amongst
notes of patients admitted to Whangarei Hospital
inpatients. The 2007 study by Cagiliero, Grant, Meigs,
between November 2009 and January 2010 was
Nathan and Wexler of 999 patients admitted to 44
used to depict nursing adherence to the Northland
hospitals across the United States of America found
District Health Board’s (NDHB) protocol “Management
hypoglycaemia occurred in 12-18% of cases. One of
of Hypoglycaemia in Patients with Diabetes”. This
largest studies (n=2,582) of inpatient hypoglycaemia
secondary level facility is the region’s main hospital,
undertaken to date also in the United States, identified
providing 223 inpatient beds and specialist care to the
that mortality during admission in patients who had at
Northland population (Northland District Health Board,
least one episode was 2.96% compared with 0.82% for
2010). Ethical approval for this study was granted by the
patients who did not develop hypoglycaemia. Inpatient
Northern X Regional Ethics Committee.
mortality increased dramatically with each additional day that hypoglycaemia was present (Greenwood, et
Whangarei Hospital has two general adult medical and
al., 2009).
two general adult surgical wards. All four wards were included to ensure that the sample was representative
The consensus in the literature is that inpatient
of the general adult inpatient population. Only patients
hypoglycaemia is largely preventable. There is
with either Type One or Type Two Diabetes who had
frequently a component within the delivery of care
experienced an episode of inpatient hypoglycaemia,
which, if modified in a timely manner, could prevent
and who were prescribed an oral hypoglycaemic agent
or reduce the risk of hypoglycaemia (Anthony, 2007;
and/or insulin were included in the study. Patients
Huynh, Maynard, & Renvall, 2008; Smith, Winterstein,
were excluded if their diabetes was diet controlled,
Johns, Rosenberg, & Sauer, 2005; Wagner, 2000).
and those receiving Metformin as a monotherapy. Hypoglycaemia is not an identified side effect of this
The evidence that poor patient outcomes are associated
medication (Medsafe, 2006). Also excluded were
with inpatient hypoglycaemia and that clinical staff fail
patients who had been admitted with hypoglycaemia;
to respond to or treat episodes effectively has prompted
those requiring a glucose insulin potassium infusion or
many institutions to develop guidelines for diabetes
receiving palliative care.
management and protocols specific to the treatment of hypoglycaemia (American College of Endocrinolgy
The study aimed to assess nursing management of
& American Diabetes Association, 2006). Despite
100 episodes of hypoglycaemia. Thirty seven cases
this, nursing care has continued to be suboptimal,
met the study criteria. Treatment and progress notes
particularly in regard to adherence to hospital protocols
were able to be accessed for 32 cases resulting in
for the management of hypoglycaemia (Anthony, 2007).
a total of 117 episodes of hypoglycaemia for audit.
The observation that many patients in our Northland
Oral therapy was used to treat 114 of these episodes.
Page 16
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand The sample was recruited retrospectively through a
An audit tool was specifically developed and trialled
biweekly review of the wards’ patient whiteboard or
for this study as no existing applicable tool could be
the shift handover sheets, which contained detailed
sourced. This included consultation with a diabetes
information about diagnosis, past medical history and
consultant and clinical nurse specialists, two of whom
current management.
independently trialled the tool. Data gained during the trial were consistent and accurate. It was therefore
The most common primary diagnoses were associated
deemed to have a degree of reliability and validity
with complications of peripheral vascular disease.
though not to the standard of a previously validated
Ten (32%) patients were admitted with either foot or
tool. Data collected included patient demographics such
lower limb complications such as ulcers or cellulitis, or
as age, gender, ethnicity (see Table 1) and information
required amputation or skin graft. Four patients had
specific to hypoglycaemic events such as time, location,
respiratory illnesses such as pneumonia; three were
number, and duration of episodes.
admitted with peritonitis; two with stroke and two with cardiac conditions. One of a further three patients had
To facilitate data collection and reduce the risk of
each undergone bowel urological or breast surgery.
transcription errors, data were entered directly into the
Other primary diagnoses included one episode each
audit tool in Microsoft Excel, where it was analysed. A
of diabetic ketoacidosis, acute renal failure, confusion,
range of descriptive statistics including nominal and
collapse, gastrointestinal bleed, and anaemia. Length of
ordinal measurements, frequency distribution, and
hospital admission ranged from 4 to 70 days, with an
measures of central tendency were used to summarise
average of 14.75 days.
the findings in the form of tables and graphs.
Table 1 Characteristics of the Sample (n=32) Characteristic
Number Percentage (n) (%)
Age in years
Max Min Average Median
Gender
Male Female
13 19
40.6% 59.4%
Ethnicity
Maori NZ European Pacific Island Other
17 13 1 1
53.1% 40.6% 3.1% 3.1%
Patient numbers by specialty
Surgical Medical
12 20
37.5% 62.5%
Diabetes
Type 1 Type 2
3 29
9.4% 90.6%
Therapy
Oral Hypoglycaemic Agents only (OHAs) Insulin Therapy only Combination Therapy (Insulin + OHAs)
9 18 5
28.1% 56.2% 15.7%
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
85 48 66.3 68
Page 17
Nursing Praxis in New Zealand Results
insufficient glucose and to supplement the initial glucose treatment with a complex carbohydrate, such as a
The NDHB protocol identifies a capillary blood glucose
meal, biscuits, or chocolate milk drink. The protocol
level (CBG) <4.0mmol/l as the clinical indicator for the
specifically states that a complex carbohydrate should
initiation of hypoglycaemia treatment. This is consistent
only be given once hypoglycaemia has been corrected.
with the standard adopted nationally in both community
In 15 (13%) episodes, complex carbohydrate not glucose
and inpatient contexts (Diabetes New Zealand, 2010).
was the first treatment provided. In 5 (4.3%) episodes,
Capillary blood glucose levels ranged from 1.1 â&#x20AC;&#x201C; 3.9
no treatment at all was documented. A retest (step
mmols/l at the time of detecting hypoglycaemia. Severe
2) of the CBG 10-15 minutes after giving glucose was
hypoglycaemia (CBG <2.2mmol/l) occurred in five (4.3%)
achieved in 35 (30.7%) episodes. The median time
cases. Of the initial CBG readings, 94 (80.3%) ranged
for all retest times identified was 30 minutes. Time to
between 3.0 and 3.9mmol/l.
retest ranged from 5 to 400 minutes, with one retest performed at 840 minutes.
The audit tool identified eight key steps in the protocol (Table 2). On detection of hypoglycaemia, the correct
Retreatment with glucose only (step 3) was correctly
amount of glucose (step 1) was administered in 46
offered to 18 (25%) of the 72 patients who continued
(40.4%) of the episodes in which oral treatment was
to experience hypoglycaemia after the initial glucose
provided (see Figure 1). LA Vitatabs were offered
treatment. Complex carbohydrate was correctly
most frequently, with sugar dissolved in water also
withheld when hypoglycaemia persisted in 44 (38.6%)
being offered. Three teaspoons of sugar, honey or
episodes (step 4). Once hypoglycaemia was corrected,
jam was identified in the protocol as an alternative to
a complex carbohydrate was provided in 44 (38.6%) of
Vitatabs. The predominant failure in step 1 was offering
episodes (step 5).
Table 2 Key Steps in the Protocol (Oral Therapy)
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Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand The next scheduled dose of diabetic medication was
this step was defined as either completing the NDHB
given at the prescribed time in 81 (71.1%) episodes (step
diabetes record sheet, or an entry in the patientâ&#x20AC;&#x2122;s
6). Patients on oral hypoglycaemic agents were more
treatment and progress notes recording the episode of
likely to have their routine medication dose withheld
hypoglycaemia. The purpose of this study was not to
post-hypoglycaemia than those receiving insulin. In 33
audit the quality of nursing documentation; therefore
(28.9%) episodes, the prescribed diabetic medication
a formal audit was not undertaken. The quality of
was not given when scheduled.
documentation ranged from the simple recording of the initial CBG reading on the diabetes record sheet,
Medical staff were informed (step 7) in 13 (11.4%)
to a comprehensive description of the episode in the
episodes where the patient was able to take oral
treatment and progress notes. Some nurses included
treatment. Nursesâ&#x20AC;&#x2122; documentation (step 8) of the
a brief care plan, but there was no documentation to
episode in the patientsâ&#x20AC;&#x2122; treatment and progress notes
show that nurses had developed strategies to prevent
gained the highest level of adherence of any step (102
recurrent episodes or had provided patient education.
episodes or 87.7%). Adherence to the protocol in
Figure 1. Adherence to steps of the NDHB hypoglycaemia protocol (oral therapy) (n=114)
The average time from detection to correction for all
hypoglycaemia, with 14 patients (43.8%) experiencing
episodes was 85.5 minutes. Within 30 minutes of
between two and four episodes and nine patients
detection, 33 (36.7%) episodes were corrected. Within
(28.1%) experiencing five or more episodes (see Figure
one hour 70 (59.8%) episodes had been corrected
3).
(see Figure 2). There was a high degree of recurrent Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Page 19
Praxis 12-11 for copy editing March 2013 Praxis 12-11 for copy editing March 2013
Nursing Praxis in New Zealand
Figure 2. Episodes of hypoglycaemia corrected over time (n=117) Figure 2. Episodes of hypoglycaemia corrected over time (n=117)
Figure 2. Episodes of hypoglycaemia corrected over time (n=117)
Figure 3. Episodes of hypoglycaemia per admission (n=32)
Figure 3. Episodes of hypoglycaemia per admission (n=32) Page 20
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Figure 3. Episodes of hypoglycaemia per admission (n=32)
Nursing Praxis in New Zealand Discussion
In this study no attempt was made to determine reasons for not performing the retest as per the protocol. Failure
The nursing management of hypoglycaemia documented
to understand the potentially serious nature of untreated
in the treatment and progress notes demonstrated low
episodes may have been a factor. Hypoglycaemia is an
adherence to the individual steps of the hypoglycaemia
adverse event. Severe hypoglycaemia is life threatening
protocol. Protocols have been defined as “systematically
and is viewed as a sentinel event when occurring
developed statements to assist practitioner and
in hospital, because in most cases it is preventable
patient decisions about appropriate health care
(Quality Improvement Committee, 2009). Nurses may
for specific clinical circumstances” (Anthony, 2008,
fail to understand this and, therefore, do not place a
p.314). They help to implement standards by including
high priority on the management of hypoglycaemia.
explicit statements regarding the standard of care
The presence of hypotension is likely to evoke a
to be provided (Bick, Fontenla, Rycroft-Malone, &
more immediate response. Some nurses perceive
Seers, 2008). An initial response to the detection of
hypoglycaemia as being a frequent event in the life of
hypoglycaemia was identified in 105 (96%) of cases
the person with diabetes and therefore expect that full
indicating that most nurses understood that treatment
recovery without undue harm will routinely eventuate.
was required. However, there was a wide variation in
The low cumulative adherence to the time specific steps
the treatment provided suggesting that management
of the protocol is indicative of poor understanding of
was not consistently based on the protocol.
the serious nature of hypoglycaemia, and can result in failure to prioritise care.
Nurses’ failure to follow clinical protocols is not a new finding. One reason for this is that protocols are
This is consistent with the findings of other studies
perceived as time-consuming for nurses to implement
(Anthony, 2007; Huynh, et al., 2008). Prolonged
(Backhaus et al., 2010). This is illustrated in this audit
episodes (average time to correction was 85.5minutes)
by the low adherence to step 2 (35 episodes or 30.7%),
were a feature of this study. All nurses receive education
which requires a retest 10 to 15 minutes after initial
about the protocol during their orientation to the ward
treatment.
and through regular in-service sessions provided on the wards. However, the low overall adherence suggests
Nurse to patient ratio continues to be one important
that nurses were either not familiar with the protocol,
determinant in regard to patient outcomes (Tourangeau
could not adhere to it for some reason, or chose to
et al., 2007). High workloads are the everyday reality
disregard it. The findings of this study raise a question
in inpatient care. The nurse who is managing an
about nurses’ understanding of the seriousness of
already high workload may find providing one to one
hypoglycaemia and the importance of timely treatment.
time specific care required by the protocol poses a significant challenge. Prioritisation of nursing time
The delivery of diabetes care in New Zealand is a cause
may be influenced by the severity of the blood glucose
for concern. Improving the knowledge and skills of
result, with a lower result being allocated a higher
all nurses providing care to people with diabetes is
priority. Conversely, the appearance and behaviour of
seen as an important strategy to improving outcomes
the patient, especially during a mild or asymptomatic
for this patient group. This realisation prompted
episode, may result in a failure to prioritise care.
the development of the National Diabetes Nursing Knowledge and Skills Framework that includes the prevention, identification, and treatment of
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Page 21
Nursing Praxis in New Zealand hypoglycaemia. These competencies have been aligned
and accuracy of the data collected are acknowledged.
to the Nursing Council of New Zealand registration
The failure to acquire precise data from the clinical
requirements (MidCentral District Health Board, 2009).
record may have increased the potential for bias in the findings (Elliot, Haber, Lobiondo-Wood, Scheider, &
The finding that 23 out of 32 cases (71.9%) experienced
Whitehead, 2007). CBG results are routinely recorded
recurrent episodes was concerning. Nurses need
on the NDHB diabetes monitoring record which is
to be aware that during hospital admission patients
held with the vital signs record on each patientâ&#x20AC;&#x2122;s
with diabetes are at increased risk for developing
clipboard. The protocol also requires documentation
hypoglycaemia. Risk factors relate to medical issues
in the patientâ&#x20AC;&#x2122;s treatment and progress notes. The
such as tight glycaemic control, a history of previous
researcher identified that the standard of nursing
episodes, severe hepatic dysfunction, and impaired renal
documentation of episodes varied greatly and not all
function. Other important risk factors include increasing
episodes were routinely recorded in the two required
age, inadequate capillary blood glucose monitoring,
clinical records. This may have been a result of nurses
and reduced carbohydrate intake (Stanisstreet, Jones,
failing to transfer vital patient information from their
Walden & Graveling, 2010). The presence of a prior
personal time management plan to official records
hypoglycaemic event is considered to be a particularly
rather than not adhering to steps of the protocol. The
important predictor for inpatient hypoglycaemia (Huynh
resulting incomplete official record of hypoglycaemia
et al., 2008). In this study, there was no evidence in
management is a confounding variable. The limitations
the nursing documentation that an assessment of
associated with the use of a newly developed audit tool,
hypoglycaemic risk factors had been undertaken.
compared to one with proven validity and reliability, are acknowledged.
Another significant factor contributing to the high recurrence of hypoglycaemia found in this study was the failure to review glycaemic management after an
Conclusions and Recommendations
episode. This finding is also consistent with other studies (Anthony, 2008; Huynh, et al., 2008; Smith
Despite the provision of a hospital hypoglycaemia
et al., 2005). The protocol requires the causes of
protocol to assist nurses to treat episodes according to
hypoglycaemia to be reviewed along with preceding
best practice, management of hypoglycaemia was found
diabetic medication doses. In this study the medication
to be suboptimal. Nurses did not consistently follow the
regimen was reviewed in only 20 episodes (17.5%).
recommended steps and in no single episode were all
These reviews did not occur at the time of the episode
the steps achieved. There was little evidence to show
but later at the request of nursing staff or as a result of
that nurses used strategies to prevent hypoglycaemia
a review by medical staff during routine ward rounds.
and their sequelae. Nurses have a key role in the
A more timely review of the diabetes medications after
management of inpatient hypoglycaemia. Education
the initial or a second episode may have reduced the
for nurses concerning the detrimental effects of
rate of recurrent hypoglycaemia.
hypoglycaemia and the need to prioritise the care of the patient with hypoglycaemia is required. A review of the
Strengths and Limitations
protocol in consultation with nurse educators and ward nurses may make the protocol a more nursing-centred
The researcher gathered all data thereby enhancing
document. Strategies to increase nursesâ&#x20AC;&#x2122; familiarity
consistency in its collection. However, gaps in the quality
with, and access to, the protocol include pocket-sized
Page 22
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand laminated cue cards, posters, regular short in-service
include factors such as knowledge of diabetes care,
sessions, and hypoglycaemia management self-audit
workload and time management and documentation.
forms. Steps to prevent recurrent hypoglycaemia
The hospitalised patient with diabetes is known to
such as risk assessment, timely medication review and
experience less favourable inpatient outcomes than
accurate nursing documentation should be developed.
the person who does not have diabetes. Episodes of
Future research should examine strategies to increase
inpatient hypoglycaemia further hinder the patient’s
timely intervention with the correct treatment, such as
return to wellbeing. It is incumbent on all nurses to
the use of ‘hypo-kits. The findings of this study indicate
provide evidence based and timely interventions for
the need for further examination of the factors which
this common diabetes complication.
contribute to non-adherence to the protocol. This may
References American College of Endocrinology & American Diabetes Association. (2006). Statement on in-patient diabetes and glycemic control. Diabetes Care, 29, 1955-1962. doi:10.2337/dc06-9913 American Diabetes Association. (2006). Standards of medical care in diabetes - 2006. Diabetes Care, 29, S4-S42. http://care. diabetesjournals.org/ Anthony, M. (2007). Treatment of hypoglycemia in hospitalised adults: A descriptive study. The Diabetes Educator, 33(4), 709-715. http://www.ncbi.nlm.nih.gov/pubmed/17684172 Anthony, M. (2008). Hypoglycemia in hospitalised adults. MedSurg Nursing, 17(1), 31-40. http://www.ncbi.nlm.nih.gov/pubmed/18429538 Backhaus, B. R., Barnachea, D. F., Gardner, K. P., Hughes, S. K., Locke, C. L., & McEuen, J. A. (2010). An evidenced-based protocol for managing hypoglycemia. American Journal of Nursing, 110(7), 40-45. doi:10.1097/01.NAJ.0000383933.45591.1c. Barnabas, K., Javed, S., Javed, Y., & Kaushal, K. (2010). A study of inpatient diabetes care on medical wards. Journal of Diabetes Nursing, 14(2), 56-62. http://www.thejournalofdiabetesnursing.co.uk Berkley, J., & Lunt, H. (2006). Diabetes epidemiology in New Zealand – does the whole picture differ from the sum of its parts? The New Zealand Medical Journal, 119(1235). http://journal.nzma.org.nz/journal/ Bick, D., Fontenla, M., Rycroft-Malone, J., & Seers, K. (2008). Protocol-based care: Impact on roles and service delivery. Journal of Evaluation in Clinical Practice, 14, 867-873. doi:10.1111/j.1365-2753.2008.01015.x. Diabetes New Zealand. (2010). Low blood glucose (hypoglycaemia) for Type 2 diabetes. Retrieved from http://www.diabetes.org.nz/ living_with_diabetes/type_2_diabetes/low_blood_glucose_hypo Cagliero, E., Grant, R. W., Meigs, J. B., Nathan, D. M., & Wexler, D. J. (2007). Prevalence of hyper-and hypoglycemia among inpatients with diabetes. Diabetes Care, 30(2), 367-369. Elliot, D., Haber, J., Lobiondo-Wood, G., Scheider, Z., & Whitehead, D. (2007). Nursing & midwifery research: Methods and appraisal for evidence-based practice (3rd ed.). Marrickville, NSW: Elsevier Australia. Maynard, G. A., Huynh, P., & Renvall, M. (2008). Iatrogenic inpatient hypoglycemia: Risk factors, treatment, and prevention: analysis of current practice at an academic medical centre with implications for improvement efforts. Diabetes Spectrum, 21, 241-247. doi:10.2337/diaspect.21.4.241 Medsafe. (2006). Information for health professionals. Retrieved from http://www.medsafe.govt.nz/ MidCentral District Health Board. (2009). National diabetes nursing knowledge and skills framework. Retrieved from http://www. nzssd.org.nz/documents/dnss/National%20Diabetes%20Nursing%20Knowledge%20and%20Skills%20Framework%202009.pdf Ministry of Health. (2007). Diabetes surveillance: Population-based estimates and projections for New Zealand, 2001–2011: Public Health Intelligence Occasional Bulletin NMiniso. 46 Retrieved from http://www.health.govt.nz/publication/diabetes-surveillancepopulation-based-estimates-and-projections-new-zealand-2001-2011 Ministry of Health. (2012b).Mortality and demographic data, 2009. Wellington, New Zealand: Author. Retrieved from http://www. health.govt.nz/publication/mortality-and-demographic-data-2009
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Nursing Praxis in New Zealand Ministry of Health. (2012a). The health of New Zealand adults 2011/12: Key findings of the New Zealand health survey. Wellington, New Zealand: Ministry of Health. http://www.health.govt.nz/ Moghissi, E. S., Korytkowski, M.T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., . . . Umpierrez, G. E. (2009). American Association of Clinical Endocrinologists and American Diabetes Association concensus statement on inpatient glycemic control. Diabetes Care, 32(6), 1119-1131. doi:10.2337/dc09-9029 Northland District Health Board. (2006). Diabetes strategy He kaupapa oranga mo te mate huka i roto i Te Tai Tokerau. Retrieved from http://www.northlanddhb.org.nz/Portals/0/Communications/Publications/diabetes-strategy-adopted.pdf Northland District Health Board. (2010). Northland District Health Board - Our hospitals. Retrieved from http://www.northlanddhb. org.nz/Services/OurHospitals.aspx Quality Improvement Committee. (2009). Sentinel and serious events in New Zealand hospitals, 2007-2008. Wellington, New Zealand: Health Quality & Safety Commission. Retrieved from http://www.hqsc.govt.nz/assets/Reportable-Events/Publications/SSEreport-2007-08.pdf Smith, W. D., Winterstein, A. G., Johns, T., Rosenberg, E., & Sauer, B. C. (2005). Causes of hyperglycemia and hypoglycemia in adult inpatients. American Journal of Health-Systems Pharmacy, 62, 714-719. http://www.ajhp.org/ Stanisstreet, D., Walden, E., Jones, E., & Graveling, A. (2010). The hospital managment of hypoglycemia in adults with diabetes mellitus. London, United Kingdom: National Health Service. Retrieved from http://www.diabetes.org.uk/Documents/About%20Us/Our%20 views/Care%20recs/Joint%20British%20Diabetes%20Societies%20Inpatient%20Care%20Group%20-%20The%20Hospital%20 Management%20of%20Hypoglycaemia%20in%20Adults%20with%20Diabetes%20Mellitus.pdf Tourangeau, A. E., Doran, D. M., McGillis Hall, L., Oâ&#x20AC;&#x2122;Brien Pallas, L., Pringles, D., Tu, J. V., & Cranley, L. A. (2007). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-44. doi:10.1111/j.13652648.2006.04084.x Turchin, A., Matheny, M. E., Shubina, M., Scanlon, J. V., Greenwood, B., & Pendergrass, M. L., (2009). Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care, 32, 1153-1157. doi:10.2337/dc08-2127 Wagner, E. H. (2000). The role of patient care teams in chronic disease management. British Medical Journal, 320, 569-572. doi:10.1136/ bmj.320.7234.569
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Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
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Nursing Praxis in New Zealand PRIMARY HEALTHCARE NZ NURSES’ EXPERIENCES OF ADVANCE DIRECTIVES: UNDERSTANDING THEIR POTENTIAL ROLE Raewyn Davidson, MN. Contractor, Hawkes Bay DHB, Napier, New Zealand. Elizabeth Banister, PhD, RN. Adjunct Professor, Graduate School of Nursing, Midwifery & Health, Victoria University of Wellington, New Zealand. Kay de Vries, PhD, MSc, RN. Senior Lecturer, Graduate School of Nursing, Midwifery & Health, Victoria University of Wellington, New Zealand.
Abstract Advance directives are one aspect of advance care planning designed to improve end of life care. The New Zealand Nurses Organisation released their first mission statement in 2010 concerning advance directives suggesting an increase in the use of these. A burgeoning older population, expected to rise over the next few years, places the primary healthcare nurse in a pivotal role to address the challenges in constructing advance directives. While literature supports the role for primary healthcare nurses in promoting advance directives, no research was found on this role in the New Zealand context. This paper presents results of a qualitative study conducted in New Zealand with 13 senior primary healthcare nurses with respect to their knowledge, attitudes, and experiences of advance directives. Results of the analysis revealed a dynamic process involving participants coming to understand their potential role in this area. This process included reflection on personal experience with advance directives; values and ethics related to end of life issues; and professional actions. Keywords: advance directives; advance care planning; primary healthcare nurses’ experience, professional action.
Introduction
care planning. Advance care planning is recognised internationally as pivotal to providing quality end of
Most nurses can expect to care for dying patients at some
life care (Phillips et al., 2011). It offers opportunities
stage of their career (New Zealand Nurses Organisation
for individuals to co-create with significant others and
(NZNO) 2010a). A burgeoning older population in New
health professionals, their healthcare wishes should
Zealand, expected to rise in the next 15 years (Ministry
they lose their decision making ability (Blackford &
of Health (MOH), 2002), will impact on healthcare
Street, 2011).
services (MOH, 2006). The vision for primary health services emphasises population health care and a wider
This study was undertaken to uncover primary
range of services such as health promotion, preventative
healthcare nurses’ knowledge, experience and attitudes
care and co-ordination across services (MOH, 2001a).
concerning their role in advance directives. In terms
Within this context, primary healthcare nurses have an
of terminology within the New Zealand context, an
important role in providing patient-centred end of life care (MOH, 2001b). In particular, primary health care nurses need to be familiar with patient and whānau/ family wishes including those concerning advance Page 26
Davidson, R., Banister, E., & de Vries, K. (2013). Primary healthcare NZ nurses’ experiences of advance directives: Understanding their potential role. Nursing Praxis in New Zealand, 29(2), 26-33. Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand advance care plan may be considered an advance
& Ahlquist, 2009; Conroy, et al., 2009), a paucity of
directive or may be aligned with other existing advance
literature exists about this facilitator role.
directives and be legally binding (MOH, 2011). In this paper both terms are used interchangeably. An advance
Research Design and Methodology
directive may be written or oral (Crane, Wittink, & Doukas, 2005; Malpas, 2011).
The purpose of this study was to capture senior primary healthcare nurses’ understanding of their
Background
role concerning advance directives in New Zealand. A descriptive exploratory research design was employed.
In 2010, the New Zealand Nurses’ Organisation
This research approach presents the phenomenon
released their first position statement about the use
under investigation in everyday language (Sandelowski,
of advance directives, including nurses’ professional
2000). Qualitative descriptive studies provide an
and legal obligations regarding informed decision
extensive summary of an event in “everyday terms of
making and advance care planning (NZNO, 2010a).
those events” (Sandelowski, p. 326).
Advance directives align with the New Zealand Nursing Council’s nursing competencies and patients’ rights to self-determination to refuse treatment and the right to
Methods
choose (Nursing Council of NZ (NCNZ), 2007). Prior to ethics approval being obtained for the study, Traditionally, advance directives, such as living wills
recommendations for engaging in Māori research
and surrogate appointments created by legislative
were followed. A consultation process took place with
provisions, focused on a limited set of circumstances,
the Māori Health Manager at the local District Health
such as when a person is in a persistent vegetative state
Board (DHB) and the Māori health co-ordinator at
or death is imminent regardless of treatment options
the local primary health organisation (PHO). The local
(Hickman, Hammes, Moss, & Tolle, 2005). A more recent
DHB human research ethics committee reviewed and
approach to advance directives involves co-creating a
approved the study. Written informed consent was
plan specific to patients’ values, relationships, culture
obtained from each participant prior to data collection.
and medical condition (Hickman, et al., 2005). Purposive sampling was employed for participant Primary healthcare is aimed at developing self-reliance
recruitment. Selection criteria included: English
and determination, and is the first level of contact
speaking, senior primary healthcare registered nurses
individuals, families and community have with national
(over five years’ experience as a registered nurse) who
health (World Health Organisation, 2001). Although end
worked in general practice, or worked with a Māori
of life care is provided in a number of settings, some
health provider for 12 months or more. A list of all
researchers suggest that advance directives in primary
general practices in the designated region was obtained
care settings be developed while the patient is well or
from the local primary health organisation (PHO). A
in early disease (Conroy, Fade, Fraser, & Schiff, 2009;
letter of invitation was sent to each nurse manager and
Putman-Casdorph, Drenning, Richards, & Messenger,
most senior nurses at each practice site. All New Zealand
2009). Despite the large interface primary healthcare
research is deemed important to Māori (Hudson, Milne,
has with the public and potential for primary healthcare
Reynolds, Russell, & Smith, 2010), with the Treaty of
nurses to facilitate advance directives (Newton, Clark,
Waitangi principles of partnership, participation and
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Page 27
Nursing Praxis in New Zealand protection embedded within the New Zealand Nursing
Findings
Council guidelines (NCNZ, 2007). Senior staff from the DHB and PHO assisted in identifying appropriate
In this section we present the findings from our analysis
individuals to help access senior primary healthcare
of primary health nurses’ perception of their role in
nurses who were Māori or worked in a Māori health
advance directives (Davidson, 2011). Two propositions
provider’s practice. Thirty-four primary healthcare
informed the analysis: (a) primary health nurses
nurses were invited to participate in the study; 13 agreed
currently do not have a role in advance directives; and
to participate.
(b) primary health nurses believe that advance directives can promote effective end-of-life care. Advance care
All members of the participant group were over 40 years
planning has gained momentum in New Zealand; for
of age and included twelve females and one male, ten
that reason a greater understanding of the primary
of whom were Caucasian, one European/Māori and
health nurses’ role is required to further advancements
two Māori. The perspectives of the Māori participants
in this field. The interview questions led participants
are addressed in another paper (forthcoming). Most
to reflect on the subject of advance directives. Most
participants had over 16 years’ experience as registered
participants had little professional experience with
nurses. With respect to level of education, three had
advance directives. However, reflection on personal
a master’s degree in nursing, two a postgraduate
experience contributed to an understanding of their
nursing diploma, one a postgraduate certificate, four
potential role with advance directives in primary care.
a bachelor’s degree in nursing and one a diploma in nursing.
The analysis of the interviews provided an understanding of primary healthcare nurses’ perceptions of their
Semi-structured audio-recorded interviews were
potential role with respect to advance directives.
conducted. The interviews were of approximately 45
Participants described a dynamic process of coming
minutes duration. Interview questions focused on
to understand this role, which included: reflection on
participants’ understanding of advance directives. Each
personal experience with advance directives; values
interview was transcribed by a professional transcriber
and ethics related to end of life issues; and professional
who signed a confidentiality agreement. Confidentiality
actions that they would take when faced with addressing
and anonymity were adhered to, including the use of
future wishes of patients.
pseudonyms on all transcribed data and written reports. Participants had limited or no professional experience A general inductive approach was used for data analysis
with advance directives and often prefaced their
(Sandelowski, 2000; Thomas, 2006). Inductive analysis
discussion with words such as, “I think …”; “From
involves reading and re-reading textual data to identify
my understanding …” or “I assume that …”. Only one
an initial list of categories that reflect the substantive
participant had any direct experience with advance
content of the interviews. Emerging themes are
directives in a primary care environment. Although it
developed through an iterative process of reviewing
was ‘difficult to broach’ this sensitive subject (“It was
the categories, clustering categories into those that
extremely difficult to broach the subject … she had to be
are similar and those that are different and identifying
in the right space”), this experience led to establishing
patterns. Participants were invited to review the
an advance directive policy within the workplace.
findings; two responded and confirmed that the findings fit with their perspective of the phenomenon of inquiry. Page 28
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Personal experience with advance directives
else, another nurse, needs to come and do that work.
Nurses’ own personal experience with advance directives was central to understanding their potential
One participant experienced tension between the
role in this area. Such experiences included: 1) their
ethical dilemma of desiring a patient to die with dignity
wishes regarding their own end of life care options,
and of acknowledging that more time living could
and 2) choices and decisions they had made regarding
benefit families facing bereavement:
Most
Just seeing what he went through … in his mid-
participants had considered their own end of life
seventies it’s relatively young. His wife was put
options: “When you start pondering it [advance
through months and months and months of hell.
directives], you realise that actually a middle-aged
He didn’t have quality of life. And ... although,
woman could have a stroke anytime … it’s good to even
you know, on the other side of that is, I suppose, it
start thinking about it.” Caring for a close family member
gave the family time to say goodbye.
care for a close family member who had died.
who was dying influenced participants’ perspective of advance directives:
Most participants were in favour of advance directives.
I’ve had two family members die, where both
They discussed the role of enabling patients to maintain
of them, I felt, weren’t comfortable. There were
a “voice when they don’t have a physical voice anymore.”
procedures done where I’m jolly sure if they could
Their values reflected experiences of caring for dying
have spoken for themselves they wouldn’t have
patients, particularly concerning the quality of the
wanted it. . . . and that was quite distressing, as a
dying, for both the patient and their loved ones. Some
daughter and granddaughter.
participants had witnessed futile interventions during
It is possible such end of life medical interventions would
the dying process and had, “seen too many people
have been different had these family members’ choices
resuscitated that shouldn’t have been ….” Others
been supported by an advance directive.
had witnessed or knew of advance directives being overridden by medical personnel: “I’ve seen someone resuscitated now twice, when it was made clear to the
Values and ethics related to advance directives
doctor that they were not to be resuscitated. . .in one case, it was even written.” These examples demonstrate
Participants’ beliefs and values influenced how they
a sense of powerlessness experienced by the nurses
viewed their role in operationalising an advance
when patients’ autonomy, rights and values are not
directive or not. That primary care nurses articulate
respected. Participants believed that choice involved a
their position about the use of advance directives was
patient’s right to change their mind or make decisions
highlighted:
that enable them to, “. . .have a bit more control over
Well, your own personal beliefs, of course –
it [end of life].” It appeared that core values such
spiritual, ethical, moral. All those things are always
as dignity, respect, and patient autonomy guided
going to be in play, and your experience over life
participants’ beliefs in ethical nursing practice: “It’s
… so it’s probably wise for the nurse, if she really
about that dignity and that respect and that caring”.
feels strongly either way [for or against the use of advance directives], to make that known to her peers, or to whomever … that maybe it’s someone
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Page 29
Nursing Praxis in New Zealand Professional actions and advance directives
ask for feedback … have they had a discussion with people they care about?
All participants asserted that the primary healthcare environment is an appropriate place for discussions about
Overall the findings revealed minimal experience with,
advance directives. Such environments are conducive to
and limited knowledge of advance directives for this
building trust and rapport with patients and families –
group. Personal and professional experiences within their
needed for such sensitive discussions. This also involved
practice informed their knowledge, as did a belief and
correct timing in initiating such discussions such as when
need to honour patients’ dignity in dying. Nevertheless,
a person was close to dying:
participants’ experienced tension between patients’
It wasn’t easy to broach the subject, but I think she
desire for a dignified death and medical interventions to
was at the stage … and when she said, “I don’t think
prolong life. The entire participant group believed that
I’m going to be around for much longer”, we took
advance directives enabled patients to have a “voice”
that cue, and said, “Well OK then, where are we
and that involvement in advance care planning was part
going, and what are we doing? And what would be
of their professional obligation. The ability to develop
your wishes? And can we have that chat?”
therapeutic relationships with patients and their families was a central part of this obligation; such relationships
Participants noted that these conversations were difficult
enabled authentic in-depth discussions about an advance
for primary healthcare nurses and for all members of the
directive. Participants believed that primary healthcare
healthcare team:
nurses are well positioned to engage in such sensitive
It’s like doing a checklist of all the things that you talk
conversations.
with somebody about. And it’s one of those things that you introduce as a topic I guess, it’s ‘have you thought about’ you know? Or yeah, but it would be
Discussion
a very difficult topic to talk about [laugh]. It wouldn’t be for the faint-hearted too because I don’t think
Personal experience with advance directives
even the doctors approach that topic successfully.
Despite advance directives being a health term in New Zealand since the 1990s, some participants were
Teamwork was seen as a central part of primary
unfamiliar with the terminology. Participants expressed
healthcare nurses’ role in advance directive discussions
gaps in knowledge about legislation concerning advance
and in providing patient-centred end of life care.
directives, and were uncertain about how to proceed with developing and implementing them. This knowledge
The importance of developing therapeutic relationships
gap concurs with findings from other nursing studies
with patients and their families was central to discussions
concerning advance directives (Duke & Thompson, 2007;
about advance directives: “This isn’t just like asking
Putman-Casdorph, et al., 2009).
someone the simple questions … It’s a decision to engage on a deeper level and I think that’s a good thing for us. It’s
Participants’ personal experiences particularly with
not easy.” Participants believed that creating an advance
death of a family member or patient influenced their
directive should be a process, not a ‘one off’ document,
views of advance directives. Their attitudes toward
drawn up during one interview: “It’s something that …
advance directives were positive, supporting findings of
you would build on. Next time you see them, you might
other researchers (Duke & Thompson, 2007; Seymour,
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Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Nursing Praxis in New Zealand Almack & Kennedy, 2010) who found that personal family
liaise as a team to successfully integrate advance directive
experience positively influenced community nurses
discussions into their role. This finding supports results
desire to engage in advance care planning discussions.
of other research on advance care planning (Minto & Strickland, 2011; Ritchie, 2011; Woytkiw, 2010).
Values and ethics concerning advance directives Duke, Yarbrough and Pang (2009) suggest that health
In order to promote patient engagement with the health
professionals may experience moral distress as a result
professional concerning advance directives, participants
of failure to honour an advance directive. This brings
identified that nurses be aware of their beliefs. According
into question the role of patient autonomy in terms of
to Moore (2005) awareness of one’s emotions, responses
respecting patient choice, an important part of holistic
and comfort levels with grief and death is needed in
nursing care. Autonomy is a core value underpinning
order to maintain authenticity; such awareness impacts
nursing ethics (NZNO, 2010b); participants’ belief in
nurses’ engagement with patients, families and other
autonomy, patient rights and patient advocacy guided
health professionals.
their beliefs and experiences with advance directives. Participants experienced tension between supporting
Participants also believed advance directives could be
dying with dignity and prolonging life. In addition,
achieved through a process of ongoing discussions rather
they had witnessed what they believed was the futile
than creating a document drawn up at one interview;
treatment of dying patients in a health system that was
this would offer patients and their family time to review
“too medicalised.” Pavlish, Brown-Saltzmann, Hersh, Shirk
the information. This finding is well supported in the
and Nudelman (2011) concurred with this form of moral
literature (Auer, 2008; Hickman et al., 2005; NZMA, 2004).
distress in their study on nurses’ descriptions of ethically
Programmes proven to be successful, such as “Preferred
difficult situations. Their findings suggest most ethical
Priorities of Care” (Reed, 2011) and “Let Me Talk” (Chan
issues for nurses relate to end of life care. These issues
& Pang, 2010) can help engage patients and their families
focused primarily on patients’ suffering unnecessarily,
in advance care planning (Maxfield et al., 2003).
due to futile medical interventions and witnessing a patient’s advance directive being overridden.
Implications for primary healthcare nursing practice Primary healthcare nurses are well suited to facilitate
Professional actions and advance directives
initiation of advance directives because of their unique
Effective communication tailored to the needs of the
relationships with patients and families. The findings of
patient was evident throughout this study. Participants
this study support the need for open communication
highlighted the need to establish trust and rapport with
about advance directives in the primary healthcare
patients in order to facilitate discussions about advance
setting. For this to occur, nurses need to have a sound
directives. Results of many studies agree that trust and
knowledge of their own personal values and the
rapport are integral to advance directive discussions (for
complexities and legalities around advance directives.
example, Munday, Dale, & Murray, 2007; Ramachandran,
They are then in a better position to work with patients
2008; Reed, 2011). The primary care environment is
and their families to broach the sensitive topic of advance
seen to be an appropriate setting for engaging in such
directives. Use of open-ended questions such as, “What is
discussions (Conroy et al., 2009; Maxfield, Pohl & Colling,
your understanding of an advance directive?”, and follow
2003; Westley & Briggs, 2004). Participants acknowledged
up questions regarding personal preferences would
the importance of involving the physician and the need to
convey respect for patient choice.
Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand
Page 31
Nursing Praxis in New Zealand Primary healthcare nurses also can take a leadership role
including the development of an advance directive. As
in educating other members of health care team about
the range of population-focused services extends in
advance directives. This can include communication
primary healthcare in New Zealand, primary healthcare
training and support. Other members of the healthcare
nurses, with both generalist and advanced skills, will be
team can be engaged in creating protocols for clear
required to meet the needs of the projected growth in the
recording of advance directive discussions with patients
older population. To meet the challenges of facilitating
and their families. Primary healthcare nurses can also
advance directives and advance care planning an in-
show leadership with educating the public about advance
depth understanding and clarification of law, ethics and
directives; for example, participation in public forums to
communication strategies is essential. Research on
discuss advance directives and their use.
primary healthcare nurses’ experiences and attitudes concerning advance directives has not previously been
Conclusion
conducted in New Zealand. Given the national drive to implement advance care planning in New Zealand
The results of this study suggest that an awareness of
results from this study provide insight into the necessity
one’s beliefs and values is integral to engaging in advance
and also the challenges for primary healthcare nurses in
directive discussions. Effective communication skills
taking forward initiatives on advance directives for New
were essential to conversations about end of life issues
Zealanders.
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Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: • Inform and stimulate New Zealand nurses. • Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession. Nursing Praxis in New Zealand publishes material that is relevant to all aspects of nursing practice in New Zealand and internationally. The Journal has a particular interest in research-based practice oriented articles. Articles are usually required to have a nurse or midwife as the sole or principal author. There is no monetary payment to contributors, but the author will receive a complimentary copy of the Journal on publication. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board. Nursing Praxis in New Zealand original research, discursive (including conceptual, position papers and critical reviews that do not contain empirical data), methodological manuscripts, commentaries, research briefs, book reviews, and practice issues and innovations. Contributions are also accepted for Our Stories, which are short pieces profiling historical and contemporary stories, which reveal the contributions of individual nurses to our profession
Guidelines for Manuscripts While we encourage authors to be creative in the way they present their information, the following requirements must be met: •
Manuscripts should be word processed, formatted for A4 size paper, with double line spacing, page numbers on the bottom right side of the page and the manuscript title in the header of each page.
•
Use a plain font (Arial, Calibri, or Times New Roman).
•
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•
Include a maximum of six (6) keywords.
•
Generally manuscripts will not exceed 3,500 words, however longer articles will be considered as long as they are focused and concise.
•
If the article is a research report then details of ethical processes followed must be included in the body of the manuscript.
•
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Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org The Editorial Board reserves the right to modify the style and length of any article submitted, so that it conforms to the Journal format. Major changes to an article will be referred to the nominated author for approval prior to publication.
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Nursing Praxis in New Zealand Manuscript Submissions • Please supply manuscripts as a Word Document by e-mail to admin@nursingpraxis.org • Manuscripts must be word processed, with double spacing, the title in the header and page numbers in the lower right of the footer. on each page. • All tables and figures must be included at the end of the document each on a seperate page. • Check you have used a plain font (Calibri, Arial or Times Roman). • No details of the author are to be displayed on the manuscript, please include this as a separate document (see below). A separate submission sheet must accompany the manuscript, detailing: • The full name, academic and professional qualifications of all authors, and current employment details. • An address to which all correspondence should be sent, contact phone numbers and e-mail addresses. • A statement that the work has not been previously published and giving written consent for publications; this must be signed by all contributing authors. • Where a manuscript is co-authored, each author must declare how they have actively participated in the development and writing of the manuscript.
Referencing It is the author’s responsibility to ensure that all references and citations are accurate and that all referencing follows 2010 APA (6th edition) conventions (see the Nursing Praxis website for examples). This includes all electronic references, which must include doi number for journal articles. References in the text should cite the author’s name(s), followed by the date of publication. Where direct quotations are used, page numbers must be given. References at the end of a manuscript should be listed alphabetically on a separate sheet formatted with a hanging indent and italicised, not underlined. E.g: American Psychological Association (APA). (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. Smythe, L., & Giddings, L. S. (2007). From experience to definition: Addressing the question ‘What is qualitative research?’ Nursing Praxis in New Zealand, 23(1), 37-57.
In the case of historical research, referencing compliant with the New Zealand Journal of History is acceptable.
Review Process All manuscripts will be blind critiqued by at least two reviewers prior to a decision being made by the Editorial Board. Subsequently the author will be notified of acceptance (along with any recommended changes) or rejection of the manuscript. Regular features are not peer reviewed. The review process takes, on average, three months.
Copyright Authors are responsible for the accuracy of their articles. After publication the article and its illustrations become the property of the Nursing Praxis in New Zealand journal.
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Nursing Praxis in New Zealand Commentaries Nursing Praxis welcomes commentaries on papers published in its pages. These should be approximately 1000 words in length and should offer a critical but constructive perspective on the published paper. Original authors will be given the opportunity to respond to published commentaries.
Research Briefs Generally should not exceed 1500 words. Content must include a statement of the topic and purpose of the research; participants and the mode of recruitment; what was done (method and procedure for data collection and analysis); and a brief indication of the findings and their implications for nursing. As the material will be read by a broad cross-section of nurses, abstracts from theses are often not suitable in their original form and so require reworking.
Our Stories Nursing Praxis in New Zealand welcomes submissions to ‘Our Stories’. We are interested in publishing short articles that focus on nursing experiences over time. Our Stories will profile historical and contemporary stories, which reveal the contributions of individual nurses to our profession. Short articles, not exceeding 1500 words, are welcomed which provide insight to the contribution that a New Zealand nurse has made to the profession either locally, nationally, internationally. Such articles could include the stories behind the research, interviews with key nurses or the stories of those who have inspired and influenced their colleagues through their passion and commitment to the profession.
Book Reviews Book reviews should not exceed 500 words. Content must include a statement about the book’s topic and purpose, key points of interest in the book, a critique of the contents, and an indication of the implications or relevance for nursing or health practice.
Practice Issues and Innovations Articles are welcomed which highlight practice issues and innovations. Such articles might constructively discuss current nursing policy, practice or describe new approaches to nursing practice. This should be prepared as outlined for manuscripts above.
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Indexes Nursing Praxis in New Zealand is indexed in: • CINAHL (Cumulative Index of Nursing and Allied Health Literature), and • ProQuest.
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