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Congestive Cardiac Failure With Digoxin Toxicity Essay

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Congestive Cardiac Failure With Digoxin Toxicity Essay

Contents (Jump to)

Criterion-1

Causes, Incidences and Risk Factors of Congestive Cardiac Failure with Digoxin Toxicity:

Comprehensive Understanding of the Disease on Patient and Family:

Criterion-2

Signs & Symptoms

Pathophysiology

Criterion-3

Drug Class

Physiological Effect

Criterion-4

Interventions-Rationales:

Comprehensive Treatment of the Identified Condition:Congestive Cardiac Failure With Digoxin Toxicity Essay

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Supportive care

Electrolyte abnormality management

Bradycardia management

Hemodynamic compromise management

Ongoing monitoring and change of medicine

CASE STUDY ON CONGESTIVE CARDIAC FAILURE WITH DIGOXIN TOXICITY

Criterion-1
Causes, Incidences and Risk Factors of Congestive Cardiac Failure with Digoxin Toxicity:
Digoxin toxicity caused by high levels of digitalis in the body. As in our case study Mrs. Sharon McKenzie, a 77 year old woman, used to take daily 250 mcg of digoxin, which is a very high dose for adult patients. Especially those, who are suffering from congestive cardiac failure, like our patient Mrs. Sharon McKenzie (Neo, et al, 2010). Body receives the therapeutic effect when it stores of 8 to 12 mcg/kg generally with minimum risk of toxicity in most patients with failure of heart and normal sinus or breathing rhythm (Mangoni, 2010).Congestive Cardiac Failure With Digoxin Toxicity Essay
People withheart failurewho have this digoxin are commonly prescribed medications called diuretics that remove excess fluid from the part of body. This is also happens that many diuretics can cause potassium loss from the body (Johnson, Inder, Nagle & Wiggers, 2010). Though ultimately it increases the risk of digitalis toxicity. Again, our patient, Mrs. Sharon McKenzie’s potassium level is low; 2.5 mmol/l. whereas a normal potassium level ranges from 3.5-5.0 mmol/l.
You are more likely to fall into that condition if you take digoxin, digitoxin, or other digitalismedicinesalong with the higher effective drugs that interact withit such as flecainide, quinidine, amiodarone, verapamil, and others. Similarly, Mrs. Sharon McKenzie’s was also taking medication with digoxin like furosemide, warfarin, and enalapril (Siabani, Leeder & Davidson, 2013).Congestive Cardiac Failure With Digoxin Toxicity Essay
In recent years the incidence of digoxin toxicity has dropped among patients in hospitals. A study has been done on 183 outpatients, who are receiving on going treatment of digoxin toxicity at 10 urban and rural Department of Veterans Affairs Medical Centers in the Rocky Mountain region, to evaluate whether a similar decline of digoxin toxicity has occurred or not. The statistics over 1-year period, of that study is like that:
Out of the 183 patients:

50 (27.3%) had one or more risk factors for digoxin toxicity.
Serum digoxin levels were elevated in 13.6% of patients.
Hypokalemia in 14.3%.
Elevated creatinine levels in 17.9%.
And possible drug interactions in 5.5% of patients.
The most common risk factor of digoxin toxicity is the patient’s elderly age. Like in our case study, Mrs. Sharon McKenzie is also 77-year old woman. However there are other risk factors too, which render the elderly more vulnerable to digoxin toxicity. These contain an age-related decline in renal function and a decrease in volume of digoxin distribution. There is also an increase in the number of comorbid conditions, including cardiovascular and chronic obstructive pulmonary disease, which heightens vulnerability to digoxin toxicity.
Comprehensive Understanding of the Disease on Patient and Family:Congestive Cardiac Failure With Digoxin Toxicity Essay
Digoxin toxicity is a life-threatening condition, and when a serious disease like congestive cardiac failure caused by digoxin toxicity then it can impact severely in a bad way on a patient as well as his/her family (Betihavas, 2011). Due to which his/her family also suffer by seeing their loved one mentally disturbed. Often the patients with CHF who are depressed or who lack social support, the higher the support from the social side the higher the rate of healing as the family and the patient both in complex and double trouble.

Criterion-2
Signs & Symptoms
Pathophysiology
Severe ventricular arrhythmias:
Sudden cardiac death and loss of consciousness are the basic signs and symptoms of the cardiac arrhythmias. Complaints such as dizziness, lightheadedness, fluttering, dizziness, and pounding, chest discomfort, quivering, shortness of breath, and forceful or painful fast beats are commonly reported with arrhythmias patients. Often, patients notice arrhythmias only after checking their peripheral pulses (Mudge, et al, 2010).Congestive Cardiac Failure With Digoxin Toxicity Essay

The pathogenesis of the arrhythmias falls into one of two basic mechanisms: increased or covered up automaticity, triggered activity, or re-entry.

Triggered activity occurs when early after depolarization and delayed after depolarization initiate spontaneous multiple depolarization, precipitating ventricular arrhythmias (Johnson, Inder, Nagle & Wiggers, 2010).
Arrhythmogenesis is probably the most common procedure and results from re-entry. It causes the change of state of mind and mood too.
2) Hyperkalemia:

Higher potassium rate in your blood can affect how your heart works. Symptoms of hyperkalemia can include:

Abnormal heart rhythm –arrhythmia– that can be life-threatening
Slowheart rate
Weakness (Neo, et al, 2010)
Hyperkalemia may result from an increase in total body potassium secondary to imbalance of intake vs. excretion or from misdistribution between intra- and extracellular space (Nanda, 2009).

3) Hypokalemia:

Usually symptoms of low potassium are mild

Weakness, tiredness, or pain in arms or legs muscles, sometimes this might be so severe to cause inability and disability to move arms or legs due to weakness of muscles (much like a paralysis) (Hughes & Crowe, 2010)Congestive Cardiac Failure With Digoxin Toxicity Essay

Tingling or numbness
Nausea or vomiting
Abdominal cramping, bloating
Constipation
Palpitations (feeling your heart beat irregularly)
Urine passing rate is too high simultaneously feeling thirsty mostly (Neo, et al, 2010).
In the heart, low potassium levels make the myositis hypo-polarized or hyper excitable. Thus, arrhythmia occurs as a result of the atrium’s lowered membrane potential due to recovery from inactivation of the Na channel, which may trigger an action potential. In addition to this, reduced potassium in the extracellular space inhibits the IKr potassium current activity, and ventricular depolarization is delayed, which thereby promotes reentrant arrhythmias (Jeon, Kraus, Jowsey & Glasgow, 2010).Congestive Cardiac Failure With Digoxin Toxicity Essay

4) Neurologic Symptoms:

In the identified condition, the patient may also go through with neurologic symptoms which are: Visual disturbances, disorientation, and confusion.You might experience confusion. Although rare, you might also see bright spots, have blurry vision, or experience blind spots. In addition, you might urinate much more or less than usual (Betihavas, 2011). Your body could also become swollen.

The physiologies of neurological symptoms are not easy to judge and too complex and our getting of them are incomplete mostly. From an evolutionary perspective it is easy to judge the neurological symptoms. Though it makes sense that the genuine physiologies of neurological symptoms are intricate and interrelated (Courtney, et al, 2009).

5) Sinus Node Dysfunction:

Sinus node dysfunction refers to a number of conditions causing physiologically inappropriate atrial rates. Symptoms may be minimal or include weakness, effort intolerance, palpitations, and syncope. Diagnosis is by ECG. Symptomatic patients require a pacemaker.Congestive Cardiac Failure With Digoxin Toxicity Essay

Sinus node dysfunction includes inappropriate and misbalancing the sinus bradycardia, alternating bradycardia and atrial tachyarrhythmia, sinus pause or arrest, and sinoatrial exit block (Jeon, Kraus, Jowsey & Glasgow, 2010).

SND also causes the abnormalities in SN impulse formation and propagation that also causes abnormalities in the atrium and in the conduction system of the heart (Higgins, et al, 2013). Slow ventricular rates and pauses at the time of stress is the general causes, furthermore, it includes following:

Fatigue
Angina
Syncope
Dizziness
Fall
Confusion
Heart failure symptoms and palpitations
Criterion-3
Drug Class
Physiological Effect
Angiotensin-converting enzyme (ACE) inhibitors:Congestive Cardiac Failure With Digoxin Toxicity Essay
ACE inhibitors cause blood vessels broadness, further descent the amount of work the heart has to do they may also have direct beneficial effects on the heart. These drugs are reducing the symptoms and the need for hospitalization moreover they are helpful to prolong life (Mudge, et al, 2010).

Beta-blockers:
Beta-blockers drugs lower down the heart rate and block excessive blockage in the heart. They also helpful in the heart disease. These drugs are usually used with ACE inhibitors and provide an added benefit. They may temporarily worsen symptoms but result in long-term improvement in heart function (Betihavas, 2011).

Although ACE inhibitors improve outcome in patients with systolic dysfunction, many patients with hypertension experience congestive heart failure due to diastolic dysfunction related to left ventricular hypertrophy. ACE inhibitors have been shown to reverse left ventricular hypertrophy in patients with hypertension.A meta-analysis of the effects of several antihypertensive agents suggested that ACE inhibitors were the most effective agent in reducing left ventricular hypertrophy (Katz & Konstam, 2012).Congestive Cardiac Failure With Digoxin Toxicity Essay

Beta blocker is helpful in improving the function of the failing LV and need to prevent or reverse progressive LV dilation, sphericity, chamber and hypertrophy. Beta blockers also lower down the heart beating rate and LV wall stress. According to recent studies from laboratories have also proven that beta blockers can satisfy cardiomyocyte apoptosis in HF. These are the basic advantages and benefit of beta-blocker for the patient of heart at any higher stage (Katz & Konstam, 2012).

Criterion-4
As a registered nurse, my care plan for a patient suffering from Congestive Cardiac Failure with digoxin toxicity would be like, (Driscoll, et al, 2009)Congestive Cardiac Failure With Digoxin Toxicity Essay

Interventions-Rationales:
I realize that I would hold the medication – Due to possibility of toxicity

Wait for Electrolytes and digoxin test, as these tests were already ordered for our patient – electrolytes can affect the action of dig and cause dysthymias and to find out the level of dig

Monitor I & O – monitoring for renal function

Monitor for edema and auscultator the lungs

Monitor symptoms, VS – S/E of dig toxicity

Call the doctor. – To get orders to carry out interventions and inform doctor

Start an IV. – For administration of medications (Mudge, et al, 2010).

Comprehensive Treatment of the Identified Condition:
The main goal of treatment is to correct cardiac toxicity.If the person has stopped breathing, as our patient Mrs.Sharon McKenzie confronting with shortness of breath, startCPRand get emergency medical help (Betihavas, 2011).

Initial treatment includes:

General supportive care
Discontinuation of digoxin therapy and prevention of further exposure
Administration of digoxin-specific antibody fragments (digoxin immune Fab)
Treatment of specific complications: for example, dysrhythmias and electrolyte abnormalities (Jeon, Kraus, Jowsey & Glasgow, 2010).Congestive Cardiac Failure With Digoxin Toxicity Essay
Supportive care
General supportive care includes attaching patients to a cardiac monitor, providing IV fluids in patients with hypotension or volume depletion (with caution for patients with CHF), supplemental oxygen, and/or repletion of electrolytes in patients with electrolyte abnormalities (Mudge, et al, 2010).

Electrolyte abnormality management
In case of Mrs. Sharon McKenzie, hyperkalemia is only corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia, because her potassium level is low i.e. 2.5 mmol/l. One study showed that insulin interacts directly with Na(+)/K(+) ATPase pump and alters the effect of digoxin (Betihavas, 2011). This supports the finding that for patients with diabetes, insulin has been shown to have cardio protective effects after digoxin intoxication. Calcium is not used to treat hyperkalemia in patients with suspected digoxin toxicity as it may induce arrhythmia or cardiac arrest.Congestive Cardiac Failure With Digoxin Toxicity Essay

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Bradycardia management
As Mrs. Sharon McKenzie’s ECG report showed sinus bradycardia, this will be treated with atropine. Atropine can be given every 3 to 5 minutes until there is a response or the 3 mg maximum dose is reached (San Miguel, et al, 2013).

Hemodynamic compromise management
As Mrs. Sharon McKenzie has signs of hemodynamic insufficiency and/or compromise (e.g., hypotension, altered consciousness or dizziness), digoxin immune Fab is given as primary management (Mudge, et al, 2010).Congestive Cardiac Failure With Digoxin Toxicity Essay

Ongoing monitoring and change of medicine
Ideally, digoxin is discontinued and a different medicine for rate control or a different inotrope prescribed (for AF, atrial flutter or CHF, respectively). If the patient has to remain on digoxin for some reason, then the dose of digoxin is adjusted for the patient’s medication profile (Edgley, Krum & Kelly, 2012).

General Pharmacology
Cardiac glycosides represent a family of compounds that are derived from the foxglove plant (Digitalis purpurea). The therapeutic benefits of digitalis were first described by William Withering in 1785. Initially, digitalis was used to treat dropsy, which is an old term for edema. Subsequent investigations found that digitalis was most useful for edema that was caused by a weakened heart (i.e., heart failure).Congestive Cardiac Failure With Digoxin Toxicity Essay

Mechanisms of action
Digitalis compounds are potent inhibitors of cellular Na+/K+-ATPase. This ion transport system moves sodium ions out of the cell and brings potassium ions into the cell. This transport function is necessary for cell survival because sodium diffusion into the cell and potassium diffusion out of the cell down their concentration gradients would reduce their concentration differences (gradients) across the cell membrane over time. Loss of these ion gradients would lead to cellular depolarization and loss of the negative membrane potential that is required for normal cell function. The Na+/K+-ATPase also plays an active role in the membrane potential. this pump is electrogenic because it transports 3 sodium ions out of the cell for every 2 potassium ions that enter the cell. This can add several negative millivolts to the membrane potential depending on the activity of the pump.Congestive Cardiac Failure With Digoxin Toxicity Essay

cellular mechanism by which digitalis stimulates the heart
Cardiac myocytes, as well as many other cells, have a Na+-Ca++ exchanger (not an active energy-requiring pump) that is essential for maintaining sodium and calcium homeostasis. The exact mechanism by which this exchanger works is unclear. It is known that calcium and sodium can move in either direction across the sarcolemma. Furthermore, three sodium ions are exchanged for each calcium, therefore an electrogenic potential is generated by this exchanger. The direction of movement of these ions (either inward or outward) depends upon the membrane potential and the chemical gradient for the ions. We also know that an increase in intracellular sodium concentration competes for calcium through this exchange mechanism leading to an increase in intracellular calcium concentration. As intracellular sodium increases, the concentration gradient driving sodium into the cell across the exchanger is reduced, thereby reducing the activity of the exchanger, which decreases the movement of calcium out of the cell. Therefore, mechanisms that lead to an accumulation of intracellular sodium cause a subsequent accumulation of intracellular calcium because of decreased exchange pump activity.Congestive Cardiac Failure With Digoxin Toxicity Essay

By inhibiting the Na+/K+-ATPase, cardiac glycosides cause intracellular sodium concentration to increase. This then leads to an accumulation of intracellular calcium via the Na+-Ca++ exchange system. In the heart, increased intracellular calcium causes more calcium to be released by the sarcoplasmic reticulum, thereby making more calcium available to bind to troponin-C, which increases contractility (inotropy). Inhibition of the Na+/K+-ATPase in vascular smooth muscle causes depolarization, which causes smooth muscle contraction and vasoconstriction.Congestive Cardiac Failure With Digoxin Toxicity Essay

By mechanisms that are not fully understood, digitalis compounds also increase vagal efferent activity to the heart. This parasympathomimetic action of digitalis reduces sinoatrial firing rate (decreases heart rate; negative chronotropy) and reduces conduction velocity of electrical impulses through the atrioventricular node (negative dromotropy).

Pharmacokinetics and toxicity
The long half-life of digitalis compounds necessitates special considerations when dosing. With a half-life of 40 hours, digoxin would require several days of constant dosing to reach steady-state, therapeutic plasma levels (digitoxin with a half-life of 160 hours, would require almost a month!). Therefore, when initiating treatment, a special dosing regimen involving “loading doses” is used to rapidly increase digoxin plasma levels. This process is termed “digitalization.” For digoxin, the therapeutic plasma concentration range is 0.5 – 1.5 ng/ml. It is very important that therapeutic plasma levels are not exceeded because digitalis compounds have a relatively narrow therapeutic safety window. Plasma concentrations above 2.0 ng/ml can lead to digitalis toxicity, which is manifested as arrhythmias, some of which may be life-threatening. If toxicity occurs with digoxin, it may take several days for the plasma concentrations to fall to safe levels because of the long half-life. There is available for digoxin toxicity an immune Fab (Digibind) that can be used to rapidly reduce plasma digoxin levels. Potassium supplementation can also reverse the toxic effects of digoxin if the toxicity is related to hypokalemia Congestive Cardiac Failure With Digoxin Toxicity Essay

Drug Interactions
Many commonly used drugs interact with digitalis compounds. The Class IA antiarrhythmic, quinidine, competes with digoxin for binding sites and depresses renal clearance of digoxin. These effects increase digoxin levels and can produce toxicity. Similar interactions occur with calcium-channel blockers and nonsteroidal anti-inflammatory drugs. Other drugs that interact with digitalis compounds are amiodarone (Class III antiarrhythmic) and beta-blockers. Diuretics can indirectly interact with digoxin because of their potential for decreasing plasma potassium levels (i.e., producing hypokalemia). Hypokalemia results in increased digoxin binding to the Na+/K+-ATPase (possibly through increased phosphorylation of the enzyme) and thereby enhances digoxin’s therapeutic and toxic effects. Hypercalcemia enhances digitalis-induced increases in intracellular calcium, which can lead to calcium overload and increased susceptibility to digitalis-induced arrhythmias. Hypomagnesemia also sensitizes the heart to digitalis-induced arrhythmias.Congestive Cardiac Failure With Digoxin Toxicity Essay

Therapeutic Uses

Therapeutic Uses of
Digitalis Compounds
Heart Failure
↑ inotropy
↑ ejection fraction
↓ preload
↓ pulmonary congestion/edema
Arrhythmias
↓ AV nodal conduction
(parasympathomimetic effect)
↓ ventricular rate in atrial flutter
and fibrillation
Heart failure
Digitalis compounds have historically been used in the treatment of chronic heart failure owing to their cardiotonic effect. Although newer and more efficacious treatments for heart failure are available, digitalis compounds are still widely used. Clinical studies in heart failure patients have shown that digoxin, when used in conjunction with diuretics and vasodilators, improves cardiac output and ejection fraction, and reduces filling pressures and pulmonary capillary wedge pressure (this reduces pulmonary congestion and edema); heart rate changes very little. These effects are to be expected for a drug that increases inotropy. Although the direct effect of digoxin on blood vessels is vasoconstriction, when given to patients in heart failure, the systemic vascular resistance falls. This most likely results from the improvement in cardiac output, which leads to withdrawal of compensatory vasoconstrictor mechanisms (e.g., sympathetic adrenergic activity and angiotensin II influences). Digitalis compounds have a small direct diuretic effect on the kidneys, which is beneficial in heart failure patients.Congestive Cardiac Failure With Digoxin Toxicity Essay

Atrial fibrillation and flutter
Atrial fibrillation and flutter lead to a rapid ventricular rate that can impair ventricular filling (due to decreased filling time) and reduce cardiac output. Furthermore, chronic ventricular tachycardia can lead to heart failure. Digitalis compounds, such as digoxin, are useful for reducing ventricular rate when it is being driven by a high atrial rate. The mechanism of this beneficial effect of digoxin is its ability to activate vagal efferent nerves to the heart (parasympathomimetic effect). Vagal activation can reduce the conduction of electrical impulses within the atrioventricular node to the point where some of the impulses will be blocked. When this occurs, fewer impulses reach the ventricles and ventricular rate falls. Digoxin also increases the effective refractory period within the atrioventricular node.Congestive Cardiac Failure With Digoxin Toxicity Essay

Specific Drugs
Three different digitalis compounds (cardiac glycosides) are listed in the table below. The compound most commonly used in the U.S. is digoxin. Ouabain is used primarily as a research tool. (See www.rxlist.com for more details on digoxin).

Drug Oral Availability* Half-life (hours) Elimination
Digoxin 75% 40 kidneys
Digitoxin >90% 160 liver
Ouabain 0% 20 kidneys
* percent absorption  Congestive Cardiac Failure With Digoxin Toxicity Essay

Side Effects, Contraindications and Warnings
The major side effect of digitalis compounds is cardiac arrhythmia, especially atrial tachycardias and atrioventricular block. Digitalis compounds are contraindicated in patients who are hypokalemic, or who have atrioventricular block or Wolff-Parkinson-White (WPW) syndrome. Impaired renal function leads to enhanced plasma levels of digoxin because digoxin is eliminated by the kidneys. Lean, elderly patients are more susceptible to digitalis toxicity because they often have reduced renal function, and their reduced muscle mass increases plasma digoxin levels at a given dose because muscle Na+/K+-ATPase acts as a large binding reservoir for digitalis. A 2012 analysis of the AFFIRM trial determined that digoxin significantly increased all-cause mortality in patients with atrial fibrillation. This calls into question the practice of using digoxin for lowering ventricular rate in patients with atrial fibrillation. Congestive Cardiac Failure With Digoxin Toxicity Essay

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Impacts of Anti-social Working Hours on Nursing Staff Essay

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Impacts of Anti-social Working Hours on Nursing Staff Essay

The aim of this research proposal is to outline a research study that is designed to determine the effects, and impacts, of anti-social working hours on nursing staff, with a view to assessing the validity of three main hypotheses: H1: The greater the number of anti-social hours worked, the more serious will be the negative effects on the professional and personal lives of nursing staff; H2: Nursing staff who have high levels of workplace support are less likely to be affected by anti-social working hours; and H3: Nursing staff who receive adequate monetary compensation for the anti-social hours they work are less likely to be adversely affected, in terms of their professional lives, by these anti-social hours. It is proposed that these hypotheses be tested through sampling twenty nursing staff, gathering both qualitative and quantitative data through the use of the Work Ability Index, a questionnaire and a logbook containing various questions the participants will be asked to complete each working day for one month.Impacts of Anti-social Working Hours on Nursing Staff Essay

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Introduction

A previous review of the relevant literature showed that there are many facets to the effects of anti-social working hours on nursing staff that are not understood. The critical literature review revealed that there were many and various effects of anti-social hours on the professional lives of nursing staff, including negative effects on performance at work, an increase in the number of mistakes made, a decrease in the patience nursing staff had towards patients, a decrease in the levels of holistic care provided and that anti-social working hours could lead to strains being placed on the relationships nursing staff have with their colleagues, their patients and the families of their patients. In addition, it was shown that anti-social working hours had negative effects on the personal lives of nursing staff, including on their home life, their personal safety and their overall health and stress levels.Impacts of Anti-social Working Hours on Nursing Staff Essay

Research questions and objectives

As a result of the findings of this critical literature review, this research proposal suggests a dual quantitative and qualitative approach to assessing the actual effects of anti-social working hours and their impacts on nursing staff, with three main hypotheses to be explored:

H1: The greater the number of anti-social hours worked, the more serious will be the negative effects on the professional and personal lives of nursing staff

H2: Nursing staff who have high levels of workplace support are less likely to be affected by anti-social working hours

H3: Nursing staff who receive adequate monetary compensation for the anti-social hours they work are less likely to be adversely affected, in terms of their professional lives, by these anti-social hours Impacts of Anti-social Working Hours on Nursing Staff Essay

Perspective and methodology

The methodology to be utilised is both qualitative and quantitative, incorporating two quantitative methods (the Work Ability Index and a logbook) and a qualitative method (a questionnaire). In order to test the effects of anti-social hours on nursing staff, it will be necessary to sample a number of nursing staff each of whom work different types/number of hours. Twenty nursing staff will be sampled in total, five who work only during the day, five who work only during the night, five who work shifts without committing to night shifts and five who work shifts and who do commit to working night shifts. Sampling such a diverse set of nursing staff, in terms of the number/type of hours worked will allow the effects of anti-social hours on different types of nursing staff to be assessed,Impacts of Anti-social Working Hours on Nursing Staff Essay

It is proposed that the Work Ability Index (Ilmarinen, 2007) be used to assess how anti-social hours are impacting nursing staff, in terms of their ability to do their jobs, and their own health. The Work Ability Index (Ilmarinen, 2007) is basically a series of questions which take in to account the demands of the work, the workers health status and the resources available for work, and is a summary of the responses to seven items, including: 1) Current work ability compared with the lifetime best; 2) Work ability in relation to the demands of the job; 3) Number of current diseases diagnosed by a physician; 4) Estimated work impairment due to these diseases; 5) Sick leave during the past twelve months; 6) Own prognosis of work ability two years from now; and 7) Mental resources.

In addition to the Work Ability Index, several supplementary questions will be asked of the sample of nursing staff, in the form of a questionnaire, in order to gauge their attitudes to work and their overall satisfaction with their work and pay, their motivation and their opinions regarding the support that is available in their workplace. In addition to the Work Ability Index, and the supplementary questionnaire, which will be used to assess how the sampled nursing staff are being impacted, in terms of the anti-social hours, the sampled nursing staff will be asked to keep a logbook of their activities over one month of work, in which they will be asked to record: their scheduled working hours; their actual working hours; how many of their overtime hours were paid; the amount of sleep they have; a rating of the quality of this sleep; whether they use any sleep aids, and what these are; a rating of their sleepiness levels; a rating of the fatigue they feel each day; a rating of their stress levels each day; a note of any errors they made whilst at work; a note of the type of error made; a note of any potential errors they would have made had another member of staff not intercepted them; and a note of any errors observed in other colleagues.Impacts of Anti-social Working Hours on Nursing Staff Essay

Methods

Sampling

The target for this research is nursing staff, in the hospital in which the researcher is employed. Due to time restrictions with the research project, which needs to be completed in two semesters, the number of participants in this study will need to be kept low, so that their responses to the Work Ability Index, the questionnaire and their records in their logbooks will be manageable, in terms of the amount of data that will result. It is therefore suggested that twenty participants are selected for the study, divided in to nursing staff covering a variety of shifts and working hours: five who work full-time, only day shifts; five who work full-time, only night shifts; five who work shifts, with no night shifts, only day shifts; and five who work shifts but who can work night shifts. Sampling the nursing staff in this way will allow an assessment of the effects of the type of extra working hours has on nursing staff, for example whether working anti-social hours at night has a greater negative effect on nursing staff than working anti-social (i..e, longer) hours during the day, for example.Impacts of Anti-social Working Hours on Nursing Staff Essay

Data collection

As has been discussed, the objectives of this research, and the associated hypotheses, will be tested through a combination of qualitative and quantitative research methods. The Work Ability Index will be utilised in order to gain an overall picture of the effect the work is having on the participants and the views the participants hold regarding their ability to do their jobs, and their own health (Ilmarinen, 2007). The Work Ability Index, as it requires participants to provide a numerical assessment of their responses to the various questions, will provide a quantitative assessment of the participants attitudes towards their work, their ability to do their work and their own health, as a function of the work they are required to do.Impacts of Anti-social Working Hours on Nursing Staff Essay

The questionnaire that will be handed out to the participants aims to provide a snapshot of the participants’ attitudes to work and their overall satisfaction with their work and pay, their motivation and their opinions regarding the support that is available in their workplace. The responses to this questionnaire are intended to be open-ended and, as such, will constitute a qualitative approach to data gathering, with participants being free to respond, at will, to the questions asked. This qualitative approach will allow the participants to outline any concerns they have and to expand upon their feelings with regards to the impact of their working hours on their ability to do their work, on their professional lives, on their personal lives and on their health, amongst other factors.

The logbook will, through the various questions it contains, allow both a qualitative and a quantitative approach to data gathering. Some of the questions will ask the participants to rate various things, with the responses being quantitative in nature, such as the quality of their sleep, the number of hours (scheduled and non-scheduled) that they worked, or their stress levels, for example. Other questions will allow for more open-ended responses, qualitative in nature, such as whether they use any sleep aids, and what these are, or whether any errors were made, with the opportunity to describe these errors.Impacts of Anti-social Working Hours on Nursing Staff Essay

Analytical processes

As the data that will be collected is both quantitative and qualitative in nature, various analyses will be necessary. For the quantitative data gathered, for example the responses to the Work Ability Index and the quantitative questions in the logbook, the data will be analysed with regards to determining any correlations between the responses, for example, whether longer hours, as recorded in the log book, correlates with lower satisfaction with their work, as recorded by the Work Ability Index. Such correlations can be performed using various statistical tests, via a statistical analysis software package, and will provide firm conclusions as to the relationships between the various variables being measured.

The qualitative data that is collected will be voluminous in nature with a great deal of responses to view and analyse (Polit et al., 2007). As Thorne (2000) suggests, the analysis of qualitative data relies on some form of deductive reasoning in order to interpret and structure the meanings that can be derived from the data collected, within the framework of the objectives of the research and the hypotheses that are being tested. It is suggested that the data be analysed using content analysis (Pope et al., 2000; Miles and Huberman, 1984). Content analysis will allow the data to be analysed and to find emergent meanings from this data in order to find inferences from what has been said by the participants and to relate these inferences to the quantitative data that will be collected (Neuendorf, 2002). Analytical induction will be used to test and re-test the intuitive ideas the researcher has regarding the content of the responses, with regard to the objectives of the research and hypotheses being addressed (Pope et al, 2000; Holloway, 1997).Impacts of Anti-social Working Hours on Nursing Staff Essay

It is expected that the correlations found within the quantitative data will be supported by the qualitative data collected, and that the qualitative data will provide more of an in-depth understanding of the actual effects and impacts of anti-social working hours on nursing staff. This combination of quantitative and qualitative data is therefore expected to be a powerful tool in terms of gaining a full understanding of the impacts of anti-social working hours on nursing staff, in terms of the effects on both their professional and private lives, with regards to fulfilling the objectives of the research and determining the validity of the hypotheses being tested.Impacts of Anti-social Working Hours on Nursing Staff Essay

Strategies to promote methodological rigour

There is a risk, in this study, that the nature of the study, and implied pressure from managers and colleagues, may lead to bias in the results gained, in that nursing staff may not feel able to reveal their true feelings about these issues for fear of retribution. In order to minimise the chances of this happening, as has been seen, anonymity will be ensured at all times, minimising the chances of bias entering in to the data and maintaining methodological rigour.

Access and Ethical issues

In order to recruit twenty nursing staff, and to allow the research to be conducted, the Manager of the nursing staff will contacted and permission will be requested to contact the nursing staff to be able to recruit participants. As this research topic touches on a delicate subject, in that managers might be wary of addressing this subject with their staff, and because making recordings in the logbook will take time out of the working day of the nursing staff, the Manager will need to be approached with care. Appendix 1 provides a copy of the suggested letter, that will be sent to the Manager of the nursing staff, in order to recruit possible subjects for the research.Impacts of Anti-social Working Hours on Nursing Staff Essay

All nursing staff on one floor of the hospital will be sent an introductory letter, given in Appendix 2, which will explain the purpose of the study, outline the aims and objectives of the study and outline what will be expected of participants, and which asks for any interested parties to come forward to volunteer themselves for the study. Participants will be selected on the basis of them being independent (i.e., not known to the researcher or any supervisors of the researcher) and will be contacted, within a few days of volunteering themselves and being selected, in order to sign a Consent Form (given in Appendix 3).Impacts of Anti-social Working Hours on Nursing Staff Essay

Following the signing of the consent form, the study will be explained in more detail to the selected participants, with the letter in Appendix 2 being sent out to selected participants, with the various components, and how they will be presented to the participants, being explained within this letter. Following this, the questionnaire will be given to the participants and they will be asked to fill this in and to return it to the researcher within a week of it being sent to them. The Work Ability Index will also be passed to the participants, at the same time as the questionnaire, and the participants will be asked to complete this, within a week, and return the completed questionnaire with the completed Work Ability Index. At the same time, the logbook will be explained in detail, and passed out to each participant, for them to start recording their responses to the questions within this, every working day for one month. The actual Work Ability Index, questionnaire and logbook that will be sent out to participants are given in Appendix 4, 5 and 6, respectively.Impacts of Anti-social Working Hours on Nursing Staff Essay

It is fundamental, at every stage of this process, that the responses of the participants are kept confidential, with only the researcher knowing which responses come from which person. This will be handled by allocating each participant a number and with the questionnaires, Work Ability Index and logbook being passed out, completed and returned, with only this number, not any names. This will ensure that only the researcher knows which participant provided which responses, ensuring that all responses will remain anonymous. Anonymity is fundamentally important in this study, given its delicate nature, dealing as it is with topics that are inflammatory within the workplace of nursing staff, and which could cause problems between nursing staff and their managers. In addition to the numbering system that will be used to protect the anonymity of participants, no personal data will be collected, other than the responses to the three tools, and the storage of all of the responses collected will be carried out in compliance with relevant data storage regulations, such as the Data Protection Act 1998. The data collected will be collected on the basis of anonymity being maintained, but, due to the nature of the study, in that the results are expected to be disseminated as widely as possible, although anonymity will be maintained, confidentiality of responses cannot be guaranteed, as it is these responses that will form the basis of the results, and conclusions of this research, which will be disseminated.Impacts of Anti-social Working Hours on Nursing Staff Essay

The researcher could be affected by the conducting of this study, because, as has been stated, the research topic touches on sensitive matters that are often the cause of conflict within the workplace between managers and nursing staff. The very fact of conducting this study within the workplace may put the researcher at risk of reprisals of some sort, although it should be noted that the study will be introduced to the Head of Department and to managers as a research study, and that, as such, the researcher should be respected, without facing reprisals, and the research allowed to continue without problems.Impacts of Anti-social Working Hours on Nursing Staff Essay

Timetable

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It is suggested that the work be conducted over the course of four months, January to April 2009. The nursing staff will be contacted, initially, and once the twenty nursing staff have been selected, the Work Ability Index and the questionnaire will be completed. Following this, the logbook will be handed out and the nursing staff will record their responses to the questions within that each working day for one month. Once the logbooks have been completed, all of the primary data will be collated and analysed, with the expectation that this process will require a further month. Once the results and conclusions have been gathered from the data, two further months will be required to write up this data in the form of the dissertation. The work would be more vigorous if a larger sample of nursing staff could be included, but this is not possible, unfortunately, given the time constraints,Impacts of Anti-social Working Hours on Nursing Staff Essay

Budget and likely funding sources

The researcher intends to apply for scholarships in order to cover the costs of the research materials needed, but, as the methodology is utilising reasonably priced materials, if a scholarship is not won, it is expected that the materials could be paid for out of the pocket of the researcher.

The expected costs are as follows:

Twenty notebooks (for the logbooks): 20 x £1.50 = 30

Paper/pens/printer ink etc. for the questionnaire/Work Ability Index = 20 x £1.00 = £20

Small gift for each participant: 20 x £2.00 = £40

Binding of dissertation: 4 x £10 = £40

Total cost = £130

Dissemination of results Impacts of Anti-social Working Hours on Nursing Staff Essay

Given the intense interest in this subject in the nursing literature, it is intended that this study be written up for publication in a peer-reviewed nursing journal. In addition, the results of the study will be presented as nursing seminars and the abstract of the work will be sent out to various conferences, with a view to the work being presented at various nursing conferences. In addition, as with all dissertations completed at academic establishments, a copy of the dissertation will be deposited in the university library, so that the work is available for reference by other interested parties.Impacts of Anti-social Working Hours on Nursing Staff Essay

An exploration of the impacts of anti-social working hours on nursing staff

I am writing to ask permission for this research to be conducted within your section. As part of this request, I am asking for permission to be granted to make contact with staff under your management, and for these staff to be asked if they will participate in my research project. I hope to be able to select a total of twenty nursing staff to be able to participate in this research project.

The research project consists of three separate sections: a survey of the participants using a Work Ability Index, a questionnaire of the participants and a logbook, which the participants will need to complete each working day for one month.

I would like the opportunity to present the research project to all of the nursing staff under your management and to select twenty participants from the staff who volunteered their participation. The research project will require the participants to volunteer their own time and any and all research costs will be covered by myself.Impacts of Anti-social Working Hours on Nursing Staff Essay

By the time of the study, the necessary ethical approval for the study will have been given by the relevant committee.

I do hope you can consider my request for access to your staff and look forward to hearing from you.

An exploration of the impacts of anti-social working hours on nursing staff

I am writing to you now to request your participation in a research study I am conducting, looking at the effects and impacts of anti-social working hours on nursing staff.

A literature review I previously worked on showed that there are many facets to the effects of anti-social working hours on nursing staff that are not well understood and that, as anti-social working hours have many negative effects on nursing staff, in terms of their professional and personal lives, I am interested in looking in to this issue in further detail.Impacts of Anti-social Working Hours on Nursing Staff Essay

The main aims of the research are to test three hypotheses:

H1: The greater the number of anti-social hours worked, the more serious will be the negative effects on the professional and personal lives of nursing staff

H2: Nursing staff who have high levels of workplace support are less likely to be affected by anti-social working hours

H3: Nursing staff who receive adequate monetary compensation for the anti-social hours they work are less likely to be adversely affected, in terms of their professional lives, by these anti-social hours

The research project will consist of three main tools, a Work Ability Index, a questionnaire and a logbook, to be filled in by participants every working day for one month. It is expected that the initial assessment, via the Work Ability Index and the questionnaire, would take around one hour of your time to complete, with the logbook taking around twenty minutes to complete each day.Impacts of Anti-social Working Hours on Nursing Staff Essay

If you have any questions or concerns about your participation, please do not hesitate to contact me and I will address these.

If you decide you would like to be part of this research project, I would be grateful if you could sign and return the attached consent form and return it to me in the attached stamped addressed envelope.

Yours sincerely, XXXXX

Appendix 3: Consent form

Research title: An exploration of the impacts of anti-social working hours on nursing staff

Name of researcher: XXXXXX

Please tick the boxes

I can confirm that I have read the participant information sheet and that I understand the aims and objectives of the proposed research _____
I have been given the opportunity to ask questions and to have these questions answered by the researcher ______
I understand that my participation in this research is voluntary and I have fully understood the amount of time my participation in this research will require  Impacts of Anti-social Working Hours on Nursing Staff Essay____
I understand that I will be able to withdraw from the research at any stage without any retribution ­­­_____
I consent to my responses being used in the dissemination of the results of this research, under the proviso that my responses will remain anonymous at all times _____
I agree to keep the research study confidential in that I should not discuss this with my colleagues or managers ____
I agree to take part in the above study ____
Name of participant:

Signature:

Date:

Name of Researcher:

Signature:

Date:

Appendix 4: Work Ability Index

The Work Ability Index (Ilmarinen, 2007) will be used to assess how anti-social hours are impacting nursing staff, in terms of their ability to do their jobs, and their own health. The Work Ability Index for each participant will be calculated as a summary of the responses to seven items, scored over a variety of ranges, giving a total possible maximum score of 49:

Current work ability compared with the lifetime best (scored from 0-10)
Work ability in relation to the demands of the job (scored from 2-10)
Number of current diseases diagnosed by a physician (scored from 1-7)
Estimated work impairment due to these diseases (scored from 1-6)
Sick leave during the past twelve months (scored from 1-5)
Own prognosis of work ability two years from now (scored from 1-7)
Mental resources (scored from 1-4)
As has been seen, in addition to the Work Ability Index, which will give a possible score out of 49, according to the status of the participants regarding their ability to work, several supplementary questions will be asked of the sample of nursing staff, in the form of a questionnaire, in order to gauge their attitudes to work and their overall satisfaction with their work and pay, their motivation and their opinions regarding the support that is available in their workplace.

The actual questionnaire is given below:

1. What are your overall feelings towards your job?

2. What is your attitude towards your work?

3. How do you feel about your pay?

4. Do you work anti-social hours?

5. Are you compensated adequately for these anti-social hours?

6. Do you feel you are forced to work anti-social hours?

7. Do you feel motivated to do your work?

8. If not, please specify the reasons behind you lack of motivation

9. Do you feel you receive enough support in your workplace?

10. If not, what could be done to improve the support available to nursing staff in your workplace?

11. How satisfied are you, overall, with your work?

12. Have you ever considered giving up the nursing profession?

13. If yes, please expand upon your reasons behind this.

14. What do you feel could be done to make your job easier?

15. What do you think managers ought to be doing to minimise the impacts of anti-social hours on you and your colleagues? Appendix 6: Logbook

The logbook is intended to be completed every working day for one month, and consists of the following questions, repeated every day:Impacts of Anti-social Working Hours on Nursing Staff Essay

In the past two decades, a lot of changes have been characterised in the healthcare working systems. One of these changes has been the assimilation of shift work systems and the flexibility in work schedules. The need for 24 hour care makes the healthcare professions to work with different shift systems such as 12 h, 8 h, 9 h or 10 hour shifts. However, the common shift work systems divide a 24-h day in two (12-h) or three (8-h) shifts. Nonetheless, this requires the staff to be adapted with the various forms of shift work schedules.

The negative impacts of shift work on workers’ health such as fatigue and sleep which are the main complain among the staff, job performance, psychosocial well-being, and job dissatisfaction have been…show more content…
With regard to sleepiness, several studies indicated that the average of sleep duration in 1910 to 2002 have decreased from 9 to 6 hours on workdays (National sleep foundation, 2002; Groger et al., 2004). Recently, a survey study of Roger et al. (2004) shows that an American Nurses have an average of 84 minutes more sleep on non workdays. Thus, shift work suggested as a cause of sleeping disorder among nurses where they feel of sleep during the shift. Considering the contributing factors of sleepiness, the literature identified that long working hours and rotating shifts are causing sleeping disorder. In the night and rotating shifts, the nurses are rarely obtained adequate amount of sleep. In fact, the nurses experiencing less sleeping hours (1 to 4 hour) than normal sleeping (Zeisler et al.,1980). Nevertheless, insufficient sleep is a significant reason of damaging planning, decision-making, and integration of information (Krueger, 1994; Harrison and Horne, 2000). Impacts of Anti-social Working Hours on Nursing Staff Essay

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Role of the Midwife as an Educator Essay

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Role of the Midwife as an Educator Essay

The researcher has used the terms “tutor” and “midwife” in an interchangeable format.
Midwifery is about far more than delivering babies. The skills that a midwife needs to carry out her job successfully are legion. In this essay we shall specifically consider the role of the midwife as an educator, and her ability to impart information successfully to a group in a planned parenting session.Role of the Midwife as an Educator Essay

In order to do this successfully it is obviously important for the midwife (or tutor) to appreciate how adults learn optimally in a different way from children. In this essay we shall explore both the theoretical and practical principles which underpin the delivery of a successful course for prospective parents. We shall also consider the importance of course evaluation in the construction and presentation of future courses.Role of the Midwife as an Educator Essay

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It is important to appreciate that adults learn optimally in a different way to children. The dichotomy is often refered to as pedagogy and andragogy. The fundamental difference between the two is that pedagogy is essentially the process whereby the tutor instructs the students and andragogy is the process which involves more of an interaction between the two, with the tutor guiding the students. (Cervero, R. M et al 1999)

In the prospective parenting classes clearly the group are likely to be mainly young adults (the researcher states that they are making a number of assumptions here) and an alternative name for andragogy is experiential learning. This involves the tutor drawing out various experiences that the group, collectively, have had and using them as a basis for discussion and communal learning. (Donaldson, J. F et al. 2000)Role of the Midwife as an Educator Essay

One could reasonably assume that the participants in the group have not had previous direct experience of parenting, but this does not preclude this method of teaching in this circumstance. They certainly will have observed friends, family and others bringing up their children and of course will have their own experiences with their own upbringing which will have formed a number of their opinions, expectations and values. These can usefully be explored and brought out in discussion for the whole group to use as a learning experience. It is likely that a typical group will include participants from different social backgrounds, ethnic groups and classes. This is also a valuable asset which can be exploited for the benefit of all.

Specific examples could be the breast feeding and weaning habits of different ethnic communities and how they differ from what is currently considered to be best practice. Clearly this type of learning is quite different from that which could be used for children (pedagogy) who have very little life experience to draw on. (Johnson-Bailey, J et al 1997)Role of the Midwife as an Educator Essay

Obviously the midwife will have their own professional learning and agenda together with a vast wealth of practical experience. This should ideally be presented in a sensitive but authoritative way, so that the group can have the opportunity to discuss, evaluate and adopt those elements that they collectively feel are or value and importance to themselves. (Ross-Gordon, J. M et al 2002).

Although adults will clearly need to assimilate information – as this is a basic definition of learning – they are far more amenable to techniques which involve self motivation and self-directed learning. (Sheared, V et al. 2001). In this context it is important that the midwife, in addition to simply acting as a tutor and resource, should also suggest other sources of information. Local libraries, NHS leaflets, Local Authority pamphlets and of course the Internet, are all valuable resource options that the prospective parents can access themselves. Part of the information providing responsibility incumbent on the midwife, is the generation of interest which will allow the group members to feel empowered to make further exploration of the area themselves. (EHC 1999)Role of the Midwife as an Educator Essay

The concept of metacognition is also important in this area. Traditionally a midwife might expect to give a talk on various important points of parenting and the prospective parents would sit passively and absorb the elements that they felt were important to them. The talk would finish and the group would disperse. Metacognition is the ability of the student to appreciate the overall context and content of what they are learning about. This is primarily a two way interaction between student and tutor. (Smith, M. C et al. 1998).Role of the Midwife as an Educator Essay

If the midwife is able to establish a dialogue between herself and the group it is easier to evaluate and assess the gaps in knowledge and then to suggest strategies for filling them. Equally, it is a valid strategy to establish where the gaps are and then to encourage the student to find the information for themselves in order to bring back to the group for discussion on the next occasion. (Titmus, C 1999).

When the tutor is constructing the course, if the andragogical approach is chosen as the most appropriate then they should:

Encourage the group members to participate and put forward their own life experiences as much as possible in order to utilise them as exploratory and discussion tools for the group as a whole.

Demonstrate to the group how their collective life experiences can be adapted and utilised within the framework of the current discussion (after Merriam, S. B et al. 1999).Role of the Midwife as an Educator Essay

This is a difficult topic since evaluation is ultimately the most appropriate tool to assess whether the particular course has been successful. There are basically three appropriate viewpoints of evaluation – whether the tutor feels that they have delivered the course successfully, whether the student feels that they have benefited from the course and whether an independent assessor would consider the course appropriate. (Vaske, J. M et al 2001).Role of the Midwife as an Educator Essay

There is not space to fully appraise all of these eventualities, but clearly it is utterly appropriate to consider the student’s appreciation of the course, whether it fulfilled their expectations and needs together with an assessment of the various areas where they felt that the learning experience was either good or lacking.

This is clearly vital, not only from the point of view of deciding whether it is appropriate to continue delivering the course as a public service, but possibly more importantly, to provide feedback to the tutor on just how their delivery was perceived and received. There is obviously no value in presenting a course which is neither appreciated nor useful to the recipients (Tice, E. T et al 1997).Role of the Midwife as an Educator Essay

Conclusions

It is clear that the presentation of a successful adult-orientated course is not just a matter of chance and an informed professional standing up and presenting a series of facts. It is obviously important to optimise the impact and usefulness of the effort involved with an appreciation of the theory and practice of adult learning.

The involvement of the audience group, particularly with an invitation and an expectation to share and learn from their own collective experiences, is clearly an important learning tool and should be maximally exploited by the tutor.Role of the Midwife as an Educator Essay

It is also important to the overall optimisation of the learning experience for the student, that the tutor should develop clear and concise learning objectives for the group and tailor the structure of the group to those objectives. Central to that process is the formulation of an appropriate learning plan, which, in this particular format does not necessarily have to be a formal written plan, but can take the form of either notes or a mentally organised format by the tutor. (Taylor, K et al 2000).

As a midwife, it is imperative that they support and empower women, ensuring they receive the best possible care, support and advice during pregnancy, labour and postpartum period.
Midwifery is an extremely diverse profession; whether it be working in the community, teaching parent and education classes or working within the clinical setting. All aspects require the same standard of care to be adhered to at all times. Providing support to the mother and her family throughout the childbearing continuum is an essential in order to help them adjust to their parental role.
A midwife is usually a woman’s first and main point of contact throughout this process. They are responsible for providing individualised care for both mother and her family, encouraging them to determine how their pregnancy progresses. This includes assisting the woman to make informed decisions about the services and options available to them and supporting them throughout the decision making process.Role of the Midwife as an Educator Essay

Hearing the word midwife leaves many people thinking of unprofessional, inexperienced women who help deliver babies naturally, without the help of medication. In truth, nurse-midwives are registered nurses who have attended additional schooling for women’s health and are taught to make women feel as comfortable as possible. In the beginning, remedies were the females’ legacies, their “birthright”; these females were known as “wise-women by the people, witches of charlatans by authorities”. (Ehrenreich, 1973). “Females were wanderers, traveling from one place to another, healing the sick and wounded.” (Ehrenreich 1973). These women were among the first human healers and they were especially helpful when it came to childbearing. Role of the Midwife as an Educator Essay
MD Marden Wagner said, “In every country where I have seen real progress in maternity care, it was woman’s groups working together with midwives that made the difference.” The Marriam Webster dictionary defines midwifery as “The art or act of assisting at childbirth”. The definition is a spot-on explanation. Midwifery is not very broad; it’s pinpointed as a specific job with detailed instructions that only deal with pregnancies. Many will argue to say that midwives only work with women who are having “normal-pregnancies”.(Goer, 2002). Normal pregnancies include a healthy mother and fetus, with no complications. “Approximately 10% – 30% of pregnant women will experience Bacterial Vaginosis (BV) during their pregnancy. An ectopic pregnancy happens in 1 out of 60 pregnancies. About 1% of all pregnant women will experience placental abruption, and most can be successfully treated depending on what type of separation occurs.” (Pregnancy Complications).

All midwives are educators. While not all midwives are preceptors (clinical teachers who train students), educating birthing families is an integral part of midwifery care. As such, learning principles of adult education can help midwives become more effective for their clients and also will help those who train students to be better preceptors.Role of the Midwife as an Educator Essay

Parents will most often parent their children the way they were parented; our early experiences, good or bad, influence us. It can be the same in clinical midwifery education; we often train midwives the same way we were trained. If weak areas existed in our own clinical training, we have to work hard to improve and create better learning experiences for our own students.

Being a good midwife does not necessarily make one a good teacher. Knowledge of basic educational principles will help a person be a more effective teacher. Theories of education regarding how people learn best are tremendously varied. Some of the early work focused on Bloom’s Taxonomy of Intellectual Behavior (1956), which defines the three overlapping learning domains: cognitive, affective and psychomotor. Further research by Howard Gardner (1983) led to the proposal of the Theory of Multiple Intelligences, using seven styles of learning: verbal/linguistic, logical/mathematical, visual, kinesthetic, musical, interpersonal and intrapersonal. A more modern approach focuses on only four types of learners: visual, aural (hearing), read/write and kinesthetic. Many educators theorize that when students know their learning style and use it to help them study, their learning, will improve. The theory of hemispheric dominance—how the right or left sides of our brains affect learning—is often used in midwifery programs because it emphasizes intuition and empathy.Role of the Midwife as an Educator Essay

Midwifery programs are often written using woman-centered learning, which is more empathic and connected. It involves the learner in the process and is less hierarchal. Many of the concepts in woman-centered learning also are present in constructivism (Bruner 1990), which is the belief that people actively construct new knowledge as they interact with their environment. When people take notes or use learned material in a practical way, such as to restate or teach, they learn it better.

Constructivism Promotes Learner Involvement
A constructivist perspective views learners as actively engaged in making meaning based on their prior knowledge and experiences. Teaching with that approach focuses on what students can analyze, investigate, collaborate, share, build and generate, based on what they already know, rather than what facts, skills and processes they can memorize and regurgitate. Some of the ways the tenets of constructivism apply to training midwives are:Role of the Midwife as an Educator Essay

Students’ prior experience and learning is recognized and valued.
New knowledge is constructed using the individual student’s prior knowledge.
Students learn from each other as well as from the teacher.
Students learn better by doing.
Allowing and creating opportunities for all to have a voice promotes the construction of new ideas.
Learning is particularly effective when constructing something for others to experience.
Ways to Incorporate Constructivist Learning Principles in Clinical Education:
Observe students teaching clients.
Role-play complications. For example, get out the pelvis and baby and have the student show you how to get some pesky shoulders unstuck.
Ask her, “How would you handle this?” at every opportunity. And listen to the response.Role of the Midwife as an Educator Essay
Provide opportunities for hands-on involvement, early and often.
If you have more than one student, have the students work together. They can practice clinical skills on each other, do group research projects, etc.
Recognize that your student has her own world-view; respect it and know that changing it takes work.
Being an effective clinical teacher is important, no matter what type of midwife you are or where you practice. Clinical experience is the core of midwifery education. All midwifery educators can improve in this area.

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I was trained much the same way as most direct entry midwives (DEM) in the US in the early seventies: a combination of self-teaching and informal apprenticeship. Many of us started attending births with very little experience and even less training. We learned from experience and shared knowledge with our peers, doctors, chiropractors and anyone else we could. Very soon we had our own students. Our students had advantages we did not, especially more formal one-on-one apprenticeships. Some midwives included classes and directed learning activities. Others focused only on the clinical aspects of training; and their students relied on self-study, distance learning and any related training they could find.Role of the Midwife as an Educator Essay

The midwife credentialing process of the North American Registry of Midwives (NARM) was designed to fully incorporate and support the apprenticeship model of training through the Portfolio Evaluation Process (PEP). As direct entry midwifery schools formed, the Midwifery Education Accreditation Council (MEAC) began accrediting schools and NARM included a track for those who graduated from an accredited program. While NARM remains committed to the PEP, the philosophical trend is toward all midwives attending an accredited school, regardless of whether they are direct entry midwives or nurse-midwives.Role of the Midwife as an Educator Essay

Some have expressed concern about the loss of the “apprenticeship model” of training. Midwives have been trained throughout the ages using the apprenticeship model. While the science of midwifery is taught in the classroom and in books, the art of midwifery is taught in a one-on-one relationship between preceptor and student. We are fortunate in this country to have such a diverse range of training options for women to become midwives. As long as NARM continues to offer the PEP, the apprenticeship model will remain a viable method of becoming a midwife.

The Midwives Alliance of North America (MANA) created the core competencies, or standards of learning, for direct entry midwives. It also provides clear and written objectives for clinical practice that were written largely by early midwives, most of whom were self-taught and apprenticeship-trained. The values of the apprentice model are built into the system.

One of the drawbacks to the apprentice model has been the reliance on only one midwife for the bulk of a student’s education. Midwifery is so complex, and so many diverse approaches are possible for handling the same situations, that the more places students can learn from the better. Today’s midwifery students have more options. They may get their didactic instruction or academics from one place, their clinical training from a number of places and their one-on-one training with one or two midwives, in a high volume birth center or from working in hospitals in the developing world.

Nurse-midwifery students have long had the advantage, in the clinical part of their training, of clear written objectives, skill check-off sheets and other written guidelines. Now, with NARM and MEAC, direct entry students have the same options. These are important tools for clinical training.Role of the Midwife as an Educator Essay

Direct entry midwives in the US face an uphill battle to have our training models recognized with the same validity as the American Council of Nurse Midwives (ACNM) models. American College of Obstetrics and Gynecology (ACOG) recently released a Statement of Position which essentially says that all midwives who do not graduate from a program accredited by ACNM’s agency, the American Midwifery Certification Board, are “lay midwives” and are unsafe and not trained. This is a slap in the face to all the work that direct entry midwives have done with our training models and our credentialing processes.Role of the Midwife as an Educator Essay

The MANA study (Johnson and Daviss 2005) was an important step in demonstrating the safety of midwifery care by certified professional midwives (CPMs). More research needs to be done on the effectiveness of various educational models. Since ACOG has recognized that midwives do not need to be trained as nurses first, with the certified midwife (CM) recognized by ACNM, the next step is just a turf battle between accrediting agencies.

Unfortunately, research is limited on midwifery education for direct entry midwives in the US. If our position in relation to out-of-hospital deliveries is that mandatory CPM training is as valid as that required for a certified nurse midwife (CNM), we need to ask whether the evidence supports our assumptions. We do not truthfully know. We can make educated guesses, but we do not have the research to support our position either way.Role of the Midwife as an Educator Essay

In my experience as a midwifery educator over the last 30 years, I have witnessed tremendous growth and change in how we train midwives. MEAC and NARM have helped us raise the bar. However, I still see the quality of direct entry midwifery education all over the map, from excellent to poor. This includes those who graduate from MEAC programs and those who don’t. We still need to ask: How do midwives think their training prepared them for practice? Are students learning what they are taught? How do students graduating from self-study and apprenticeship-only models hold up in comparison to graduates from accredited schools? How does distance education compare to onsite programs?

To answer some of these and other questions, I conducted a short, informal study that focused on the clinical aspects of training midwives. Role of the Midwife as an Educator Essay

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Risk Pregnancy and Women with Complex Health Essay.

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Risk Pregnancy and Women with Complex Health Essay.

 

For this assignment I have been asked to look at the care I have seen and been involved in giving to a woman with a high risk pregnancy. I intend to identify how my practice could be developed to meet the similar needs of women in the future. To do this I am going to use a reflective approach. I am going to look at the normal anatomy and physiology and analyse the patho-physiology in relation to high risk pregnancy and birth.Risk Pregnancy and Women with Complex Health Essay.

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For most women, their midwife is their first point of contact so they have a crucial role to play in identifying any risks. Included in their extensive role is facilitating pregnancy and childbirth as a positive and fulfilling experience. This is most fundamental for those women whose childbearing experience has been categorised as high risk (Page, 2006).

A pregnancy is classed as high risk if there are any factors that may adversely affect the fetal or maternal outcome. Risk factors must be identified as early as possible to increase the chances of an improved outcome (Queenan et al, 2007).Risk Pregnancy and Women with Complex Health Essay.

When a woman is booked for her maternity care, her medical and obstetric history is taken to ascertain whether she would be suitable for midwifery led care (low risk) or consultant or obstetric led care (high risk). A woman can change from either group during her pregnancy. For example, she may start her care as low risk but then something may happen or a condition may develop so she may therefore require consultant input into her care.

Factors which could mean a woman has a high risk pregnancy include epilepsy, diabetes, cardiac problems, multiple pregnancy, hypertension, obesity and previous obstetric complications, i.e. caesarean section, previous haemorrhage (whether that be antepartum, intrapartum or postpartum), recurrent miscarriages or previous intra-uterine death.

Using Gibbs’ (1988) reflective cycle, I am going to discuss a woman I recently cared for whilst working on Central Delivery Suite, whose pregnancy had been assessed as high risk. This was due to her having had a previous emergency caesarean section and a previous ventouse delivery.

In accordance with The Code (NMC, 2008) I have changed all names mentioned to respect their confidentiality.

Description:

Laura, aged 39 years old, was 39+1 weeks pregnant, gravida three, para two. As just mentioned, her obstetric history meant she would see an obstetric consultant during her pregnancy. As Laura was planning on having a vaginal birth after caesarean section (VBAC) this increased her risk. It was also apparent she had tested positive for Group B Streptococcus (GBS) in both her previous pregnancies. Laura had gone into spontaneous labour. Laura and her partner had both requested antibiotics to be started as soon as possible due to the previous GBS. This was not something my mentor could agree to as Laura had not tested positive for it at any point during this pregnancy.Risk Pregnancy and Women with Complex Health Essay.

However, due to Laura’s admission temperature reading being 38.1°C and in view of the previous two pregnancies testing positive for GBS, it was decided by the obstetric consultant on duty that she would receive antibiotics during labour. We confirmed she was in established labour by performing a vaginal examination, with consent, and finding the cervix was 4-5 cms dilated, partially effaced and membranes were felt intact. After Laura was cannulated, the antibiotic Benzylpenicillin (Penicillin G) 3g was administered intravenously. Then at four-hourly intervals she was given 1.5g until delivery. Due to Laura’s high risk status a cardiotocograph (CTG) was commenced to keep a trace on the fetal heart rate and the uterine contractions.

Laura laboured for approximately 6 hours in total, and went on to have a normal vaginal delivery of a healthy baby boy.

Postnatally, Laura’s observations were taken and baby observations were also taken six hourly and observed for a minimum of twelve hours in accordance with Local Trust Guidelines (Local Trust, 2005).

Feelings:

This event particularly sticks in my mind due to my own curiosity about Group B Streptococcus. When Laura was showing a temperature of 38.1°C, I recognised this was out of the normal range so I informed my mentor. I knew a high temperature could indicate a sign of infection so it was important I made my mentor aware. I felt calm at the time and knew my mentor and the obstetric consultant had the matter under control. My mentor made me feel included in the situation and explained fully what she was doing and when. She went through the process of preparing the drugs and the IV line with me.

I was very happy with the outcome of the situation. At the end of the day, we all wanted a normal, natural delivery of a healthy baby and that was achieved.

Evaluation:

The ultimate goal of this situation was a healthy mother and baby, which was successfully achieved. I am glad the consultant made the decision that Laura would be started on antibiotics as I was aware of how anxious she was.Risk Pregnancy and Women with Complex Health Essay.

Analysis:

The final outcome was Laura had a healthy baby with no signs of GBS disease.

Contributing factors to this were how I relayed important information to my mentor and how the obstetric consultant made the right choice offering Laura antibiotics, even though she had not tested positive for GBS in this pregnancy.

I believe Laura should have been offered a test for GBS to confirm if it was present in this pregnancy or not. She was very anxious about the situation so I feel this would have at least helped put her mind at rest knowing either way. Her and her partner had come to CDS demanding antibiotics as a precaution anyway, and luckily for her, her high temperature meant she received them. Had she not had the high temperature that decision would have been down to the consultant.

Conclusion:

I learnt from this experience the correct drugs to be given in labour, and the quantities and times stages they should be given. I also learnt the drug to be given if the woman is allergic to the primary choice drug. Plus, from using this topic as my high risk assignment, the further reading I have undertaken has also taught me a lot.

Action Plan:

If the situation happened again, I would feel more confident in my knowledge of explaining to the woman and her family why we would advise her to have the antibiotics. In this particular situation, Laura knew a lot about GBS due to her previous pregnancies being tested for it and she was then subsequently treated during the labours. However, if a woman I was caring for had little knowledge of GBS, I feel I could explain it.

Laura was classified as high risk due to her previous obstetric history. However, I am going to concentrate on the Group B streptococcus (GBS) she was concerned she had, after having it in both previous pregnancies. I also have a personal interest around GBS as this was something I tested positive for during my pregnancy and I did not really understand what it was or the complications of it. I was screened routinely as I was living in Spain at the time. Laura was only aware of her GBS, in her previous pregnancies, due to routine screening in Germany. She had not been screened here in the UK for GBS in this pregnancy, due to the uncertainty of clinical evidence and cost effectiveness of the routine screening (NICE, 2003). As mentioned in my reflection, this was something Laura was concerned about and requested she receive antibiotics during her labour as a precaution.Risk Pregnancy and Women with Complex Health Essay.

Group B streptococcus is a common type of streptococcus bacterium. Approximately a third of men and women are ‘carriers’ of GBS in their intestines and a quarter of women carry it in their vagina. Most people are unaware they are carriers as it can be difficult to detect and does not cause any symptoms. Carrying it is perfectly normal as it is one of many different bacteria’s that live within our bodies.

Problems can arise when GBS is transmitted to the fetus. This could happen if the membranes rupture, during labour or the delivery. The fetus could come into contact with GBS if the bacterium travels upwards from the woman’s vagina and into the uterus due to the membranes not being there to protect the fetus. If there are prolonged rupture of membranes there is increased risk of transmission due to more time for the micro-organisms to be transported from the vagina into the cervix, and then to the uterus. According to the Group B Strep Association there is also evidence that GBS may cross intact membranes to expose the fetus whilst it is still in the womb. This could therefore cause preterm births, stillbirths or miscarriages. The fetus could also be exposed while passing through the birth canal. A preterm infant would be more susceptible as their lesser-developed bodies and immune systems are more vulnerable to GBS infection than older infants. The fetus could become infected if they swallow or inhale the bacteria (GBSA, 2011). If the fetus acquires GBS in utero this is known as early onset (Chapman, 2003).Risk Pregnancy and Women with Complex Health Essay.

GBS can also be found on the hands and in the respiratory tract of a colonised person. So once a baby is born, GBS could be passed on to it from the hands. This is why, especially within the first 3 months of a baby’s life, it is so important for anyone who comes into contact with a baby, washes and dries their hands thoroughly. If the baby was to develop the disease from repeated exposure, this is called late onset (Chapman, 2003).

In Laura’s case, we were concerned about in utero transmission which could cause early onset GBS disease. This gave us the option for the administration of prophylactic antibiotics during labour, and at least two hours before delivery, which has been shown to reduce the frequency of neonatal GBS infection (Local Trust Guideline, 2009). Antibiotics given during labour can be very effective at preventing this transmission.Risk Pregnancy and Women with Complex Health Essay.

A guideline written by The Royal College of Obstetricians and Gynaecologists (RCOG, 2003) state a woman should be offered intrapartum antibiotic prophylaxis if they have the following risk factors:

â- previous baby affected by GBS

â- GBS bacteriuria detected during the current pregnancy

â- preterm labour (less than 37 completed weeks of pregnancy)

â- prolonged rupture of the membranes (more than 18 hours before delivery)

â- fever in labour (a temperature of more than 37.8°C)

Although Laura only had one of the above risk factors, she was offered the antibiotics at the discretion of the consultant.

Women must also be reminded of the risks with taking antibiotics and be given all the information so they can make an informed choice. The antibiotics a woman receives will also depend if she has any allergies to medication. The recommended antibiotic for those allergic to penicillin is clindamycin, 900mg administered intravenously, from onset of labour and every 8 hours until delivery (GBSS, 2007, & Local Trust Guideline, 2005).

During my placement on the Neonatal Unit, I also cared for a baby that had to be admitted for antibiotics as its mother had tested positive for GBS during her pregnancy. She was unable to receive antibiotics as the the delivery was so fast and there was not enough time. Therefore the baby was admitted to the Neonatal Unit so he could receive antibiotics. Blood cultures from the baby were obtained and he was treated with penicillin until the culture results were available. This enhanced the importance of the woman receiving the prophylactic antibiotics during labour.

In any high risk situation it is vital that maternal and fetal well being is monitored.

As Laura was high risk she was placed on continuous cardiotocograph (CTG) monitoring.

This gave us a recording and trace of the fetal heart rate so we could indentify any deviation from the norm, in comparison with the baseline for that baby. The primary aim of the CTG is to identify a fetus that may be hypoxic so additional assessments of fetal well-being can be used (i.e. fetal blood sampling) or the fetus being delivered by an instrumental vaginal birth or caesarean section. The use of this kind of technology is justified in being able to save the life a fetus that is shown to be in distress.

The CTG detects the fetal heart rate (FHR) and the uterine activity (toco) simultaneously and displays it in the form of graph. It is important to check the maternal pulse at the same time as applying the CTG, to ensure the machine is recording the fetal heart rate, and not the mothers. The modern machines we use at my Trust have a maternal pulse sensor which the mother applies to her finger, which then records the maternal pulse rate on the graph that is printed out.

The continuous electronic monitoring using the CTG is vital to get a contemporaneous recording of the fetal heart rate. It will give us the baseline heart rate (usually between 110-160 beats per minute), accelerations (momentary increases in the fetal heart rate) and decelerations (momentary decreases in the fetal heart rate). Some aspects of labour will cause natural alterations in the FHR patterns. For example, the pattern will be different when the fetus is asleep or awake. External factors, like uterine contractions and maternal movement can cause the FHR to change. The FHR can also be affected by opiate based painkillers, like pethidine. Some of these changes are quite subtle and can only be detected by continuous CTG e.g. baseline variability, temporal shape of decelerations.Risk Pregnancy and Women with Complex Health Essay.

To be a competent midwife, it is imperative I have knowledge on how to interpret the recorded traces of a CTG. I have seen many CTG traces whilst on my hospital placement due to the high number of high risk women my Trust cares for. However, I still feel I am learning new things every time I see one, as everyone is different. I can distinguish between baseline tachycardia (where the fetal heart rate baseline rises above 160 beats per minute) and baseline bradycardia (the opposite, where the fetal heart rate baseline goes below 110 beats per minute) (Mukherjee, 2007).Risk Pregnancy and Women with Complex Health Essay.

Baseline tachycardia could be physiological if the trace is from a preterm fetus due to immaturity or secondary to maternal pyrexia or dehydration. It could also be a sign of fetal hypoxia. The fetus would try to increase the cardiac output mainly by increasing the heart rate to supply vital organs with oxygen and nutrients.

Baseline bradycardia could be physiological if the trace is from a post-term fetus or possibly a large fetus, provided there are also accelerations present and there baseline variability is above the normal range (>5 beats per minute). If it is just baseline bradycardia with no other normal or reassuring factors, this would need immediate action.Risk Pregnancy and Women with Complex Health Essay.

Another form of technology used within Laura’s pregnancy was screening. When she was initially booked for her antenatal care, her blood and urine would have be sent for screening, after she consented to this. She would also have attended ultrasound scans which are also a form of screening. This is something that is offered to all pregnant women and regardless of their risk status, it is used in both low and high risk pregnancies. It is a process which has been developed, which was not done previously due to lack of knowledge and technology. The standard screening during the antenatal period is urine; to check for any sign of infection, and blood; to check the woman’s blood group, her rhesus status, her iron levels, if she is immune to rubella, and to check for hepatitis B, syphilis and HIV (NHS Choices, 2011).

In line with the National Institute for Clinical Excellence (2003) pregnant women should be offered evidence based information and support to enable them to make informed decisions regarding their care. This means women should be informed of all screening tests available to them. I believe this should include information about screening which is not necessarily available within the NHS but could be carried out privately, for example, GBS screening.

There are arguments for and against introducing routine screening for GBS in the UK. Plumb, Holwell and Clayton (2007) argue that in the UK, GBS prevention is inadequate. They believe the NHS should offer testing for GBS in late pregnancy, thus giving women the opportunity to establish whether their baby is at higher risk of developing the GBS infection.

My current Trust guideline (2005) state there is not enough evidence for it at this time.

GBS awareness campaigners, Group B Strep Support, are pushing for routine testing to be introduced in the UK (Prince, 2011). According to GBSS, Western countries that routinely test, have a lower incidence of infection in new born babies, where as cases in the UK are on the rise. Even since the introduction of the Royal College of Obstetrics and Gynaecologist’s guideline for preventing GBS infection in newborns, in 2003, there has not been a decrease in either the number or the incidence of GBS infections in babies (GBSS, 2007).

The table below shows the how the GBS infection in babies has increased throughout England, Wales and Northern Ireland.

Year report published

Number

All cases

(babies 0-90 days old

Incidence per 1000 live births

Number

Early onset (babies 0-6 days old) Incidence per 1000 live births

Number

Late onset (babies 7-90 days old) Incidence per 1000 live births

Number

2003/3004

311

0.48

207

0.32

104

0.16

0.48

2006/2007

409

0.61

248

0.37

161

0.24

0.61

2007/2008

421

0.61

258

0.37

163

0.24

0.61

2008/2009

470

0.66

279

0.39

191

0.27

0.66

(data published by the Health Protection Agency taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc)

Table 1 Number and rate (per 1000 live births) of group B streptococcal bacteraemia reports in infant’s 0‐90 days old in England, Wales and Northern Ireland: 2003-2009.

The overall number of GBS infections within adults is also reported to have increased by more than 72% from 2001 to 2008:

(data published by the Health Protection Agency

taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc)

Table 2 Number of GBS infections in both males and females

within England, Wales and Northern Ireland: 2001-2008.

A better indication of the rise in GBS infections would be taken from women only, who are 35-37 weeks pregnant. I believe this would give more of an insight into pregnancy GBS infection rates.

While the evidence states the increase in rates, I could not find any reasons for the increases. Some factors I believe may contribute to the rise include the lack of personal hygiene, modern living or even due to lifestyle. For example, many years ago clothing and underwear used to be boiled when washing but now people may be washing their clothes on a 40°C wash and this may not be enough to kill all the bacteria.Risk Pregnancy and Women with Complex Health Essay.

It may not be due to any of these factors; it may just be we have a better awareness of GBS now then what we did years ago. With the constant improvement of technology, we will also be finding out new things.

Although the internet is not a form of technology we use within midwifery, it is certainly a form of technology we definitely need to be aware of. Within the last ten years or so, the internet has become increasingly popular. This means the general public can find about anything, more importantly medical information they may not have been able to access before. Therefore, we need to be aware of those women that we care for, that may have either some basic knowledge or an in-depth knowledge of a medical issue, for instance GBS. The NHS even has a website called NHS Choices (www.nhs.uk) which people can access to check symptoms and research illnesses and also pregnancy. I think this is mainly a good thing, although women may read so much into something they find online and it may make them more anxious or worried. It should not replace the direct contact with their midwife.Risk Pregnancy and Women with Complex Health Essay.

The Nursing and Midwifery Council (NMC, 2008), state we should be delivering care based on the best available evidence. By reading the research I have found to write this assignment I am adhering to The Code by giving women evidence based advice. I may not be able to radically change my operational practice but I will definitely be more aware of what to look for and how to manage the situation. I will also ensure I am aware of those women who may have a more in-depth knowledge about GBS and understand their anxieties.Risk Pregnancy and Women with Complex Health Essay.

From writing this assignment I have identified the risks of GBS, who the risks affect and to what degree it could affect them. I feel I would be able to recognise the signs and be aware of the treatment and management. I have acknowledged the main technology used is for the screening of GBS within the laboratory investigation systems and believe this should be carried out routinely within the UK.Risk Pregnancy and Women with Complex Health Essay.

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