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I SSU E 5 VO LU M E 1 9 S E P T E M B E R- OC TO B E R 2 026

CPD MODULE

POLYENDOCRINE METABOLIC OVARIAN SYNDROME MANAGEMENT FOR GPNs AND ANPs

IAANMP SUPPLEMENT ✽ Association news

IN FOCUS

Disc - shaped lesions

✽ Annual Conference 2026 preview

✽ Showcasing excellence in ANMP research and innovation

IgA nephropathy PVC - related bloodstream infections

FROM EVIDENCE TO EVERYDAY CARE – RESEARCH AND THE NMBI CODE IN GENERAL PRACTICE NURSING

SUPPORTING THE I R I S H A S S O C I AT I O N O F A DVA N C E D N U R S E M I DW I F E P R AC T I T I O N E R S

THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONAL USE ONLY

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IMPORTANT NOTICE: Breastfeeding is best. Aptamil Pepti 1 is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. For enteral use only. Refer to label for details. References: 1. Giampietro, et al. Pediatr Allergy Immunol. 2001;12:83-6. 2. Sorensen, et al. Allergy. 2021;76:333(674). 3. Data on file: Updated independent taste panel report, Campden BRI, October 2020. n=102 HCPs (dietitians and GPs). Campden BRI home usage taste test. Aptamil Pepti 1 and Aptamil Pepti Syneo vs all other UK EHFs suitable from birth. 4. Maslin, et al. Pediatr Allergy Immunol. 2018; 29(8):857- 62. 5. Data on file: Market comparison of Ireland EHF prices per 400g tin, MIMS, August 2026. www.mims.ie. 6. IQVIA Data, June 2026, Moving Annual Total (MAT), volume EHF market share (Ireland). Accurate at time of publication: August 2026

EDITORIAL

] A message from Denise and the team at NiPI

Evidence-based practice: Friend or foe?

elcome to the latest edition of Nursing in Practice Ireland (NiPI). We talk a lot about research, science, and data, in both the journal and in practice, because evidence-based practice (EBP) is a cornerstone of healthcare. It has transformed care delivery, clinical guidance, and patient outcomes across the globe. EBP is not, however, without its challenges, limitations, and complexities. Language, in particular, is often identified as a barrier to EBP, with many healthcare professionals reporting that the terminology used can be off-putting, particularly when it sounds overly academic or complex. This then creates the impression that EBP is inaccessible or excessively theoretical. Indeed, throughout my 20-year nursing career, observational evidence would certainly suggest that this language can, and does, discourage engagement and make the approach feel more complicated than it needs to be. In reality, however, nurses are engaging in, and working in accordance with, EBP on a daily basis. In this edition of NiPI, Professional Development Coordinators for General Practice Nursing, Kathy Taaffe and Marie Courtney, break down this sometimes-daunting lexicon, and provide practical guidance for nurses in general practice – and beyond – about how to engage in EBP, practice development,

and quality improvement in accordance with the NMBI Code. For your own practice development, there is a monstersized, evidence-based, CPD module in this issue. Clinical expert in women’s health, ANP Catriona Keye, delivers a comprehensive overview of the recently renamed polyendocrine metabolic ovarian syndrome (PMOS), better known as polycystic ovary syndrome. A freshly published international consensus statement proposed the renaming of PMOS to reflect the growing recognition that the condition extends beyond ovarian dysfunction alone, and encompasses complex endocrine, metabolic, reproductive, and cardiometabolic processes. Catriona explores all of these aspects of the disorder alongside best practice recommendations for its management. Infection prevention and control (IPC) is strongly represented in this edition of NiPI. In her article, IPC ADON, Grace Kinahan, describes the implementation and evaluation of a successful, multimodal quality improvement strategy to improve peripheral venous catheterisation outcomes, while Consultant Microbiologist Dr Jayanta B Sarma reflects on changing cultures and the contribution IPC nurses make to the overall discipline. Staying with professional reflections, Theresa Lowry Lehnen describes her day-to-day life in a dynamic ANP-led university medical centre in her first article. Theresa’s

accounts highlight the autonomous, expert nature of the advanced practitioner role and its value within the overall healthcare system. In her second article, she examines the complexities of IgA nephropathy, focusing on the recently updated KDIGO 2025 guideline. Also among the clinical content, Dr Johnny Loughnane provides an in-depth article on disc-shaped lesions, covering conditions like discoid eczema, tinea incognito, palmoplantar pustulosis, and more. The article also contains a diverse range of helpful images to practically guide diagnosis and management strategies. We hope you enjoy another nurse-led, diverse, and packed edition of NiPI. Thank you to the IAANMP for being a valued part of our publication and to all our contributors for sharing their knowledge and expertise to promote clinical excellence and optimal patient outcomes. As always, we welcome feedback, suggestions, and new contributors.

New authors and contributors are very welcome to get in touch. If you would like to write an article for NiPI, contact denise@greenx.ie

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

To contribute to the IAANMP supplement, contact iaanmp@gmail.com

IN THIS ISSUE

EDITOR Denise Doherty denise@greenx.ie

CONTENTS

04 10 22 29 31 43

News

All the latest healthcare and nursing news from around Ireland

Practical guidance on managing common skin conditions

A message from your PDCs

From evidence to everyday care – research and the NMBI Code in general practice nursing

IgA nephropathy

Reducing the rate of Staph aureus bloodstream isolates associated with PVCs

A retrospective review of a quality improvement project

Emerging therapies and updated KDIGO guidance

Bare above the wrist, bare below the elbow

A reflection about what two phrases taught about the culture of healthcare

Updates from the Irish Association of Nurse Midwife Practitioners

CPD module: polyendocrine metabolic ovarian syndrome management for GPNs and ANPs

The lived experience of an ANP working in a nurse-led university medical centre

Dr Theresa Lowry Lehnen talks about the complexities of delivering care to a diverse student population

IAANMP official supplement

A deep dive into what was termed polycystic ovary syndrome until recently

Getting the diagnosis right when faced with disc-shaped dermatology lesions

Products

The latest in pharmaceutical innovations, research, and products

Crossword

Test your knowledge on your tea-break

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

SUB-EDITORS Emer Keogh emer@greenx.ie Elaine Walsh elaine@greenx.ie CREATIVE DIRECTOR Laura Kenny laura@greenx.ie ADVERTISEMENTS Graham Cooke graham@greenx.ie ADMINISTRATION Daiva Maciunaite daiva@greenx.ie

Please email editorial enquiries to Denise Doherty denise@greenx.ie Nursing in Practice Ireland is produced by GreenCross Publishing Ltd (est. 2007). © Copyright GreenCross Publishing Ltd. 2026 Front cover design: Laura Kenny Additional imagery: iStock.com

Please email publishing enquiries to Publisher and Director, Graham Cooke graham@greenx.ie The contents of Nursing in Practice Ireland are protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means – electronic, mechanical or photocopy recording or otherwise – whole or in part, in any form whatsoever for advertising or promotional purposes without the prior written permission of the editor or publishers. DISCLAIMER The views expressed in Nursing in Practice Ireland are not necessarily those of the publishers, editor or editorial advisory board. While the publishers, editor, and editorial advisory board have taken every care with regard to accuracy of editorial and advertisement contributions, they cannot be held responsible for any errors or omissions contained.

accompanying parathyroid hormone elevations increase with increasing degree of renal impairment. Adequate eczema. Uncommon (≥ 1/1000 to < 1/100): Diverticulitis, cel ulitis, ear infection, lichenoid drug eruptions and intake of calcium, vitamin D and regular monitoring of calcium is especial y important in these patients. injection site reactions. Rare (≥ 1/10,000 to < 1/1,000): Osteonecrosis of the jaw, hypocalcaemia (including severe Skin infections: Patients receiving Prolia may develop skin infections (predominantly cel ulitis) requiring symptomatic hypocalcaemia resulting in hospitalisation, life-threatening events and fatal cases), atypical your postmenopausal patients with f e mor a l f r a c t u r e s, and hyper s ensi t i v i t y ( i n c l u di n g r a sh, ur t i c a r i a , f a c i a l swel l i n g, er y t h ema and anaphylactic hospitaliFor sat ation and if sympt o ms dev e l o p t h en t h ey shoul d c o nt a c t a heal t h c a r e pr o f e ssi o nal i m medi a t e l y . increased risk of fractures 1/10,000): Hypersensitivity vasculitis. Please consult the Summary of Product Osteonecrosis of® the jaw (ONJ): ONJ has been reported rarely in patients receivingPROLIA Prolia for osteoporosis. reactions). Very rare (< ® IA PRESCRIBE PRESCRIBE P stics for a ful description of undesirable effects. Pharmaceutical Precautions: Prolia must not be Delay treatment in patients with unhealed open soft tissue lesions in the mouth. A dental examination with Characteri2,3 2,3 BY BRAND NAME BY BRAND N mi x ed wi t h ot h er medi c i n al pr o duc t s . St o r e at 2° C t o 8° C ( i n a r e f r i g er a t o r ) . Pr o l i a may be exposed t o r o om prProlia eventaProlia tive dentisistry andaanbiologic individual benefit: risk assessment i s r e c o mmended pr i o r t o t r e at m ent wi t h Pr o l i a – HPRA and Irish legislation is a biologic – HPRA and Ir s recommend brand-name of biologicss For your postmenopausal days in its original container. Once removed iwith n patientrecommend s winoth concautomatic omitant risk factors. Refesubstitution r to the SmPCpati foprescribing r riskefants ctors forwiONJ.tPathibrand-name entosteoporosi s should be temperature (up to 25°C) for a maximum single period of up to 30 prescribi with no automatic substitution at pharmacy level encouragedat to maintainpharmacy good oral hygiene, receive routine dental1check-ups and immediatelevel ly report oral from the refrigerator Prolia must be used within this 30 day period. Do not freeze. Keep in outer carton to protect atsymptoimsncreased ri s k of fractures during treatment with Prolia. While on treatment, invasive dental procedures should be performed from light. Legal Category: POM. Presentation and Marketing Authorisation Number: Prolia 60 mg: Pack of only after careful consideration and avoided in close proximity to Prolia administration. The management plan of 1 pre-fil ed syringe with automatic needle guard; EU/1/10/618/003. Price in Republic of Ireland is available on request. Marketing Authorisation Holder: Amgen Europe B.V., Minervum 7061, NL-4817 ZK Breda, P patieReliable. nts who developReliable. ONJ should be setCommitted. up in close col aboration between the treating physiProven. cian and a dentist or Committed. d safety The only denosumab for up withto long-term 10efficacy years and safety for up to 10 years The only denosumab The herlfacilities, ands. Further inofformatmanufacturing ion is availablewith from Amgen Irelandfacilities, Limited, 21long-te Northwood Court, Santry, or a l sur g eon wi t h exper t i s e i n ONJ . Tempor a r y i n t e r u pt i o n of t r e at m ent shoul d be c o nsi d er e d unt i l t h e c o ndi t i o n etwork Proliaof is manufactured manufacturing using the Amgen GlobalNetNetwork d to a including Ireland’s Dún Laoghaire reliable supplythe A PrDún olsupply ia is a registered tand rademarusing kLaoghaire of Amgen Inc. Date of PI preparation: May 2026 resolves andconsistent contributing risProlia kincluding factors are mitigated where possibis le. Osteand onecmanufactured rosis of tsite, hIreland’s e externreliable alcommitted auditory Dublin D09 TX31to, Iraeland.consistent canal: Osteonecrosis of the external auditory canal has been reported with Prolia. Refer to the SmPC for risk (Ref: IRL-162-26-80021) factors. The possibil ty of osteonecrosis of the external auditory canal should be considered in patients receiving denosumab who present with ear symptoms including chronic ear infections. Atypical femoral fracture (AFF): AFF has been reported in patients receiving Prolia. Discontinuation of Prolia therapy in patients suspected to Adverse reactions/events should be rHIGHeported to the Health Products Regulatory Authority (HPRA) using the available methods via www.RISKhprFORa.ie. Adverse reactions/events should also be reported to havProl e AFF shouliad be® coinsisderaed pendibinog evlaoluatgiion ofcth1e pat–ieHPRA nt based on an indiand vidual benefiIrt riissk assessment . h l e gi s l a ti o n FRACTURE During denosumab treatment, patients should be advised to report new or unusual thigh, hip, or groin pain. Amgen Limited on +44 (0)1223 436441 or Freephone 1800 535 160. Patrecommend ients presenting with such symptbrand-name oms should be evaluated for an incprescri omplete femoral fbractiunre. Long-t g oferm biologics

For your postmenopausal patients with osteoporosis at increased risk of fractures1

HIGH RISK FOR FRACTURE

HIGH RISK FOR

1 ®

2,3

1 FRACTURE

2,3

PRESCRIBE PROLIA 2,3 BY BRAND NAME 1,4–8

4,10

HPRA: Health Products Regulatory Authority.

® ce for Biological and (denosumab) Biosimilar Summary of Product Medicines Characteristics. Amgen. Last Use accessed inNovember Acute 2025. 2.Hospitals. HSE. HSE Guidance for Biological Available and Biosimilar Medicines at: https://www.hse. Use in Acute Hospitals. Available at: https://www.hse. References: 1. Prolia HPRA: Health Products Regulatory Authority. ute-hospitals.pdf. ie/eng/about/who/acute-hospitals-division/drugs-management-programme/protocols/guidance-for-biological-medicines-in-acute-hospitals.pdf. Published May 2024. Accessed November 2025. 3. HPRA. Published May 2024. Guide Accessedto November Biosimilars 2025. 3. HPRA. Guide to Biosimilars References: Prolia® (denosumab) Summary of Product Characteristics. Amgen.Published Last access 41-guide-to-biosimilars-for-healthcare-professionals-v4.pdf?sfvrsn=688c384d_10. for Healthcare Professionals. Available at:1. https://assets.hpra.ie/data/docs/default-source/external-guidance-document/aut_g0141-guide-to-biosimilars-for-healthcare-professionals-v4.pdf?sfvrsn=688c384d_10. Published ie/eng/about/who/acute-hospitals-division/drugs-management-programme/protocols/gu bility/. Accessed September 2025. Accessed November November 2025. 4.2025. Amgen. Reliability. 5. Available Curtis at: https://www.amgen.com/science/manufacturing/reliability/. JR, et al. J Bone Miner Res. Accessed 2024;39:826–34. November 2025. 5. Curtis JR, et al. J Bone Miner 6. Res. Amgen. 2024;39:826–34. 6. Amgen. for Healthcare Professionals. Available at: https://assets.hpra.ie/data/docs/default-source/ 52. 8. Amgen. Therapeutic Data areas. Available on at:file. https://www.amgen.eu/therapeutic-areas/. REF-110731. 9.Accessed Bone November HG, 2025. et 7. Amgen. al. Lancet Data on file. REF-110752. Diabetes 8. Amgen. Data on Endocrinol. file. REF-110731. 9. Bone HG,2017;5:513–23. et al. Lancet Diabetes Endocrinol. 2017;5:513–23. September 2025. Accessed November 2025. 4. Amgen. Reliability. Available at: https://www.am 10. Amgen. About Amgen. Available at: https://www.amgen.ie/about-amgen/. Accessed November 2025. Therapeutic areas. Available at: https://www.amgen.eu/therapeutic-areas/. Accessed Novembe 10. Amgen. About Amgen. Available at: https://www.amgen.ie/about-amgen/. Accessed Novem ® reatment: Long-term antiresorptive treatment may contribute antiresorptive treatment: to an Long-term increased antiresorptive treatment risk may contribute for adverse to an increased risk for adverse PROLIA (denosumab) Brief Prescribing Information s ONJ and AFF toofsignificant suppression of bone outcomes such as ONJ and AFF Treatment due to significant suppression discontinuation: of bone remodelling. Treatment discontinuation: Please refer todue the Summary Product Characteristics (SmPC) before prescribing Prolia. Pharmaceutical Form:remodelling. ® needle umab discontinuation, decrease in mineral density (BMD) denosumab is discontinuation, expected decrease in bone (see mineral section density (BMD) is expected 5.1 (see ofsection 5.1 of Pre-filledPROLIA syringe with automatic guard containing 60 mg bone of denosumab in 1 ml solution for injection for Following (denosumab) Brief Prescribing Information ng to an increased risk for fractures. Thus, monitoring theBMD SmPC), leading isto recommended, an increased risk for fractures. Thus,before monitoring andofalternative BMD is recommended, and alternative single usePlease only. Indication: Treatment of osteoporosis in postmenopausal women at increased risk of fractures. of refer to the Summary of Product Characteristics (SmPC) prescribing Prolia. Pha d be considered according to clinical guidelines. Concomitant treatment should be considered medication: according to clinical guidelines. Patients Concomitant medication: being Patients being In postmenopausal women Prolia significantly reduces the risk of vertebral, non-vertebral and hip fractures. Pre-filled syringe with automatic needle guard containing 60 mg of denosumab in 1 ml soluti ia shouldTreatment notsingle be concomitantly with treated with Prolia should containing not be treated concomitantly medicinal with other denosumab products. containing medicinal products. of bone treated loss associated with hormone ablation in men with prostate cancerother at increased denosumab riskof of osteoporosis use only. Indication: Treatment in postmenopausal women at increase cipients: This medicine contains 47 mgProlia sorbitol (E420) each for Excipients: mL of This medicine solution. contains The sorbitol of additive (E420) in each mL of solution. effect The non-vertebral additive effect fractures.In In men with prostate cancer receiving hormone ablation, significantly reduces the risk of inWarnings postmenopausal women Prolia significantly reduces the47 mg risk vertebral, y administered containing sorbitol (orinwith fructose) of concomitantly administered and ablation dietary products containing intake sorbitol (or fructose) of and sorbitol dietary intake of sorbitolcancer a vertebral Treatment fractures. products Treatment of bone of loss associated with long-term systemic glucocorticoid therapy adult bone loss associated hormone in men with prostate ould be taken into account. medicine contains 0.1 (or fructose) mg should of be polysorbate taken into account. This medicine 20contains in each 0.1 mg ofProlia polysorbate mL 20 of in each mL of patients at increased risk of fracture. In Dosagemen and This Administration: 60 mgprostate Prolia administered as acancer subcutaneous fractures. with receiving hormone ablation, significantly re bates may cause allergic reactions. Interactions: Prolia solution. did Polysorbates not affect may cause allergic the reactions. pharmacokinetics Interactions: Prolia did not affect the pharmacokinetics of of injection once every 6 months. Patients must be supplemented with calcium and vitamin D. No dosage vertebral fractures. Treatment of bone loss associated with long-term systemic glucocortico ch is metabolized by cytochrome P450 3A4 (CYP3A4). midazolam, There which is metabolized are by no cytochrome clinical P450 3A4 (CYP3A4). data There on are no the clinical data on the adjustment required in patients with renal impairment. No data is available in patients with long-term systemic patients at increased risk of fracture. Dosage and Administration: 60 mg Prolia administered n of denosumab hormone replacement therapy (HRT), of be denosumab however and hormone replacement the potential therapy (HRT), however for the potential for glucocorticoid therapy and and severeonce renal impairment (Glomerular filtration rate, GFR < 30 mL/min).Patients Prolia should co-administration injection every 6 months. must supplemented with calcium and vitam mic interactions would considered low. In postmenopausal interactions women wouldNo be with considered low. osteoporosis In postmenopausal women with the osteoporosis the not be used in children aged < 18be yearsrequired because of safety concerns of serious hypercalcaemia. Giverenal Prolia pharmacodynamic adjustment in patients with impairment. data is available in patients with lo s and pharmacodynamics Prolia were by pharmacokinetics previous and pharmacodynamics alendronate of Prolia were therapy. not altered by previous Fertility, alendronate therapy. Fertility, patients the package leaflet and patient of reminder card. Re-evaluate the not need for altered continued treatment glucocorticoid therapy and severe renal impairment (Glomerular filtration rate, GFR < 30 mL/ actation: periodically There are or of data from the pregnancy use and of lactation: Prolia There are (denosumab) no or limited amount of data from the in usepregnant of Prolia (denosumab) in pregnant based on theno benefits andlimited potential risks of amount denosumab on an individual patient basis, particularly not be used in children aged < 18 years because of safety concerns of serious hypercalc not recommended for use inHypocalcaemia pregnant women ofis child-bearing not recommended for use in pregnant potential women and women not of child-bearing using potential not using after 5 or more years of use. Contraindications: or hypersensitivity to the activeand substancewomen or to women. Prolia the package leaflet and patient reminder card. Re-evaluate need for con Women should be advised not to become pregnant contraception. Women andshould for be advised at not least to become 5 pregnant months during and for after atthe least 5 months after any of thepatients product excipients. Special Warnings and Precautions: Traceability: Clearly record the name and during periodically based onof the and risks of denosumab an individual patient Prolia. It is denosumab excreted treatment in human with Prolia. It ismilk. unknown whether A risk/benefit denosumab is excreted in on human decision milk. A risk/benefit decision batchunknown number of administeredwhether product to improve traceability biological benefits products.is Hypocalcaemia: Identifypotential after 5 or more years of use. Contraindications: Hypocalcaemia or hypersensitivity to the acti in patients who are breast feeding potential risks be made to in patients the whobreastfed are breast feeding including newborn/infant. potential risks to the breastfed newborn/infant. patients at risk for hypocalcaemia. Hypocalcaemia must be correctedincluding by adequate intake of calcium and vitamin should the product excipients. Special and Precautions: Traceability: rec ave indicated that the absence of RANKL during pregnancy Animal studies may have indicated interfere that the absence with of RANKL maturation during pregnancy may interfere ofwith the maturation ofClearly the D before any initiation ofof therapy. Clinical monitoring of calcium levels is recommended before each dose and, in Warnings batch number product improve ofNobiological Hypoc leading patients to impaired lactation post-partum. No are mammary available gland leading totraceability impaired on lactation the post-partum. effect data of are available Prolia on theproducts. on effect of Prolia on predisposed to hypocalcaemia, within 2of weeks administered after the initial dose. Measure calcium levels if data suspected to patients at risk for hypocalcaemia. Hypocalcaemia must be corrected by adequate intake of c ndesirable Effects: The adverse fertility. Undesirable reported: Effects: The following Very adverse common reactions have been reported: (≥ 1/10) Very common (≥ 1/10) symptoms of hypocalcaemia occur. following Concomitant glucocorticoid treatment is anreactions additional risk factor have for humanbeen D before initiation of therapy. Clinical monitoring of calcium levels is recommended before y, musculoskeletal pain (including severe cases). Common (≥ musculoskeletal 1/100 painto (including < severe 1/10) cases). urinary Common (≥ 1/100 tract to < 1/10) urinary tract hypocalcaemia. Renal Impairment: Patients with severe renal impairment (creatinine clearance < 30 mL/min) or pain in extremity, patients predisposed to hypocalcaemia, within 2 weeks after the initial dose. Measure calcium respiratory sciatica, abdominal discomfort, tract infection, sciatica, rash, constipation,alopecia abdominal discomfort, and rash, alopecia and receivingtract dialysis are atinfection, greater risk of developing hypocalcaemia. Theconstipation, risks of developing hypocalcaemia and infection, upper respiratory symptoms of Diverticulitis, hypocalcaemia occur. Concomitant glucocorticoid treatment is an addition mon (≥ 1/1000 to < hormone 1/100): ear eczema. infection, Uncommon (≥ 1/1000 lichenoid to < 1/100): Diverticulitis, drug cellulitis, eruptions ear infection, lichenoid and drug eruptions and accompanying parathyroid elevations increase with increasing degree ofcellulitis, renal impairment. Adequate Renal with severe impairment (creatinine ctions. Rare 1/10,000 to <monitoring 1/1,000): of the injection jaw, site reactions. hypocalcaemia Rare (≥ 1/10,000 renal to < 1/1,000): Osteonecrosis (including of the jaw, hypocalcaemia severe (including severe clearan intake (≥ ofhypocalcaemia. calcium, vitamin D and regular of calcium Impairment: isOsteonecrosis especially important in thesePatients patients. receiving dialysis are at greater risk of developing hypocalcaemia. The risks of developing h pocalcaemia resulting life-threatening hypocalcaemia resulting and in hospitalisation, fatal cases), life-threatening events atypical and fatal cases), atypical Skin infections: Patients receiving in Prolia hospitalisation, may develop skin infections (predominantly cellulitis) requiring symptomaticevents accompanying hormone elevations withrash, increasing of renal imp s, and hypersensitivity (including rash, urticaria, facial femoral swelling, fractures,increase and hypersensitivity erythema (including and urticaria, anaphylactic facial swelling,degree erythema and anaphylactic hospitalisation and if symptoms develop then parathyroid they should contact a health care professional immediately. intake of calcium, vitamin D Prolia and regular monitoring of calcium is especially important rare (< Osteonecrosis 1/10,000): Hypersensitivity vasculitis. Please reactions). consult Very rare (< 1/10,000): theHypersensitivity Summary vasculitis. Please ofconsult Product the Summary of Product of the jaw (ONJ): ONJ has been reported rarely in patients receiving for osteoporosis. Skin infections: Patients receiving may skin infections c or a full description of undesirable effects. Pharmaceutical for Precautions: a fulldevelop description of undesirable Prolia effects. Pharmaceutical must Precautions: not(predominantly Prolia bemust not be Delay treatment in patients with unhealed open soft tissue lesions in the mouth. A dental examination Prolia with Characteristics hospitalisation and ifisto symptoms develop they should ato health care r medicinal products. Store at 2°C 8°C prior (in a refrigerator). with otherProlia medicinal products. may Store at be 2°C tocontact exposed 8°C (in a refrigerator). Prolia may room be exposed to room profess preventative dentistry and an individual benefit: risk assessment recommended to treatment with Prolia mixedthen to 25°C) for a maximum single of (ONJ): up to 30 days temperature in been its(uporiginal to 25°C) for a maximum container. singlerarely period of up to Once 30 days in itsremoved original container. Once removed in patients with concomitant risk factors. Refer of to theperiod SmPC for jaw risk factors for ONJ. Patients should behas Osteonecrosis the ONJ reported in patients receiving Prolia ator Prolia must be used within this 30 dayand period. Do not fromfreeze. theopen refrigerator Prolia Keep must be used in within outer this 30lesions day carton period. Do not freeze. to Keep in outer carton to protect A dental encouraged to maintain good oral hygiene, receive in routine dental check-ups immediately report oral Delay treatment patients with unhealed soft tissue in protect the mouth. Category: POM. Presentation and Marketing from light. Legal Category: Number: POM. Presentation Prolia and Marketing 60 Authorisation mg: Number: Pack Prolia of 60 mg: Pack of symptoms during treatment with Prolia. While on treatment, invasive dental procedures shouldAuthorisation be performed benefit: preventative dentistry and an individual risk assessment is recommended prior to tre ge with automatic needle guard; EU/1/10/618/003. in syringe Republic with automatic needle of guard; Ireland EU/1/10/618/003. is available Pricerisk in Republicfactors of Ireland on is availablefor on only afterin carefulpatients consideration and avoided in close proximity to Prolia administration. Therisk management planPrice of 1 pre-filled with concomitant factors. Refer to the SmPC for ONJ. P ting Authorisation Holder: Amgen Europe request. Marketing Authorisation 7061, Holder: NL-4817 Amgen dental Europe B.V., Minervum ZK Breda, 7061, NL-4817 ZK Breda, patients who develop ONJ should be set up to in close maintain collaboration between thegood treating physician andB.V., a dentist or Minervum encouraged oral hygiene, receive routine check-ups and imme . Furtheroral information available from Amgen Ireland Limited, Netherlands.on Furthertreatment, 21 information Northwood is available from AmgenCourt, Ireland Limited, Santry, 21 Northwood Court, Santry, surgeon with expertise in ONJ.is Temporary interruptiontreatment of treatment should be considered until Prolia. the condition The symptoms during with While invasive dental procedures sho , Ireland.resolves Prolia is a trademark of Amgen Dublin D09 Date TX31, Ireland. of Prolia PI is a registered preparation: trademark Amgen Inc. May Date of PI2026 preparation: May 2026 and contributing riskregistered factors are mitigated where possible. Osteonecrosis of the external auditory Inc. only after careful consideration and avoided in close proximity to of Prolia administration. The ma -80021) canal: Osteonecrosis (Ref: IRL-162-26-80021) of the external auditory canal has been reported with should Prolia. Refer to thebe SmPCset for risk up patients who develop ONJ in close collaboration between the treating physici factors. The possibility of osteonecrosis of the external expertise auditory canal should be considered in patients receiving oral surgeon with in ONJ. Temporary interruption of treatment should be considered denosumab who present with earand symptomscontributing including chronic ear infections. Atypical fracture (AFF): resolves riskfemoral factors are mitigated where Osteonecrosis of the ons/events should be receiving reported to the Health Products Adverse Regulatory reactions/events should Authority be reported possible. to the Health(HPRA) Products Regulatory Authority (HPRA) AFF has been reported in patients Prolia. Discontinuation of Prolia therapy in patients suspected to canal: Osteonecrosis of the external auditory canal has been reported with Prolia. Refer to able methods via www.hpra.ie. Adverse reactions/events using the available should methods viaalso www.hpra.ie. be Adverse reported reactions/events should to also be reported to have AFF factors. should be considered pending evaluation of the patient based on an individual benefit risk assessment. of The possibility of osteonecrosis the external auditory canal should be considered in d on +44 (0)1223 436441 or Freephone 1800 535 160. Amgen Limited on +44 (0)1223 436441 or Freephone 1800 535 160. During denosumab treatment, patients should be advised to report new or unusual thigh, hip, or groin pain. denosumab who present with ear symptoms including chronic ear infections. Atypical femo Patients presenting such symptoms should be evaluated for an incomplete femoral fracture. Long-term AFF with has been reported in patients receiving Prolia. Discontinuation of Prolia therapy in pati have AFF should be considered pending evaluation of the patient based on an individual benefi Intended for healthcare professionals in the Republic of Ireland only. During denosumab treatment, patients should be advised to report new or unusual thigh, © 2025 Amgen Inc. All rights reserved. Patients presenting with such symptoms should be evaluated for an incomplete femoral fra Amgen Ireland Ltd. 21 Northwood Court, Santry, Dublin 9, D09 TX31. Date of preparation: May 2026. IRL-162-26-80029 Intended for healthcare professionals in the Republic of Ireland only. © 2025 Amgen Inc. All rights reserved. Amgen Ireland Ltd. 21 Northwood Court, Santry, Dublin 9, D09 TX31. Date of preparation: May 2026. IRL-162-26-80029

c substi Iwi ntendedthfor healnothcarautomati e professionals in the Republ ic of Ireland onlty.ution ©at2025pharmacy Amgen Inc. All rights reserved.level2,3 Amgen Ireland Ltd. 21 Northwood Court, Santry, Dublin 9, D09 TX31. Date of preparation: May 2026. IRL-162-26-80029

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New MoleMaps campaign to highlight skin cancer risks in Ireland The Marie Keating Foundation has launched a new national skin cancer awareness campaign urging people in Ireland to protect their skin from ultraviolet (UV) radiation year-round, rather than associating sun protection solely with holidays abroad. The campaign was rolled out nationwide throughout July and August, and emphasised the importance of everyday sun protection amid Ireland’s high rates of skin cancer. Director of Nursing Services at the Marie Keating Foundation, Helen Forristal, said: “Almost nine in 10 cases of skin cancer are considered preventable through simple SunSmart behaviours, including seeking shade during the middle of the day, covering up, wearing sunscreen, protecting your eyes, and avoiding sunbeds. The earlier skin cancer is detected, the better the outcome… Taking a few minutes to check your skin could make all the difference.” Ireland has one of the highest rates of melanoma in Europe, despite its relatively cool climate. This is a key message of the campaign – it is exposure to UV radiation, rather than heat, that

Ms Jacinta O’Brien

increases the risk of skin cancer. Skin cancer is now the most common cancer in Ireland, with approximately 11,500 cases diagnosed each year, accounting for around 34 per cent of all invasive cancers in the country. More than one in five people in Ireland are estimated to develop skin cancer during their lifetime. Around 90 per cent of cases are non-melanoma skin cancers. While melanoma accounts for approximately 11 per cent of skin cancer

diagnoses, it is responsible for around 63 per cent of skin cancer deaths. Ms Jacinta O’Brien, from Bray, Co Wicklow, also spoke at the launch. She was 38 when she was first diagnosed with skin cancer and has since experienced three recurrences, all of which were successfully treated. She also spoke about her uncle, who died from melanoma at the age of just 19. Describing herself as “very fair-skinned”, Ms O’Brien said she was aware of the importance of protecting her skin and provided insight into the lived experience of her diagnosis. “While living in London, I noticed a mole on my forehead had started to itch. Even though I was initially told it was ‘nothing’, I trusted my instincts and kept pushing until it was removed. A few weeks later, I got the news; it was melanoma, already at stage 2. I’m here today because the original mole was on my face – somewhere I could see it. That made all the difference. Melanoma has changed my life in ways I never could have imagined and now I do everything I can to encourage people to protect their skin, trust their instincts, and get anything unusual checked. A tan is never worth the risk.”

Recruitment for 10 specialist crisis nursing teams for EDs nationwide commences Minister for Mental Health Mary Butler TD has announced the start of recruitment for 10 specialist mental health nursing teams aimed at strengthening out-of-hours crisis supports in emergency departments (EDs) nationwide. Recruitment is now underway, with the HSE and hospital management working to have the new teams in place as soon as possible.

The new teams are part of a broader programme of mental health crisis service reform being delivered under the national policies Sharing the Vision and Connecting for Life (2026-2035). Minister Butler secured more than €15million in dedicated funding for crisis supports and targeted suicide prevention measures in Budget 2026. This includes €4million for community-based teams and services

and €2.8million to establish specialist out-of-hours mental health crisis nursing teams in all Model 4 hospitals, as well as Mercy University Hospital, Cork. The teams will comprise Advanced Nurse Practitioners (ANPs) and Clinical Nurse Specialists (CNSs), providing specialist support to people presenting to EDs during a mental health crisis. The new posts are being introduced in

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

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response to evidence showing that many presentations involving self-harm and suicidal ideation occur during evening and overnight hours, when additional specialist support is required. The following hospitals will receive a new team of four staff – two ANPs and two CNSs: ✽ Tallaght University Hospital ✽ St James’s Hospital ✽ Mater Hospital ✽ Beaumont Hospital ✽ St Vincent’s University Hospital ✽ Waterford University Hospital

✽ University Hospital Limerick ✽ Cork University Hospital ✽ Mercy University Hospital ✽ University Hospital Galway. Minister Butler said: “Operating out of hours, the teams will support frontline hospital staff in responding to people who present in crisis. While we are directing the majority of our investment towards community-based alternatives to EDs, we know from both evidence and experience that hospitals must also be equipped to provide a more effective and compassionate response

to people in acute mental distress. “Improving crisis mental health services is one of my key priorities for 2026. We are investing across the entire crisis care pathway, including these new specialist nursing teams, new community-based Crisis Resolution Teams, additional Crisis or ‘Solace’ Cafés, and six new Suicide Crisis Assessment Nursing teams to support GPs in the community. Our goal is to ensure that people experiencing a mental health crisis can access support quickly, compassionately, and as close to home as possible.”

Global nursing leaders call for crucial investment in cancer workforce International nursing and palliative care organisations are calling for urgent investment in the nursing workforce as cancer cases are projected to rise sharply worldwide. The International Council of Nurses (ICN), International Society of Nurses in Cancer Care, and International Children’s Palliative Care Network (ICPCN) issued a joint statement in response to the World Health Organisation’s (WHO) Global Status Report on Cancer 2026. The WHO report projects that annual cancer diagnoses could almost double by 2050, reaching 35 million cases. It also highlights significant inequalities in cancer survival, with five-year breast cancer survival at 87 per cent in highincome countries compared with 42 per cent in many low-income countries. The three organisations said the report demonstrates that medicines and technology alone will not be enough to meet the growing cancer burden. Stronger health systems and a well-supported nursing and multidisciplinary workforce are essential to improving outcomes. They are urging governments and health

systems to make sustained investments in nursing and care that prioritises quality of life, equitable access, and support for patients and families throughout the cancer journey. The joint statement warns that workforce shortages, burnout, and poor retention are putting the quality, safety, and continuity of cancer care at risk. The organisations called for investment in nursing education, retention, safe staffing, continuing professional development, and advanced practice roles. They also stressed the importance of specialist cancer nursing as treatments become increasingly complex, calling for greater investment in cancer nursing education, nurse-led services, and nursing leadership. Palliative care was highlighted as a core component of cancer care, including for children. The ICPCN called for national cancer strategies to include children’s palliative care, access to pain relief, trained nurses within multidisciplinary teams, and family-centred models of care ICN President, José Luis Cobos Serrano, said: “The report’s title, ‘The Future We Choose Together’, is exactly right. We

cannot continue to accept avoidable deaths, unequal treatment outcomes, and unacceptable working conditions for health professionals. It is time to choose a future in which cancer care is equitable, person-centred, and accessible, and the nursing and health workforce is fully supported and empowered. “Nurses are the largest part of the health workforce, the most trusted health professionals, and often the first, most frequent, and most continuous point of contact for people affected by cancer. Across the cancer journey, they provide prevention education, vaccination, screening, early detection, treatment support, psychosocial care, rehabilitation, coordination, and palliative care. “Leaders must make the choice to structurally enable nurses through funded nursing workforce plans, safe staffing, decent working conditions, and continued education and leadership roles. That is how nurses can transform health systems to deliver care that reaches people earlier, supports positive treatment outcomes, reduces suffering, and protects dignity at every stage.”

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New research may present a breakthrough in understanding anxiety A new study of almost 700,000 people has identified the largest number of genetic links with anxiety symptoms to date. Anxiety disorders are among the most prevalent mental health conditions worldwide. Prof Cherie Amour, School of Psychology, Queen's University, Belfast, co-authored the study, led by King’s College London and QIMR Berghofer Medical Research Institute and published in Nature Human Behaviour. The genome-wide association study analysed genetic data from almost 700,000 people of European ancestry to identify genetic differences associated with more severe anxiety symptoms. The research was conducted as part of the Psychiatric Genomics Consortium, an international group focused on large-scale psychiatric genetic studies. The findings suggest environmental influences, gene-environment interactions, and other genetic effects also contribute to anxiety risk. The data demonstrates: ✽ 74 locations where genetic differences were linked to anxiety, including 39

novel findings ✽ Several genes, including PCLO and SORCS3, are particularly active in brain tissue and involved in communication between nerve cells ✽ Common genetic variation accounts for around 6 per cent of differences in anxiety symptom severity between people. Prof Armour said: “Anxiety is one of the most common mental health conditions in our society and this study is an important step forward. It underlines that biological risk works hand-in-hand with people’s experiences and environments. Understanding

both is how we’ll improve prevention and support. I hope that findings like these help us identify who may be most vulnerable, so that we can reach people earlier and offer the right support before symptoms become debilitating.” The researchers also calculated polygenic scores for anxiety across European, African, and South Asian populations. While the findings suggest some genetic variants may be shared, more data is needed to understand population-specific risks, particularly among people of African and South Asian ancestry. The study also identified genetic correlations between anxiety and a range of mental and physical health conditions, including depression, irritable bowel syndrome, chronic pain, coronary artery disease, endometriosis, and migraine. First author Dr Megan Skelton stressed that genetic risk does not determine whether someone will develop anxiety. “It’s important to highlight that even someone with a very high genetic risk might not develop anxiety, and someone with a low genetic risk could.”

An Irish-led international collaboration has produced the first globally agreed definition of neonatal encephalopathy, a serious condition affecting the brains of newborn babies which is associated with significant risks of disability and death. The landmark work, led by researchers at Trinity College Dublin, the Coombe Hospital, and the Health Research Board Neonatal Encephalopathy PhD

Training Network (NEPTuNE), has been published in The Lancet Child and Adolescent Health following an extensive international consultation involving clinicians, researchers, and families from 52 countries. Neonatal encephalopathy affects between one and four infants in every thousand births globally and is even more common in lower-income

countries. Yet, despite its prevalence and severity, doctors and researchers have long used different terms such as neonatal encephalopathy, hypoxicischaemic encephalopathy (HIE), and perinatal asphyxia interchangeably, and without consistent definitions. The result has led to difficulties in comparing studies and uncertainty in communication with families. The new

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

Image: iStock.com/ Jay Yuno

Trinity team leads first international collaboration to define neonatal encephalopathy

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consensus definition, developed through the DEFiNE (Definition of Neonatal Encephalopathy) project, involved 378 participants worldwide and represents the first internationally agreed attempt to standardise terminology in the field. Prof Eleanor Molloy, a Professor of Paediatrics at the School of Medicine in Trinity College Dublin and senior author of the study, said: “Words matter in medicine. When doctors and researchers use different terms to describe the same condition, it can create confusion for families and impede scientific progress. This new definition provides a common language that will improve communication, support research, and ultimately contribute to better care for babies and their families.” The consensus defines neonatal encephalopathy as a heterogeneous clinical condition characterised by abnormal or impaired brain function with multiple potential causes. It recognises that the condition can

arise from a range of factors, including oxygen deprivation, infection, stroke, genetic disorders, and metabolic disease. Importantly, the definition moves beyond earlier approaches that focused largely on babies eligible for cooling therapy after oxygen-related injury, and instead encompasses all infants with neonatal encephalopathy, regardless of gestational age, severity, or underlying cause. Lead author, Dr Aoife Branagan, who conducted the research while at Trinity’s School of Medicine and is now completing a neonatal fellowship at McGill University, Montreal, said: “For decades there has been debate over how to define neonatal encephalopathy. Reaching international agreement is a crucial first step towards improving diagnosis, developing new treatments, and ensuring that families receive clearer explanations about their child’s condition and prognosis.” A notable feature of the project was the involvement of parents and caregivers

alongside clinicians and scientists. Family representatives participated throughout the process, helping to shape both the wording and the priorities of the final definition. The researchers believe that adopting a single, internationally recognised definition will improve the design of clinical trials and facilitate more accurate investigations into the causes of newborn brain injury. The DEFiNE team’s next objective is to establish internationally agreed diagnostic criteria and further refine the terminology surrounding related conditions such as HIE and perinatal asphyxia. The researchers were helped by the Newborn Brain Society, which is a global, professional medical society made up of neonatologists, neurologists, researchers, and allied healthcare professionals. They were also helped by global patient and family support organisation Hope for HIE and UK-based charity PEEPS for HIE which is dedicated entirely to supporting those affected by HIE.

INMO to ballot nurses and midwives for industrial action over ‘realistic’ pay increase The Irish Nurses and Midwives (INMO) has announced that it will ballot its members for industrial action, up to and including strike action, following the Government’s failure to establish a clear basis for negotiations on a new public sector pay agreement. The decision was made by the INMO’s Executive Council on July 14. INMO General Secretary, Phil Ní Sheaghdha, explained that the ballot aims to ensure nurses and midwives working in the public sector receive a “realistic” pay increase that reflects their work. “With no public service pay agreement currently in place, we believe the Government must get real about the actual costs facing ordinary nurses and

midwives simply to get to work, and that this must form part of any national agreement,” she said. “There is high-level unhappiness across the health service, particularly around the non-implementation of agreements and the lack of progress on local bargaining claims lodged under the expired agreement. Workers are under constant pressure to do more with less, and the cost of living is hitting especially hard for those delivering services on behalf of the HSE using their own cars – staff who don’t have the option of working from home because nursing and midwifery are simply not that kind of service. On top of that, we're seeing poor working conditions, overcrowded

workplaces, recruitment restrictions, and a failure to fill maternity leave absences in a workforce that is predominantly female. That leaves workers in this category carrying unsafe workloads and living with the fear that they may not be able to provide safe care.” INMO President, Caroline Gourley, added: “There isn’t a workplace in the country that the cost of living crisis isn’t a hot topic amongst our members. Nurses and midwives have been left particularly exposed to the cost of living crisis. When we are rostered to work, we are expected to show up. For the majority of us that means getting in the car. We have to travel to work at significant personal costs.”

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National Clinical AI Congress to bring healthcare leaders together in Dublin Healthcare and industry showcasing technologies professionals from across across radiology, Ireland are being invited to prescribing, diagnostics, attend the inaugural Allworkflow optimisation, Ireland Clinical AI Congress patient management, and and AI Tech Expo, a new clinical decision-making. national event focused on Speaking ahead of the practical application of the Congress, Prof Peter artificial intelligence (AI) Doran, Director of the UCD in healthcare. Hosted by Clinical Research Centre Athena Pharmaceuticals in and Professor of Clinical partnership with University Trials at the UCD School of College Dublin (UCD), Medicine, said: “Artificial knowledge partner Cloud21, intelligence presents and industry supporters, the enormous opportunities to free entry one-day Congress transform patient outcomes will take place on Saturday, and clinical workflows, 12 September 2026, from but its true value will 8.30am to 4pm in O’Reilly only be realised when Hall, UCD. innovation is anchored in The event will bring robust clinical evidence, together clinicians, sound trial methodology, healthcare leaders, and multidisciplinary academics, policymakers, governance. This Congress industry, and technology provides an essential innovators to examine how national platform for AI is transforming patient clinicians and researchers care, while addressing the to actively engage with governance, regulatory, deployed technologies and and ethical challenges of shape the safe, evidenceHealth Service Executive currently has the its adoption. There will based adoption of AI across following opportunity: Ireland’s health system.” be a strong emphasis on practical, real-world implementation, showcasing Congress highlights will how AI is already being include: deployed in hospitals, ✽ National and international perspectives on AI strategy primary care, and pharmacy in healthcare settings, as well as the Labour Ward, Galway University HSE AI forHospitals Care 2026implications for patient ✽ The 2030 Strategy care and communications in Closing Date: Ireland and internationally. ✽ Real-world AI 10:00am on Friday the 28th of November 2025 implementation case studies The programme will from Irish hospitals feature senior leaders from Perspectives primary the HSE,For Irish hospitals, and and ✽ Further information application detailsfrom please visit: and secondary care international healthcare https://www.rezoomo.com/job/86101/ or organisations, alongside ✽ Practical guidance on about.hse.ie/jobs/job-search/ AI governance, ethics, and an interactive AI Tech Expo

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✽ An interactive AI Tech Expo ✽ A poster exhibition showcasing AI-related healthcare projects ✽ Networking with clinicians, pharmacists, GPs, nurses, healthcare executives, academics, and digital health innovators. Athena Pharmaceuticals is also inviting healthcare professionals to submit abstracts for the Congress poster competition. Up to 12

projects will be shortlisted, with €2,250 in bursaries available, including an award for the most outstanding innovation. The competition is open to healthcare professionals, including those in training or education, with submissions closing on 4 September 2026. CME/CPD accreditation is pending confirmation. Further information and registration are available at www.aiclinicalcongress.com.

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PROFESSIONAL DEVELOPMENT ✽ AUTHORS: Kathy Taaffe and Marie Courtney, Professional Development Coordinators for General Practice Nursing

A message from your PDCs: From evidence to everyday care – research and the NMBI Code in general practice nursing The importance of incorporating research and evidence-based practice into everyday primary care

he purpose of this final article in our series is to explore the development of evidencebased practice (EBP), examine its relationship with the Nursing and Midwifery Board of Ireland (NMBI) Code of Professional Conduct and Ethics, and demonstrate how, as general practice nurses (GPNs), we can incorporate research into everyday primary care practice through practical examples, clinical audit, and continuous quality improvement (QI).

Why research matters in general practice nursing

GPNs work in one of the most dynamic areas of healthcare, delivering personcentred care across the lifespan while managing acute presentations, chronic disease, preventive healthcare, screening programmes, and health promotion. Sláintecare and integrated-care reform place this work within a wider objective of coordinated, person-centred care delivered increasingly through primary and community services.1 As patient complexity increases and healthcare continues to evolve, the ability to provide safe, effective, and evidence-informed care has become a professional and ethical obligation rather than an aspiration. Research, therefore, supports contemporary nursing practice by enabling clinicians to evaluate, improve, and justify aspects of the care they provide.2 EBP is widely regarded as an important

foundation of high-quality healthcare. Rather than relying solely on tradition, personal experience, or established routines, EBP integrates the best available research evidence with clinical expertise and the patient’s values and circumstances.3,4 This approach supports clinical decisions by combining scientific evidence with the circumstances, priorities, and expectations of the individual receiving care. Many nurses will recognise the phrase: ‘We’ve always done it this way’. Although long-standing clinical practices often arise from valuable experience, tradition alone cannot justify continuing an intervention when stronger evidence demonstrates that a safer or more effective alternative exists. Modern nursing therefore requires practitioners to question established routines, critically appraise emerging evidence, and adapt practice when research demonstrates improved patient outcomes. Within Irish primary care, GPNs are well positioned to influence population health. Every patient encounter presents an opportunity to apply current evidence to improve clinical outcomes while ensuring care remains individualised. As autonomous practitioners, GPNs increasingly lead QI initiatives, undertake clinical audits, and contribute to multidisciplinary research that is designed to improve healthcare delivery. Recognising the central importance of research, the NMBI Code of Professional

Conduct and Ethics (2025) explicitly identifies research as a key component of professional nursing practice.2 The NMBI Code incorporates professional guidance on ethical conduct in research that applies across nursing roles, including clinical practice, leadership, and education. It also requires registrants to maintain and develop professional competence and to use professional judgement in practice.2,5 This reflects the growing expectation that registered nurses and midwives will not only implement evidence, but also contribute to its generation through audit, service evaluation, and QI initiatives. For GPNs, research is therefore not confined to universities or specialist research centres. It is embedded within our everyday clinical practice. Activities such as reviewing vaccination uptake, evaluating diabetes outcomes, auditing cervical screening attendance, or assessing wound-healing protocols all contribute to improving the quality and safety of patient care. By embracing research as an integral component of professional practice, GPNs strengthen clinical decision-making, improve patient outcomes, and demonstrate the accountability and leadership expected of the nursing profession.

The evolution of EBP

For much of human history, healthcare was based largely on observation, experience, and tradition. Treatments

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PROFESSIONAL DEVELOPMENT

were passed from one generation to the next with little objective evidence to support their effectiveness. Although many interventions undoubtedly benefited patients, others persisted for centuries despite causing harm because there was no systematic way of evaluating if they truly worked. Practices such as bloodletting, based on the ancient theory of balancing the body’s four humours, remained common well into the 19th century.6 The transition from tradition to scientific enquiry did not occur overnight. It evolved gradually through the work of pioneering clinicians who challenged accepted practice by asking simple but profound questions: ‘Does this intervention actually work?’ and ‘How can we know?’ In 1747, James Lind compared treatments for scurvy among sailors aboard HMS Salisbury by dividing 12 sailors into six groups of two. All ate the same diet but took a different supplement. Lind observed marked improvement in those receiving citrus fruit, an early example of comparative clinical investigation.7 Florence Nightingale later demonstrated how systematic collection, analysis, and

presentation of mortality data among soldiers during the Crimean War could identify preventable causes of death and drive improvements in care, sanitation, and hospital design.8 In the 20th century, Archie Cochrane highlighted the importance of evaluating healthcare interventions and promoted rigorous evaluation of healthcare services. He believed that healthcare professionals had both an ethical and professional responsibility to provide treatments that had been shown to be effective.9 His work ultimately inspired the establishment of the Cochrane Collaboration in 1993, a renowned international organisation dedicated to producing systematic reviews that synthesise evidence from multiple clinical studies. The 1948 Medical Research Council streptomycin trial became a landmark in the development of randomised controlled trials.10 The term and teaching model of evidence-based medicine were developed at McMaster University in the early 1990s, with Guyatt and colleagues emphasising critical appraisal and the use of evidence from clinical research in decision-making.4 David Sackett and colleagues refined the concept by defining evidence-based practice as the integration of three

LEVEL

RESEARCH DESIGN

TYPICAL PRIMARY CARE EXAMPLE

Systematic reviews and meta-analyses

Cochrane review of wound cleansing

Randomised controlled trials

New diabetes medication

III

Cohort studies

Long-term cardiovascular outcomes

Case-control studies

Risk factors for cervical cancer

Case series

Evaluation of a new wound clinic

Expert opinion and consensus

Clinical guidance where research is limited

essential components:11 ✽ The best available research evidence ✽ The clinician’s expertise and professional judgement ✽ The patient’s preferences, values, and individual circumstances. These developments established a principle that remains highly relevant to nursing – healthcare practice should be open to systematic questioning. However, not every clinical question can or should be answered by a randomised controlled trial. Qualitative research, observational studies, and mixedmethods approaches are essential for addressing questions concerning patient experience, professional behaviour, service organisation, implementation, and context.

The hierarchy of evidence

Not all research provides the same level of confidence. Some study designs are more susceptible to bias than others, meaning that as clinicians we must critically evaluate the quality of evidence before applying it to practice. Sackett et al’s hierarchy of evidence ranks research according to its methodological strength and risk of bias.11

Understanding EBP in primary care

The word research can evoke images of university laboratories, pharmaceutical trials, or complex statistical analysis. While these are important components of healthcare research, they represent only a small part of the research undertaken to improve patient care. As a GPN, EBP is far more accessible. It occurs every day through clinical audits, QI initiatives, service evaluation, and the thoughtful application of emerging evidence to routine clinical practice. Primary care provides important opportunities for research as it is a major setting for first-contact care and long-established relationships between clinicians and patients. Caring for people across the lifespan allows for

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the observation of patterns of illness, the monitoring of treatment outcomes, and the identification of opportunities to improve care. Consequently, GPNs are well placed to contribute to evidence generation while simultaneously improving the quality and safety of clinical care. GPNs make many clinical decisions each day, many of which require interpreting and applying evolving evidence in the context of individual patient needs. Importantly, EBP does not require GPNs to abandon clinical experience or professional judgement. It is not a separate activity undertaken outside clinical work; it is embedded within every consultation, assessment, and intervention. Research supports GPNs by enabling them to: ✽ Provide care that reflects current evidence rather than tradition ✽ Improve patient safety through systematic evaluation ✽ Identify unwarranted variation in practice ✽ Strengthen clinical decision-making ✽ Contribute to multidisciplinary service development ✽ Demonstrate professional accountability in accordance with the NMBI Code. Perhaps most importantly, research gives nurses confidence. When clinical decisions are supported by robust evidence, GPNs can explain the rationale underpinning their recommendations, address misinformation with authority, and advocate more effectively for their patients. Asking simple questions such as: ‘Are our patients receiving annual diabetic foot assessments?’;12 ‘Why are some eligible women not attending for CervicalCheck?’;13 or ‘How can we improve childhood immunisation uptake?’14 can lead to meaningful improvements in our patient outcomes. However, not every activity involving data collection constitutes research. Within primary care, GPNs frequently undertake activities such as clinical audit, service evaluation, and QI projects. Although these activities

share many principles of research, their objectives differ. Understanding these differences is essential because each has different governance, ethical, and regulatory requirements. RESEARCH: Research aims to generate

new, generalisable, or transferable knowledge to answer or refine relevant questions.15 Examples include: ✽ Does a new wound dressing reduce healing time compared with standard care? ✽ What factors influence vaccine hesitancy among adults attending Irish general practice? ✽ Does continuous glucose monitoring improve glycaemic control in patients with type 2 diabetes managed in primary care? Depending on its design and purpose, research may require ethical review, formal protocols, and appropriate governance because findings may be intended to inform practice beyond the participating setting. CLINICAL AUDIT: An established

component of clinical effectiveness and governance. In Ireland, national clinical audit is defined as a cyclical process of systematic, structured review and evaluation against explicit clinical standards, followed by action where improvement is required.16 For example, a GPN may audit the earlier questions of whether patients with diabetes receive annual foot examinations;12 eligible women are invited for CervicalCheck;13 influenza and childhood vaccination targets have been achieved;14 or blood pressure is recorded at recommended intervals for patients with hypertension. Practices should therefore consider undertaking clinical audit and how protected time can support completion of the audit cycle. SERVICE EVALUATION: Service

evaluation determines whether an existing healthcare service meets

patients’ needs and achieves its intended objectives.17 It is primarily concerned with understanding and improving an existing service in its local context rather than generating generalisable research knowledge. Examples include: ✽ Evaluating patient satisfaction with a nurse-led clinic ✽ Assessing waiting times for chronic disease reviews ✽ Reviewing patient experience following implementation of online appointment booking. The findings help practices refine services and improve patient experience. Practices can use local service evaluation methods to identify opportunities to improve access, experience, and service delivery. QI: An ongoing, structured approach to

improving healthcare systems through measurement, testing, and adaptation of changes.18 Rather than implementing large-scale changes, QI encourages clinicians to test interventions on a manageable scale, measure their impact, and adapt accordingly. Many GPNs embed QI within everyday clinical work. Examples include: ✽ Introducing SMS reminders to improve cervical screening attendance ✽ Redesigning vaccine recall systems ✽ Developing electronic consultation templates ✽ Improving documentation of smoking status ✽ Introducing bespoke clinics and assessments for adolescents ✽ Increasing uptake of annual chronic disease reviews. Unlike one-off projects, QI is continuous. Every improvement generates further questions, encouraging a culture of learning throughout the practice.

Why research matters to GPNs

GPNs have an important position within Irish primary care, often building long-

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term therapeutic relationships with patients, allowing them to observe subtle changes in health, recognise gaps in care, and evaluate the effectiveness of interventions over time. This continuity places GPNs at the centre of QI. The NMBI Code incorporates professional guidance on ethical conduct in research and applies to registrants across roles and settings, including leadership and education.2 This reflects the modern expectation that nurses contribute to evidence-informed healthcare throughout their careers. For GPNS, this contribution may involve: ✽ Participating in practice audits ✽ Collecting outcome data ✽ Implementing national clinical guidelines ✽ Evaluating new models of care ✽ Participating in multidisciplinary research ✽ Presenting QI projects ✽ Disseminating findings through publications or conferences. These activities strengthen professional practice while simultaneously improving patient care.

The NMBI Code: Translating research into professional practice

The NMBI Code provides the professional framework for safe, ethical, and person-centred practice and sets expectations for accountability, competence, collaboration, and leadership. 2 For GPNs, the Code reinforces that maintaining competence requires more than preserving existing knowledge; it demands an ongoing

commitment to lifelong learning, critical reflection, and the integration of emerging evidence into clinical practice. In many respects, EBP and the NMBI Code are inseparable. Research tells us what the evidence suggests should be done, while the Code guides how that evidence should be applied professionally, ethically, and compassionately. Professional accountability has always been central to nursing. Every clinical assessment, intervention, and recommendation made by a GPN carries professional responsibility. The commitment to practice within competence and maintain and develop competence throughout our professional life1,5 means that clinical knowledge cannot remain static. As new evidence emerges, GPNs have a responsibility to critically evaluate it, determine its relevance to their practice, and modify care where appropriate. For example, recommendations for childhood immunisation schedules, chronic disease management, antimicrobial stewardship, and wound care continue to evolve. A GPN who regularly reviews national guidance from the HSE, National Immunisation Office, Irish College of General Practitioners, and peer-reviewed literature demonstrates both professional competence and accountability. Equally important is recognising when evidence is uncertain. Professional accountability does not require GPNs to know every answer – rather, it requires that we know where to find reliable evidence and when to seek advice from colleagues or specialist services.

The NMBI Code provides the professional framework for safe, ethical, and person-centred practice

Respect for autonomy

Respect for autonomy is an important principle in healthcare ethics and is reflected in the NMBI Code's emphasis on respect, person-centred care, and ethical decision-making.2 Respect for autonomy requires clear information and support for informed decision-making – research participation also requires compliance with applicable ethical and governance requirements.2 Respecting autonomy means ensuring that individuals receive sufficient information to understand the purpose of any proposed intervention, the potential benefits and risks involved, and their right to decline without prejudice to their ongoing care. Within general practice, this principle extends beyond formal research projects. A GPN introducing a new recall system for diabetic reviews, inviting patients to participate in a service evaluation, or collecting patientreported outcome measures should always ensure that communication is clear, transparent, and respectful. Supporting autonomy also requires GPNs to recognise differences in health literacy, cultural beliefs, and individual preferences. EBP should never become evidence-imposed practice. Instead, research findings should inform shared decision-making between the GPN and patient, allowing care to be tailored to each individual’s circumstances and values. A practical example of this is familiar to all GPNs: A patient declines influenza vaccination having read conflicting information online. Rather than dismissing their concerns, the GPN explores the reasons for their hesitation, provides balanced evidence from trusted sources, and supports the patient in making an informed decision. The patient may still decline the vaccine – that is their right. We must remember, evidence informs the conversation, but respect for autonomy guides the consultation.

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PROFESSIONAL DEVELOPMENT

Beneficence and non-maleficence

The ethical principles of beneficence and non-maleficence – promoting benefit while avoiding unnecessary harm – are important considerations in nursing care. Research provides the evidence that allows clinicians to determine whether interventions are more likely to benefit or harm patients. Consequently, introducing new evidence into practice requires careful consideration of both potential benefits and unintended consequences. Consider wound management. Although evidence comparing tap water with saline for wound cleansing is of low or very low certainty,19 tap water is frequently cited as being as effective as sterile saline. However, EBP does not mean that saline should never be used. The choice should be guided by the individual wound, the patient’s needs, and local clinical guidance rather than by a blanket approach. This highlights the importance of understanding the available evidence, assessing each patient individually, and selecting the most appropriate intervention based on clinical need rather than routine or habit. This also illustrates an important principle often overlooked in discussions about EBP: Tradition should never be the sole reason for continuing a clinical intervention, and crucially, evidence does not replace clinical judgement. Rather, it strengthens it.

Confidentiality in an era of digital healthcare

General practice increasingly relies on electronic health records, disease registers, and digital communication systems. These technologies create valuable opportunities for audit, research, and QI, but also increase the professional responsibility to safeguard confidential patient information.19 The NMBI Code requires protection of privacy and confidentiality, while the General Data Protection Regulation (GDPR) governs the processing and protection of personal

data.2,19 For GPNs undertaking clinical audit or service evaluation, practical safeguards include: ✽ Anonymising data before analysis ✽ Using encrypted passwordprotected files ✽ Restricting access to authorised personnel ✽ Ensuring secure disposal of identifiable information ✽ Following local data governance policies. Maintaining confidentiality is not simply a legal requirement – it is fundamental to maintaining public trust in the nursing profession.

Professional integrity

Research depends upon honesty. Whether conducting a large clinical study or a simple practice audit, the integrity of the findings depends on accurate data collection, transparent reporting, and willingness to acknowledge limitations. What happens if a clinical audit determines that only 70 per cent of eligible patients have received an annual diabetic foot assessment despite a practice target of 90 per cent? Professional integrity requires that these findings are reported accurately rather than selectively presenting favourable findings. Honest reporting allows the practice team to identify barriers, develop improvement strategies, and measure progress through re-audit. The primary purpose of any clinical audit is QI rather than assigning blame.15 Creating a culture where results are viewed as opportunities for learning rather than criticism encourages continuous QI throughout the practice.

Leadership through evidence, not title

One of the most significant developments within modern nursing is the recognition that leadership is not determined by job title or years of service. The NMBI Code recognises

leadership as a professional responsibility shared by every registered nurse – therefore, every GPN has opportunities to influence clinical practice.2 Clinical leadership is key to the delivery of safe, effective care and is the responsibility of all nurses and midwives, regardless of grade, role, or position. Leadership may involve: ✽ Introducing evidence-based protocols ✽ Leading vaccination campaigns ✽ Coordinating chronic disease programmes ✽ Leading and presenting audit findings ✽ Mentoring colleagues or students ✽ Questioning outdated practices ✽ Championing patient safety initiatives. Each of these activities reflects leadership grounded in evidence, not authority or seniority. By questioning established routines and advocating for best practice, GPNs can become catalysts for positive change within their practices and across primary care. One nurse asking, ‘Could we improve this?’ can influence the practice of an entire clinical team.

Clinical audit: Research in action in general practice

If the concept of research is intimidating – or evokes images of universities, laboratories, and complex statistical analysis – it is reassuring to consider that one of the most valuable forms of evidence generation occurs every day within general practice through clinical audit.15 Clinical audit enables evaluation of whether care delivered reflects current evidence and national standards while identifying practical opportunities for improvement by asking a simple but important question: ‘Are we providing the standard of care our patients should receive?’ By answering this question systematically, GPNs become active contributors to EBP, translating

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PROFESSIONAL DEVELOPMENT

research findings into measurable improvements in patient care.

The PDSA Cycle

The Plan-Do-Study-Act (PDSA) cycle is widely used within the model for improvement to test and adapt changes on a small scale.21 ✽ PLAN: Identify a problem, establish a measurable objective, and develop a strategy for improvement.

✽ DO: Implement the intervention on a small scale while collecting relevant data.

✽ STUDY: Analyse the results and compare outcomes with the agreed standard.

✽ ACT: Adopt the change if successful, modify it if necessary, or develop an alternative strategy before repeating the cycle. THE APPROACH SUPPORTS ITERATIVE LEARNING: Teams plan a test, carry it

out, study the results, and act on what is learned before the next test. Rather than attempting extensive redesign of the GP practice or service, the PDSA approach promotes continuous improvement through a series of small, measurable changes. Each audit provides an opportunity not only to improve patient outcomes, but also to demonstrate professional accountability in accordance with the NMBI Code. Importantly, the final stage is not the end of the process. Every completed audit may raise new questions, making QI an ongoing professional responsibility rather than a finite project.

An example of the PDSA cycle in action in general practice

the previous 12 months. Initially, this appears to be an isolated oversight. However, the GPN pauses and asks a simple question: Is this happening across the whole practice? That single question marks the beginning of a clinical audit. Rather than relying on anecdotal impressions, the GPN aims to determine whether eligible patients with diabetes are receiving foot assessment in accordance with the practice’s own standard of 90 per cent of patients with type 2 diabetes. Audit begins with the same curiosity as research, and in this example, a curious nurse.

Applying the PDSA cycle: A diabetes foot screening audit plan

PLAN: Using the electronic patient

management system, the GPN identifies eligible patients included in the local audit population, according to the practice’s predefined inclusion criteria. The audit standard is established before data collection begins. While an audit must be conducted against a standard, this is a locally selected audit standard, and not necessarily a national standard. This predefined standard ensures that results can be interpreted objectively.

Applying the NMBI Code

During a routine diabetes clinic, the GPN notices that several patients attending for annual review have no documented foot examination within

The Plan-Do-Study-Act cycle is widely used within the model for improvement to test and adapt changes on a small scale

Before accessing patient records, the GPN considers the ethical responsibilities outlined within the NMBI Code: ✽ Patient confidentiality remains paramount.

✽ Only information necessary for the audit is extracted. ✽ Electronic data should be minimised, appropriately protected, and accessed only by authorised personnel in accordance with dataprotection and local governance requirements.2, 20 ✽ For an internal audit, the practice should follow its local governance requirements and applicable dataprotection and ethics processes. Patients contacted following the audit should receive clear information about the purpose of the service review where appropriate. EBP is therefore supported by ethical practice. DO: The audit is undertaken over two weeks. Following analysis of the electronic records, the GPN discovers that only 68 per cent of eligible patients have a documented annual foot examination. Although disappointing, the findings provide valuable information. Rather than identifying poor performance, the audit has identified an opportunity for improvement.

Further review reveals several contributory factors: ✽ Inconsistent use of electronic consultation templates ✽ Missed opportunities during routine consultations and influenza vaccination clinics ✽ No structured patient recall system ✽ Variation in documentation between clinicians.

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

Wegovy®® delivers quality weight loss1,2,5 and provides Wegovy delivers quality weight loss1,2,5 1,3ɬ and provides cardiovascular risk reduction 1,3ɬ cardiovascular risk reduction

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The injections can be administered in the same body area but should be at least 5 severe. The safety and efficacy of Wegovy®® has not been investigated in patients treated with other products mgapart. one after eachsites other. The injections can be administered in the body area shoulddeposits. be at least 5 severe. Themanagement, safety and efficacy Wegovy has not been investigated patients treated with products for weight with of type 1 diabetes, with severe renal or in hepatic impairment or other with congestive cm Injection should always be rotated to reduce the risksame of injection sitebut amyloid The cmofapart. Injection sites should be rotated to reduce risk injection site amyloid The weight management, withAssociation type 1 diabetes, severe renal or hepatic impairment or with congestive heart failure New York Heart (NYHA)with class IV. Use in these patients is not recommended. 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Use these patients. semaglutide used in maintenance dose of semaglutide mg once-weekly is reacheddosing by starting with dose of 0.25 mg.The To limited maintenance dose of semaglutide 2.4 mg once-weekly is reached by starting with a dose of 0.25 mg. To impairment, with inflammatory bowel disease. Use with caution in these patients. If semaglutide is used in reduce the likelihood of gastrointestinal symptoms, the dose should be escalated over a 16-week period to combination with a sulfonylurea or insulin, patients should be advised to take precautions to avoid reduce the likelihood of gastrointestinal symptoms, the dose should be escalated over a 16-week period to combination with a sulfonylurea or insulin, patients should be advised to take precautions to avoid the maintenance dose. If needed, the dose can be increased to 7.2 mg once weekly after a minimum of 4 hypoglycaemia while driving and using machines. Fertility, pregnancy and lactation: Women of the maintenance dose. If needed, the dose can be increased to 7.2 mg once weekly after a minimum of 4 hypoglycaemia while driving and using machines. Fertility, pregnancy and lactation: Women of weeks on the 2.4 mg dose in adults with BMI ≥ 30 kg/m22 at treatment initiation. If no additional clinical childbearing potential are recommended to use contraception when treated with semaglutide. There are weeks on the 2.4 mg dose in adults with BMI ≥ 30 kg/m at treatment initiation. If no additional clinical childbearing potential are recommended to use contraception when treated with semaglutide. There are improvement in body weight is observed with 7.2 mg, lower the dose to 2.4 mg once weekly. In case of limited data from the use of semaglutide in pregnant women. Therefore, semaglutide should not be used improvement in body weight is observed with 7.2 mg, lower the dose to 2.4 mg once weekly. In case of limited data from the use of semaglutide in pregnant women. Therefore, semaglutide should not be used significant gastrointestinal symptoms, consider delaying dose escalation or lowering to the previous dose during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, semaglutide should be significant gastrointestinal symptoms, consider delaying dose escalation or lowering to the previous dose during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, semaglutide should be until symptoms have improved. Adolescents: For adolescents ages 12 years and above, the same dose discontinued. Semaglutide should be discontinued at least 2 months before a planned pregnancy due to the until symptoms have improved. Adolescents: For adolescents ages 12 years and above, the same dose discontinued. Semaglutide should be discontinued at least 2 months before a planned pregnancy due to the escalation schedule as for adults should be applied. The dose should be increased until 2.4 mg (maintenance long half-life. In lactating rats, semaglutide was excreted in milk. A risk to a breast-fed child cannot be escalation schedule as for adults should be applied. The dose should be increased until 2.4 mg (maintenance long half-life. In lactating rats, semaglutide was excreted in milk. A risk to a breast-fed child cannot be dose) or maximum tolerated dose has been reached. Weekly doses higher than 2.4 mg are not recommended excluded. Semaglutide should not be used during breast-feeding. Effect on fertility unknown. Undesirable dose) or maximum tolerated dose has been reached. Weekly doses higher than 2.4 mg are not recommended excluded. Semaglutide should not be used during breast-feeding. Effect on fertility unknown. Undesirable in the adolescent population. Patients with type 2 diabetes: When initiating Wegovy®®, consider reducing the effects: Very common (≥1/10): Headache, vomiting, diarrhoea, constipation, nausea, abdominal pain, fatigue. in the adolescent population. Patients with type 2 diabetes: When initiating Wegovy , consider reducing the effects: Very common (≥1/10): Headache, vomiting, diarrhoea, constipation, nausea, abdominal pain, fatigue. dose of concomitantly administered insulin or insulin secretagogues (such as sulfonylureas) to reduce the Common (≥1/100 to <1/10): Hypoglycaemia in patients with type 2 diabetes, dizziness, dysgeusia, dose of concomitantly administered insulin or insulin secretagogues (such as sulfonylureas) to reduce the Common (≥1/100 to <1/10): Hypoglycaemia in patients with type 2 diabetes, dizziness, dysgeusia, risk of hypoglycaemia. Missed dose: If a dose is missed, it should be administered as soon as possible and dysaesthesia, diabetic retinopathy in patients with type 2 diabetes, gastritis, gastrooesophageal reflux risk of hypoglycaemia. 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Wegovy Wegovy® 0.5 ® stagerenal renaldisease. disease.Hepatic Hepaticimpairment: impairment:No Nodose doseadjustment adjustmentisisrequired requiredfor forpatients patients with with mild mild or or moderate moderate EU/1/21/1608/006. 0.5 ® (3 ml ml cartridge) cartridge) EU/1/21/1608/012. EU/1/21/1608/012.Wegovy Wegovy®®11mg mgFlexTouch FlexTouch®®EU/1/21/1608/008. EU/1/21/1608/008.Wegovy Wegovy 1.7 FlexTouch®® (3 hepatic ® hepaticimpairment. impairment.Experience Experienceininpatients patientswith withsevere severehepatic hepatic impairment impairment isis limited. limited. Semaglutide Semaglutide is is not not FlexTouch 1.7 EU/1/21/1608/009. Wegovy Wegovy®® 2.4 2.4 mg mg FlexTouch FlexTouch®® EU/1/21/1608/010. 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Therefore, the increased risk of residual gastric content due to delayed gastric emptying deep sedation. Therefore, the increased risk of residual gastric content due to delayed gastric emptying IE26SEMO00055. should shouldbebeconsidered consideredprior priortotoperforming performingprocedures procedureswith with general general anaesthesia anaesthesia or or deep deep sedation. sedation. Use Use of of GLP-1 GLP-1receptor receptoragonists agonists may may be be associated associated with with gastrointestinal gastrointestinal adverse adverse reactions. reactions. 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(0%). ɬ People living ɬ People livingwith withoverweight overweightororobesity obesityand andestablished establishedcardiovascular cardiovasculardisease diseasewithout withoutdiabetes. diabetes. Ŧ The co-primary greater for for Wegovy Wegovy®® 7.2 7.2 mg mgvs vsplacebo. placebo.11Applying Applyingthe thetrial trialproduct productestimand, estimand,the theproportion proportionofofpatients patientswith witha a body Ŧ The co-primaryendpoints endpointswere werepercentage percentagechange changeininbody bodyweight weightand andthe theproportion proportionof ofpatients patients with with aa body body weight weight reduction of 5% or greater body weight reduction weight reductionofof≥5% ≥5%was wasgreater greaterwith withWegovy Wegovy®®7.2 7.2mg mg(93.2%), (93.2%),vs vsplacebo placebo(35.7%). (35.7%).11 ¥Confirmatory ¥Confirmatorysecondary secondaryendpoint. endpoint. ®® References:1.1.Wegovy Wegovy SummaryofofProduct ProductCharacteristics Characteristicswww.medicines.ie www.medicines.ie2. 2.Wharton WhartonS, S, Freitas Freitas P, P, Hjelmesæth Hjelmesæth J, et al. Once-weekly semaglutide References: Summary semaglutide 7.2 7.2 mg mg in in adults adultswith withobesity obesity(STEP (STEPUP): UP):aarandomised, randomised,controlled, controlled, phase trial.Lancet LancetDiabetes DiabetesEndocrinol. Endocrinol.2025; 2025;S2213-8587(25)00226-8. S2213-8587(25)00226-8.3.3.Lincoff LincoffAM, AM,Brown-Frandsen Brown-Frandsen K, K, Colhoun Colhoun HM, et al. Semaglutide and cardiovascular phase 3b3btrial. cardiovascular outcomes outcomesin inobesity obesitywithout withoutdiabetes. diabetes.NNEngl EnglJ JMed. Med. 2023;389(24):2221-22324.4.Vrints VrintsC,C,Andreotti AndreottiF,F,Koskinas KoskinasKC, KC,etetal. al.2024 2024ESC ESCGuidelines Guidelinesfor forthe the management management of of chronic chronic coronary syndromes. Eur 2023;389(24):2221-2232 Eur Heart Heart J.J. 2024;45(36):3415-3537. 2024;45(36):3415-3537.5.5.Hjelmesæth HjelmesæthJ,J,Bhat BhatS,S,Garvey GarveyWT, WT,etetal.al. strength: theSTEP STEPUP UPtrial. trial.Presented Presentedat: at:The The61st 61stEuropean EuropeanAssociation Associationfor forthe theStudy Studyof ofDiabetes Diabetes (EASD) (EASD) Annual Annual Meeting; September 15-19, 2025; strength: the 2025; Vienna, Vienna, Austria. Austria. TM ® ® and FlexTouch Wegovy areregistered registeredtrademarks trademarksofofNovo NovoNordisk NordiskA/S. A/S.Live LiveLighter LighterTM trademark owned owned by by Novo Nordisk A/S. March 2026; and FlexTouch® ®are isisaatrademark 2026; IE26SEMO00057. IE26SEMO00057. Wegovy Novo NordiskLimited, Limited,First FirstFloor, Floor,Block BlockA,A,The TheCrescent CrescentBuilding Building, ,Northwood NorthwoodBusiness BusinessPark, Park,Santry, Santry, Dublin Dublin 9. 9. D09 D09 X8W3, Ireland. Tel: 01 8629 700, Novo Nordisk 700, infoireland@novonordisk.com infoireland@novonordisk.comwww.novonordisk.ie www.novonordisk.ie

PROFESSIONAL DEVELOPMENT

STUDY: The audit findings are

presented during the practice clinical meeting. Importantly, the discussion focuses on systems rather than individuals. The purpose is not to assign blame but to understand why variation has occurred. The multidisciplinary team agrees that relatively simple changes could substantially improve performance and the practice IT system has the capabilities to support implementation of the necessary improvements. These include: ✽ Introducing an electronic diabetes review template ✽ Creating automated patient recall reminders ✽ Adding prompts within chronic disease consultations ✽ Allocating protected clinic time for annual reviews. Because the audit findings are based upon objective data rather than opinion, they provide a strong foundation for service improvement. ACT: The agreed interventions are

implemented over the following six months. When the audit is repeated, compliance has increased from 68 to 88 per cent. Although the original target of 90 per cent has not yet been achieved, the practice has demonstrated measurable improvement while identifying further opportunities for refinement. The improvement means that a greater proportion of patients received the preventive assessment specified in the audit standard. The example demonstrates how audit can identify gaps and support improvement – it does not by itself establish a reduction in ulceration, infection, or hospital admission. The cycle therefore continues. Continuous improvement, rather than perfection, is the true objective. This example illustrates that research in general practice does not

always involve complex methodologies, but rather one observant nurse, a welldefined clinical question, a structured audit, and one single measurable improvement. The cumulative impact of these seemingly small changes can be profound, improving patient safety, strengthening clinical governance, and embedding a culture of continuous learning within the practice, as this approach can be applied to other clinical care provision. Reflect on your own clinical area and ask yourself: ✽ Which aspect of care concerns me most? ✽ What national standard applies? ✽ Can I measure our current performance? ✽ What one change could improve patient outcomes? ✽ When will I repeat the audit? Every successful clinical audit begins with professional curiosity. Be the curious nurse.

Creating a research culture in general practice

EBP is most effective when it becomes part of the culture of a healthcare organisation rather than the responsibility of individual clinicians.21 While GPNs have an important role in maintaining their own professional competence, sustainable improvements in patient care occur when the entire practice team embraces continuous learning, critical reflection, and QI. We know that a research culture does not require sophisticated

laboratories, dedicated research departments, or university affiliations. Instead, it is characterised by curiosity, collaboration, and a willingness to question whether current practice represents the best available care. In general practice, where our longterm relationships with patients provide unique opportunities to observe health outcomes over time, fostering such a culture can have a profound impact on both patient care and professional development.

What does a research culture look like?

Research-active practices are not defined by publishing numerous scientific papers. Rather, they are practices where members of the multidisciplinary team regularly ask questions, evaluate outcomes, and seek opportunities to improve care. These are simple questions: ✽ Are we meeting national clinical standards? ✽ Could this service be organised more effectively? ✽ Why are some patients not engaging with preventive programmes? ✽ Has new evidence changed the way we should practice? ✽ What do our patients tell us about their experience of care? Asking these questions transforms routine clinical work into opportunities for learning and improvement. Research-active GPNs recognise that every consultation contributes to wider population health.

Every successful clinical audit begins with professional curiosity. Be the curious nurse

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PROFESSIONAL DEVELOPMENT

✽ A blood pressure review contributes to cardiovascular disease prevention ✽ A smoking cessation conversation reduces future cancer risk ✽ A childhood vaccination protects both the individual child and the wider community ✽ A clinical audit improves care for every future patient attending the practice. This broader perspective transforms routine nursing interventions into meaningful public health contributions. Importantly, a research culture encourages curiosity without criticism. It recognises that identifying opportunities for improvement reflects professional maturity rather than professional failure. If your practice meetings focus almost exclusively on operational issues such as appointment availability and staffing, it is worth considering introducing a 10-minute evidence update at the end of each monthly meeting. Each month, one member of the team presents a recent guideline, research paper, or QI project relevant to primary care. Over time, discussing evidence becomes a normal part of practice life rather than an occasional educational exercise. Such small changes can have a lasting influence on professional culture, and may lead to the establishment of a practice journal club or formal reflection and sharing of consultations that went well or presented a challenge. These initiatives may appear modest individually, but collectively they contribute to interprofessional learning, 23 leading to improvements in patient safety, healthcare quality, and service efficiency.

CPD

Healthcare knowledge expands rapidly. New evidence, updated guidelines, and evolving technologies require nurses to engage continuously in professional learning throughout their careers.

CONTACT DETAILS FOR PDCs Integrated Health Areas of HSE West and Northwest

Marie Courtney marie.courtney@hse.ie 086 787 2408 Integrated Health Areas of Cork and Kerry

Elizabeth Carroll elizabeth.carroll2@hse.ie 087 491 2159 Integrated Health Areas of Carlow, Kilkenny, South Tipperary, and Wexford/ Waterford

Marie Cantwell marie.cantwell@hse.ie 087 607 8925 Integrated Health Areas of Dublin North County and Dublin North City and West

Mairead Murphy mairead.murphy11@hse.ie 087 120 6184 Integrated Health Areas of HSE West and Northwest

Kathy Taaffe kathy.taaffe@hse.ie 087 132 1424

#PDCGPN

Continuing professional development (CPD) should therefore extend beyond mandatory education requirements. The NMBI Code places CPD at the centre of professional practice. 2 Competence is not maintained by relying on knowledge acquired during undergraduate education but through continuous engagement with emerging evidence, national guidelines, and reflective learning. 5 For GPNs, lifelong learning may involve: ✽ Critically appraising new research ✽ Participating in clinical audit ✽ Attending professional education programmes ✽ Contributing to QI initiatives ✽ Mentoring colleagues and students ✽ Presenting practice innovations at conferences ✽ Collaborating with multidisciplinary research projects. Learning therefore becomes an integral part of everyday practice rather

than an activity reserved for formal education. CPD should not simply accumulate certificates; it should change practice.

Conclusion

EBP has transformed modern healthcare by ensuring that clinical decisions are informed by the best available evidence, by professional expertise, and the values of the individual receiving our care. 24 For GPNs, this approach is neither an academic ideal nor an additional responsibility. It is fundamental to safe, ethical, and accountable professional practice. Research often begins in an ordinary consultation room, when a GPN is curious and asks: ‘Could we do this better?’. Every audit completed, every clinical guideline implemented, and every outdated practice thoughtfully reconsidered represents evidence-

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PROFESSIONAL DEVELOPMENT

based nursing in action. The NMBI Code links professional practice with accountability, competence, ethical decision-making, and ongoing professional development. Research provides the evidence; professional judgement determines how that evidence is applied; and compassionate, person-centred care remains the ultimate goal.

GPNs have an important role within Irish primary care. Through continuity of care, they influence the health of individuals, families, and communities throughout the lifespan. By embracing professional curiosity and integrating research into everyday practice, GPNs not only improve the quality of care they deliver today, but also contribute to the future

development of nursing and primary healthcare in Ireland. Research is therefore integral to nursing practice. For GPNs, professional curiosity, critical appraisal, and quality improvement provide practical routes from evidence to safer, more person-centred care. One important take-away question to ask yourself: Am I a curious GPN? ✽

References

administration of the British Army. London: Harrison; 1858.

department-of-health/publications/clinicaleffectiveness/.

9. Cochrane AL. Effectiveness and efficiency: random reflections on health services. London: Nuffield Provincial Hospitals Trust; 1972.

17. NHS England. Health and Growth Accelerator Programme national evaluation. London: NHS England; 2026. Available at: www.england.nhs.uk/health-and-growthaccelerator-programme-national-evaluation/.

1. Department of Health. Delivering Sláintecare Reform. Dublin: Government of Ireland; 2019 (updated 2025 Jul 29). Available at: www. gov.ie/en/department-of-health/publications/ delivering-sl%C3%A1intecare-reform/. 2. Nursing and Midwifery Board of Ireland. Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives: Incorporating the Scope of Practice and Professional Guidance. Dublin: NMBI. Available at: www.nmbi.ie/StandardsGuidance/Code. 3. Evidence-Based Medicine Working Group. Evidence-based medicine: A new approach to teaching the practice of medicine. JAMA. 1992;268(17):2420-2425. doi:10.1001/ jama.1992.0349017009203. 4. Guyatt GH, Cairns J, Churchill D, et al. Evidence-based medicine: A new approach to teaching the practice of medicine. JAMA. 1992;268(17):2420-2425. doi:10.1001/ jama.1992.03490170092032. 5. Nursing and Midwifery Board of Ireland. What is competence? Dublin: NMBI. Available at: www.nmbi.ie/Standards-Guidance/ Professional-Competence-Scheme/What-isCompetence. 6. Jhang JS, Dalle Ave AL. Phlebotomy or bloodletting: From tradition to evidence-based medicine. Transfusion. 2012;52(5):1067-1071. doi:10.1111/j.15372995.2012.03548.x. 7. Bartholomew M. James Lind’s Treatise of the Scurvy (1753): An annotated edition. Postgrad Med J. 2002;78(925):695-696. doi:10.1136/pmj.78.925.695. 8. Nightingale F. Notes on matters affecting the health, efficiency, and hospital

10. Streptomycin in tuberculosis Trials committee. Streptomycin treatment of pulmonary tuberculosis: A Medical Research Council investigation. Br Med J. 1948;2(4582):769-782. doi:10.1136/ bmj.2.4582.769. 11. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based medicine: What it is and what it isn’t. BMJ. 1996;312:71-72. doi:10.1136/bmj.312.7023.71. 12. Health Service Executive. Diabetic foot model of care. Dublin: HSE; 2021. Available at: https://about.hse.ie/publications/hcpdiabetic-foot-model-of-care/. 13. Health Service Executive, National Screening Service. CervicalCheck. Dublin: HSE. Available at: https://www2. healthservice.hse.ie/organisation/ cervicalcheck/. 14. National Immunisation Office. National immunisation schedule and programme guidance. Dublin: Health Service Executive; 2025. Available at: https://healthservice.hse. ie/staff/information-healthcare-workers/ national-immunisation-office/. 15. Health Service Executive Research and Development. How do we define research? Dublin: Health Service Executive. Available at: https://hseresearch.ie/what-isresearch-2/. 16. National Clinical Effectiveness Committee. Clinical effectiveness. Dublin: Department of Health; 2019 (updated 2025 May 15). Available at: https://www.gov.ie/en/

18. Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 2007;16(1):2-3. doi:10.1136/ qshc.2006.022046. 19. Fernandez R, Green HL, Griffiths R, et al. Water for wound cleansing. Cochrane Database Syst Rev. 2022;(9):CD003861. doi:10.1002/14651858.CD003861.pub4. 20. Government of Ireland. Data Protection Act 2018 (Section 36(2)) (Health Research) Regulations 2018, S.I. No. 314/2018, as amended. Dublin: Stationery Office; 2018. 21. Flynn M. Quality and safety: Reflections on leading quality safe care. World of Irish Nursing and Midwifery. 2022 Apr;30(3):41. 22. Institute for Healthcare Improvement. Model for improvement. Boston (MA): IHI. Available at: www.ihi.org/library/model-forimprovement. 23. University College Cork. Interprofessional Learning. College of Medicine and Health. Cork: UCC; 2026. Available at: www.ucc.ie/ en/med-health/interprofessionallearningipl/. 24. Melnyk BM, Gallagher-Ford L, Long LE, Fineout-Overholt E. The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews Evid Based Nurs. 2014;11(1):5-15.

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✽

AUTHOR: Dr Theresa Lowry Lehnen: PhD, FFNMRCSI, RANP (General Practice), MSc, RNP, M Ed, PGDE (QTS), IUHPE HPP, PG Dip Coronary Care, BSc (Hons), RGN

IgA nephropathy: Emerging therapies and updated KDIGO guidance

In the past five years there has been a remarkable transformation in the management of IgAN driven by advancements in understanding disease pathogenesis

mmunoglobulin A nephropathy (IgAN), also known as Berger’s disease, remains the most common primary glomerulonephritis worldwide and is a leading cause of chronic kidney disease (CKD) and kidney failure among young and middle-aged adults. Despite decades of research, treatment options were historically limited to supportive care and nonspecific immunosuppression. However, the past five years have witnessed a remarkable transformation in the management of IgAN, driven by advances in understanding disease pathogenesis and the development of targeted therapies.1 The publication of the KDIGO (Kidney Disease Improving Global Outcomes) clinical practice guideline for the management of IgAN and IgA vasculitis in 2025 represents the most substantial advance in guidance since the KDIGO glomerular diseases guideline published in 2021. Building on the 2024 public review draft and incorporating evidence available up to August 2024, the guideline reflects a fundamental shift from a predominantly supportive-care approach towards risk-stratified, mechanism-based management.1 Rather than focusing solely on the consequences of glomerular injury, clinicians are now encouraged to address both the underlying disease-specific mechanisms and the downstream pathways leading to nephron loss simultaneously.1 This approach is particularly relevant,

as several novel therapies targeting different pathogenic mechanisms have entered clinical practice. The emergence of targeted-release budesonide, endothelin receptor antagonists, complement inhibitors, and therapies directed against B-cell activating pathways has transformed expectations regarding disease modification and longterm renal preservation.1

Epidemiology and disease burden

IgAN occurs across all ethnic groups but shows marked geographic variation in reported incidence and prevalence. The highest rates are observed in East Asian populations, where routine population-based urine screening programmes enable earlier detection, including of asymptomatic disease. Reported prevalence in Europe is lower, although IgAN still accounts for approximately 20-30 per cent of biopsyconfirmed primary glomerulonephritides and remains a significant cause of CKD and progression to end-stage kidney disease. 2 The disease most commonly presents between the second and fourth decades of life, although diagnosis may occur at any age. Men are affected more frequently than women, particularly in European populations. Clinical presentations vary considerably, ranging from asymptomatic microscopic haematuria to rapidly progressive glomerulonephritis. Macroscopic haematuria following upper respiratory tract infections remains a classic

presentation, although many patients are identified incidentally during investigation of persistent proteinuria or declining renal function. 2 Long-term outcome studies consistently demonstrate that IgAN is not a benign condition, with a substantial proportion of patients progressing to advanced kidney disease over time. Approximately 30-40 per cent of individuals develop kidney failure within 20 years of diagnosis. Disease progression is strongly associated with persistent proteinuria, hypertension, reduced estimated glomerular filtration rate (eGFR), and adverse histopathological features, all of which are recognised as key predictors of renal decline. 3

Pathogenesis

Understanding of the pathogenesis of IgAN has advanced considerably over the past decade. The current disease model is based on the multihit hypothesis, which describes a stepwise process involving aberrant IgA1 production, formation of pathogenic immune complexes, and subsequent glomerular deposition. This framework provides the mechanistic basis for the development of emerging targeted therapies aimed at interrupting specific stages of disease progression. 4 The initial pathogenic step in IgAN is increased production of galactosedeficient IgA1 (Gd-IgA1), primarily originating from mucosal-associated lymphoid tissue. This abnormal form of IgA1 is immunogenic, and triggers an

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autoimmune response, leading to the generation of anti-glycan antibodies. These antibodies bind to Gd-IgA1, forming circulating immune complexes that are deposited in the glomerular mesangium, where they initiate inflammation and mesangial injury.4 Mesangial deposition of immune complexes triggers a downstream cascade of inflammatory and injurious processes within the glomerulus. This includes activation of the complement system, release of pro-inflammatory cytokines, mesangial cell proliferation, podocyte injury, and progressive extracellular matrix expansion leading to fibrosis. Increasing evidence indicates that activation of the alternative and lectin complement pathways plays a central role in driving ongoing renal injury and disease progression. Histopathological studies consistently demonstrate glomerular deposition of complement components, including C3, properdin, factor H-related proteins, and mannose-binding lectin pathway-associated molecules, highlighting the importance of complement activation in the pathobiology of IgAN. 5 Genetic studies have further reinforced the central role of mucosal immune dysregulation, complement pathway regulation, and adaptive immune responses in determining susceptibility to IgAN. These findings have significantly advanced understanding of disease biology and have enabled the development of more targeted therapeutic strategies

that act on specific pathogenic pathways. 5

Risk stratification and prognosis

The 2025 KDIGO guideline places strong emphasis on early risk stratification and a personalised approach to management. Rather than adopting a uniform treatment strategy for all patients, clinicians are encouraged to assess individual risk of disease progression and to tailor therapy accordingly. This approach supports more targeted use of emerging disease-specific treatments alongside optimised supportive care.1 Proteinuria remains the most important modifiable predictor of renal outcome in IgAN. Persistent proteinuria above 0.5g/day is now recognised as a marker of increased risk of progression, while levels exceeding 1g/day are strongly associated with a more rapid decline in kidney function. As a result, reduction and sustained control of proteinuria has become the primary therapeutic target, supported by extensive evidence demonstrating a consistent association between proteinuria reduction and improved long-term renal outcomes.1 The International IgAN prediction tool remains a cornerstone of contemporary risk stratification. This validated model integrates key clinical and pathological variables, including age, sex, blood pressure, eGFR, proteinuria, use of immunosuppressive therapy, and Oxford MEST-C histopathological features,

Persistent proteinuria above 0.5g/day is now recognised as a marker of increased risk of progression and decline in kidney function

to estimate the risk of a 50 per cent decline in kidney function or progression to kidney failure. By combining clinical and biopsy data, it provides a robust framework for individualised prognosis and supports more informed treatment decision-making.6 The 2025 KDIGO guideline also emphasises the importance of longitudinal assessment rather than reliance on single time-point measurements, recognising that disease activity, treatment response, and risk of progression in IgAN can change significantly over time. Continuous reassessment of clinical parameters such as proteinuria, blood pressure, and eGFR is essential to ensure timely adjustment of therapy and more accurate risk stratification.1

KDIGO 2025: A paradigm shift in management

The 2025 KDIGO guideline represents the most significant revision of IgAN management recommendations since the original 2021 publication. Perhaps the most important conceptual shift is the recognition that effective management of IgAN must target both the underlying disease-specific mechanisms and the downstream pathways that drive progressive nephron loss. Earlier therapeutic strategies focused largely on supportive care, particularly blood pressure control and reduction of proteinuria. While these interventions remain fundamental to management, they are now understood to represent only one component of a broader, more integrated treatment approach that also addresses the immunological and inflammatory processes driving disease progression.1 The guideline proposes a dual-pathway framework. Disease-specific interventions target pathogenic IgA production, immune complex formation, complement activation, and glomerular inflammation. Concurrently, nephroprotective therapies address hyperfiltration

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KIDNEY DISEASE

injury, hypertension, proteinuria, and cardiovascular risk factors.1 The ultimate therapeutic objective is to reduce annual eGFR decline to less than 1mL/min/1.73m² per year, thereby approximating physiological age-related kidney function loss.1

Supportive care remains the foundation of treatment

Alongside the development of novel targeted therapies, optimised supportive care remains the cornerstone of IgAN management. All patients should receive comprehensive nephroprotective treatment as baseline standard of care, with disease-specific therapies introduced in those who continue to demonstrate a high risk of progression despite maximised supportive measures.1 Renin-angiotensin system inhibition remains the first-line treatment for proteinuric disease. Both angiotensinconverting enzyme inhibitors and angiotensin receptor blockers reduce intraglomerular pressure, decrease proteinuria, and slow progression of kidney dysfunction.1 The KDIGO guideline advocates intensive blood pressure control, with a target systolic blood pressure below 120mmHg, where tolerated. Evidence from CKD populations consistently demonstrates that tighter blood pressure control reduces progression risk and cardiovascular complications.1,7 Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have emerged as a key component of supportive therapy in IgAN. Subgroup analyses from the DAPA-CKD and EMPA-KIDNEY trials demonstrated consistent renal benefit in patients with IgAN, including reductions in proteinuria and a slower rate of decline in eGFR, supporting their role as standard nephroprotective therapy in this population. 8,9 These benefits appear independent of diabetes status

The ultimate therapeutic objective is to reduce annual eGFR decline to less than 1mL/ min/1.73m² per year and have resulted in widespread incorporation of SGLT2i into routine IgAN management. Lifestyle interventions, including dietary sodium restriction, smoking cessation, weight management, and cardiovascular risk reduction, remain integral to long-term care.1

Targeted-release budesonide: The first disease-specific therapy

The approval of targeted-release budesonide marked the beginning of a new therapeutic era in IgAN. Unlike conventional corticosteroids, this formulation delivers high concentrations of budesonide to Peyer’s patches within the distal ileum, a major site of pathogenic IgA production.10 The NefIgArd phase III trial demonstrated significant reductions in proteinuria accompanied by preservation of kidney function. Patients receiving targeted-release budesonide experienced substantially slower eGFR decline compared with placebo, and benefits were sustained beyond treatment completion.10 The targeted delivery system reduces systemic corticosteroid exposure and minimises adverse effects traditionally associated with glucocorticoid therapy. Although mild steroid-related effects still occur, rates of serious infection, diabetes, osteoporosis, and

weight gain are substantially lower than those observed with conventional systemic corticosteroids.10 The KDIGO guideline now recommends targeted-release budesonide for patients with IgAN who continue to have persistent proteinuria despite optimised supportive care and who remain at increased risk of disease progression.1

Endothelin receptor antagonism: Sparsentan and atrasentan

Endothelin-1 is a key mediator of glomerular haemodynamic stress and contributes to kidney injury through multiple mechanisms, including intraglomerular hypertension, podocyte damage, inflammation, and fibrosis. As a result, pharmacological inhibition of endothelin signalling has emerged as a promising therapeutic strategy aimed at reducing proteinuria and slowing progression of CKD.11 Sparsentan is a dual-acting agent that combines endothelin type A receptor antagonism with angiotensin II type 1 receptor blockade in a single molecule. In the PROTECT trial, sparsentan achieved significantly greater reductions in proteinuria compared with irbesartan alone, supporting its efficacy as a highly potent antiproteinuric therapy and reinforcing its role as an important emerging treatment option in IgAN.12 Longer-term analyses suggest that sparsentan may contribute to meaningful preservation of kidney function, although continued follow-up is required to confirm effects on hard renal outcomes such as kidney failure. The degree of proteinuria reduction observed with sparsentan is greater than that typically achieved with conventional renin-angiotensin system blockade – and approaches levels previously seen only with more intensive immunosuppressive regimens.12 Atrasentan is a highly selective

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

Patientsatatrisk risk of of Patients anaphylaxisshould should carry anaphylaxis carry 1 2 Adrenaline auto-injectors 2 Adrenaline auto-injectors1 ABBREVIATED PRESCRIBING INFORMATION EpiPen (adrenaline) 300 micrograms solution for injection in pre-filled pen, ABBREVIATED INFORMATION EpiPen PRESCRIBING Junior (adrenaline) 150 micrograms solution for injection in pre-filled pen

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It is ofrecommended patients are with prescribed two Method EpiPen of or symptoms an anaphylacticthat shock in detail the patient. administration: EpiPen in EpiPen Junior pens which theyAuto-Injectors should carryare at intended all times.for Theimmediate physicianadministration prescribing an are determined to be at increased riskthat for anaphylaxis, individuals EpiPen orpatients, EpiPenwho Junior Auto-Injector must ensure the patientincluding understands the with history of anaphylactic reactions. For intramuscular the indications for ause and the correct method of application. Therefore,administration the physicianinto should anterolateral thigh, not the buttock. It is designed to inject through clothing or directly discuss the patient information leaflet, the correct handling of the Auto-Injector and the through the skin. The patient/carer should be informed that following each use of EpiPen possible or symptoms of an anaphylactic shock in detail with the patient. Method of EpiPen Junior • They should call for immediate medical assistance, ask for an administration: EpiPen are even intended for immediate ambulance and Auto-Injectors state “anaphylaxis” if symptoms appear administration to be improving.in patients, who are determined to be at increased riskwith for anaphylaxis, including • Conscious patients should preferably lie flat feet elevated but sit up ifindividuals they have with a history ofdifficulties. anaphylactic reactions. Forshould intramuscular into the breathing Unconscious patients be placed onadministration their side in the recovery position. The the patient shouldIt ifispossible remain with through another person until anterolateral thigh,• not buttock. designed to inject clothing or medical directly assistance arrives. through the skin. The patient/carer should be informed that following each use of EpiPen Presentation: Solution for injection in pre-filled pen (Auto-Injector). Clear and colourless or EpiPen Junior • They should call for immediate medical assistance, ask for an solution. EpiPen: A single dose (0.3 ml) contains 300 micrograms (0.3 mg) adrenaline ambulance and state “anaphylaxis” even if symptoms appear to be improving. (epinephrine). EpiPen Junior: A single dose (0.3 ml) contains 150 microgram (0.15 mg) • Conscious patients should preferably lie flat with feet elevated but sit up if they have adrenaline (epinephrine). Contraindications: There are no known absolute breathing difficulties. Unconscious patients should be placed on their side in the recovery contraindications to the use of EpiPen or EpiPen Junior during an allergic emergency. position. Warnings • The patient should if possible remain with anotherEpiPen person until medical and precautions: All patients who are prescribed or EpiPen Junior assistance arrives. should be thoroughly instructed to understand the indications for the use and the correct Presentation: Solution for injection in pre-filled pen (Auto-Injector). Clear and colourless method of administration. It is strongly advised also to educate the patient’s immediate parents, teachers) 300 for the correct usage the adrenaline EpiPen or solution. associates EpiPen: A(e.g. single dose caregivers, (0.3 ml) contains micrograms (0.3ofmg) EpiPen Junior in case support is needed theml) emergency situation. The patient (0.15 shouldmg) be (epinephrine). EpiPen Junior: A single dose in (0.3 contains 150 microgram instructed to dial 112, ask for ambulance, state anaphylaxis to seek emergency medical adrenaline (epinephrine). Contraindications: There are no known absolute assistance immediately after administering the first dose in order to have close monitoring contraindications to the use of EpiPen or EpiPen Junior during The an Auto-Injectors allergic emergency. of the anaphylactic episode and further treatment as required. should Warningsbeand precautions: All patients who prescribed Junior injected into the anterolateral aspect of are the thigh. PatientsEpiPen should or be EpiPen advised not to should beinject thoroughly instructed to understand the indications for the use and the correct into the buttock. In case of injection performed by a caregiver, immobilization of the patient’s leg should be ensured during injection to minimize the risk of leg laceration, bent method of administration. It is strongly advised also to educate the patient’s immediate needle other injuries. The product is for single usecorrect only andusage in no case theEpiPen used pen associates (e.g.orparents, caregivers, teachers) for the of the or shouldinbe reused. Adrenaline is ordinarily administeredsituation. with extreme patients EpiPen Junior case support is needed in the emergency The caution patientto should be who have a heart disease. Adrenaline should only be prescribed to those patients, but also instructed to dial 112, ask for ambulance, state anaphylaxis to seek emergency medical those suffering from diabetes, hyperthyroidism, hypertension and elderly individuals if the assistance immediately after administering the first dose in order to have close monitoring potential benefit justifies the potential risk. There is a risk of adverse reactions following of the anaphylactic and further treatment as required. The Auto-Injectors should epinephrine episode administration in patients with severe renal impairment, prostatic adenoma be injected into to the anterolateral aspect of the PatientsInshould advised not to leading residual urine, hypercalcaemia andthigh. hypokalaemia. patientsbe with angle-closure inject intoglaucoma, the buttock. In case induces of injection by a caregiver, immobilization of the epinephrine pupilperformed dilation (mydriasis), which can precipitate an acute angle-closure by during further narrowing theminimize drainage angle. In of contrast, in open-angle patient’s leg should beepisode ensured injection to the risk leg laceration, bent adrenaline (epinephrine) reducing aqueous needle orglaucoma, other injuries. The product is forlowers singleintraocular use only pressure and in nobycase the used pen production and enhancing outflow through the trabecular meshwork. In patients patients should behumor reused. Adrenaline is ordinarily administered with extreme caution to with Parkinson's disease, epinephrine may be associated with a transient worsening of who have a heart disease. Adrenaline should only be prescribed to those patients, but also Parkinson symptoms such as rigidity and tremor. The patient/carer should be informed those suffering from diabetes, hypertension and elderlybyindividuals if the about the possibility of hyperthyroidism, biphasic anaphylaxis which is characterised initial resolution potential followed benefit justifies the potential risk.some There is alater. risk Patients of adverse reactions following by recurrence of symptoms hours with concomitant asthma epinephrine with severe renal impairment, adenoma mayadministration be at increased in riskpatients of a severe anaphylactic reaction. Accidentalprostatic injection into hands feet resulting peripheral ischaemia been reported. Patients may treatment leading toorresidual urine,inhypercalcaemia and has hypokalaemia. In patients withneed angle-closure glaucoma, epinephrine induces pupil dilation (mydriasis), which can precipitate an acute angle-closure episode by further narrowing the drainage angle. In contrast, in open-angle glaucoma, adrenaline (epinephrine) lowers intraocular pressure by reducing aqueous humor production and enhancing outflow through the trabecular meshwork. In patients

following the accidental injection. In patients with thick sub-cutaneous fat layer, there is a risk for adrenaline not reaching the muscle tissue resulting in a suboptimal effect. A following the accidental injection. In patients thickEpiPen sub-cutaneous layer, there is a second injection with an additional EpiPen may be with needed. and EpiPenfat Junior risk for adrenaline not reaching therarely muscle in a suboptimal effect. A contain sodium metabisulfite which may causetissue severeresulting hypersensitivity reactions including symptoms and bronchospasm in be susceptible secondanaphylactic injection with an additional EpiPen may needed.people, EpiPenespecially and EpiPen Junior those with asodium history of asthma. Patients withmay theserarely conditions must be carefully instructed reactions contain metabisulfite which cause severe hypersensitivity in including regard to the circumstances under which EpiPen or EpiPen Junior should be used. This especially anaphylactic symptoms and bronchospasm in susceptible people, medicinal product contains less than 1 mmol sodium (23 mg) per dose, that is to say those with a history of asthma. Patients with these conditions must be carefully instructed essentially 'sodium -free'. Patients should be warned regarding related allergens and in regard to the circumstances under which EpiPen or EpiPen Junior should be used. This should be investigated whenever possible so that their specific allergens can be medicinal product contains less than 1 mmol sodium (23 mg) per dose, that is to say characterised. essentiallywith 'sodium -free'. Patients should be warned and Interactions other medicinal products and other forms of regarding interaction:related Cautionallergens is should inbe investigated whenever possible that to their specificincluding allergens can be indicated patients receiving drugs that may sensitiseso the heart arrhythmias, digitalis and quinidine. The effects of adrenaline may be potentiated by tricyclic characterised. antidepressants, monoamine oxidase inhibitors (MAO-inhibitors) catechol -O-methyl Caution is Interactions with other medicinal products and otherand forms of interaction: transferase inhibitors), thyroid theophylline, oxytocin, including indicated inhibitors in patients(COMT receiving drugs that may hormones, sensitise the heart to arrhythmias, parasympatholytics, certain antihistamines (diphenhydramine, chlorpheniramine), digitalis and quinidine. The effects of adrenaline may be potentiated by tricyclic levodopa and alcohol. Adrenaline inhibits the secretion of insulin, thus increasing the blood antidepressants, inhibitors and glucose level. It may monoamine be necessary oxidase for diabetic patients (MAO-inhibitors) receiving adrenaline to catechol increase -O-methyl transferase (COMT inhibitors), thyroid hormones, theophylline, oxytocin, their dosage of inhibitors insulin or oral hypoglycaemic drugs. The alphaand beta-stimulatory parasympatholytics, certain antihistamines (diphenhydramine, chlorpheniramine), effects of epinephrine may be antagonized during concomitant treatment with alphaand levodopa and alcohol. inhibits the agents. secretionFertility, of insulin, thus increasing beta-receptor blockers orAdrenaline parasympathomimetic pregnancy and the blood lactation: Clinical experience the treatment of receiving pregnancyadrenaline is limited. to increase glucose Pregnancy: level. It may be necessary forindiabetic patients Adrenaline shouldofbeinsulin used during only if the potential the their dosage or oralpregnancy hypoglycaemic drugs. The benefit alpha-justifies and beta-stimulatory potential for the foetus. Breast-feeding: Adrenaline not orally bioavailable; any alpha- and effects risk of epinephrine may be antagonized during is concomitant treatment with adrenaline excreted in breast milk would not be expected to have any effect on the nursing beta-receptor blockers or parasympathomimetic agents. Fertility, pregnancy and infant. Fertility: As adrenaline is a substance that naturally occurs in the body, it is unlikely lactation: Pregnancy: Clinical experience the treatment ofeffects: pregnancy that this drug would have any detrimental effects oninfertility. Undesirable Side is limited. Adrenaline should used during pregnancy if theactivity potential effects associated withbeadrenaline's alpha and betaonly receptor maybenefit includejustifies the potentialsuch risk as fortachycardia the foetus. Adrenaline is not effects orally on bioavailable; any symptoms andBreast-feeding: hypertension as well as undesirable the adrenaline excreted central nervous system. in breast milk would not be expected to have any effect on the nursing Very common (≥1/10): None infant. Fertility: As adrenaline is a substance that naturally occurs in the body, it is unlikely Common <1/10): have None any detrimental effects on fertility. Undesirable effects: Side that this(>1/100, drug would For details of uncommon, rare and very rarely reported events and those of effects associated with adrenaline's alpha and adverse beta receptor activity may include unknown frequency, see SmPC.

symptoms such as tachycardia and hypertension as well as undesirable effects on the central nervous system. Very common (≥1/10): None Reporting of adverse reactions: Reporting suspected Common (>1/100,adverse <1/10):reactions None after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal For details of uncommon, rare and very rarely reported adverse events and those of product. Healthcare professionals are asked to report any suspected adverse reactions unknown frequency, see SmPC. via HPRA Pharmacovigilance, Website: www.hpra.ie. Adverse reactions/events should also be reported to the marketing authorisation holder at the email address: pv.ireland@viatris.com or phone 0044(0)8001218267.

Reporting of adverse reactions: Reporting suspected adverse reactions after authorisation of the medicinal product is

Legal Category: Subject to prescription which may be renewed (B) important. It allows continued monitoring of the benefit/risk balance of the medicinal Marketing Authorisation Number: PA23355/011/001 (EpiPen Junior), PA23355/011/002 product. Healthcare professionals are asked to report any suspected adverse reactions (EpiPen) via HPRA Pharmacovigilance, Website: www.hpra.ie. Adverse reactions/events should Marketing Authorisation Holder: Viatris Healthcare Limited, Damastown Industrial Park, also be reported to DUBLIN the marketing Mulhuddart, Dublin 15, Ireland authorisation holder at the email address: pv.ireland@viatris.com oravailable phone 0044(0)8001218267. Full prescribing information on request from: Viatris, Dublin 17. Email: info.ie@viatris.com Date of Revision of Abbreviated Prescribing Information: 2025 (B) Legal Category: Subject to prescription which may 18 be Nov renewed Reference Number: IE-AbPI-EpiPen-EpiPenJunior-v004

Marketing Authorisation Number: PA23355/011/001 (EpiPen Junior), PA23355/011/002

1.(EpiPen) EpiPen® (adrenaline) 300 micrograms solution for injection in pre-filled pen and ® Marketing Viatris Healthcare Limited, Damastown Industrial Park, JuniorAuthorisation (adrenaline) 150 Holder: micrograms solution for injection in pre-filled pen EpiPen Summaries of Product Available at: www.medicines.ie. Last accessed: Mulhuddart, DublinCharacteristics. 15, DUBLIN Ireland 13th 2026. information available on request from: Viatris, Dublin 17. Email: FullFebruary prescribing

info.ie@viatris.com Date of Revision of Abbreviated Prescribing Information: 18 Nov 2025 Reference Number: IE-AbPI-EpiPen-EpiPenJunior-v004 Job code: IE-EPI-2026-00003 www.viatris.ie

Date of preparation: February 2026

1. EpiPen® (adrenaline) 300 micrograms solution for injection in pre-filled pen and EpiPen® Junior (adrenaline) 150 micrograms solution for injection in pre-filled pen Summaries of Product Characteristics. Available at: www.medicines.ie. Last accessed: 13th February 2026. www.viatris.ie Job code: IE-EPI-2026-00003 Date of preparation: February 2026

KIDNEY DISEASE

endothelin-A receptor antagonist that has progressed to regulatory approval following positive results from the ALIGN study. Treatment with atrasentan has been associated with clinically meaningful reductions in proteinuria, alongside an acceptable safety and tolerability profile. The emergence of two endothelin-targeting therapies represents a significant advance in nephroprotective treatment options for IgA nephropathy, expanding therapeutic choice for patients at higher risk of disease progression.13

Complement inhibition

Recognition of complement activation as a key mediator of glomerular injury in IgAN has generated substantial interest in the development of targeted complement-directed therapies aimed at interrupting this pathogenic pathway. Iptacopan is an oral factor B inhibitor that selectively targets the alternative complement pathway. Results from the APPLAUSE-IgAN trial demonstrated clinically meaningful reductions in proteinuria, together with a slower rate of decline in kidney function. These findings support the concept that complement activation is not simply a biomarker of disease activity, but a key driver of disease progression in IgAN.14 By limiting complement-driven inflammation and subsequent structural damage within the kidney, these agents may slow disease progression while offering a more selective approach than conventional broad immunosuppressive therapy, with the potential for improved tolerability.14 Additional complement-targeting therapies are currently under investigation, including agents directed against factor D, MASP2, C5, and other key components of the complement cascade. As understanding of disease heterogeneity and pathway-specific

injury in IgAN continues to evolve, complement inhibition is expected to play an increasingly important role within future precision medicine approaches over the coming decade. 2

BAFF and APRIL inhibition: Suppressing pathogenic IgA production

B-cell activating factor (BAFF) and A proliferation-inducing ligand (APRIL) are important regulators of B-cell maturation and IgA production. Elevated levels of these cytokines are consistently observed in patients with IgAN and are associated with increased production of pathogenic Gd-IgA1.1 Sibeprenlimab is a monoclonal antibody targeting APRIL. Clinical trials have demonstrated substantial reductions in proteinuria accompanied by decreases in circulating Gd-IgA1 concentrations. The observed effects support the concept that direct suppression of pathogenic IgA production may alter disease trajectory.15 Atacicept is a dual inhibitor of BAFF and APRIL signalling pathways, both of which play central roles in B-cell maturation and antibody production. Early clinical studies have demonstrated encouraging reductions in proteinuria alongside improvements in disease-associated biomarkers. This class of therapy is particularly promising because it targets upstream drivers of aberrant IgA production, rather than focusing solely on downstream inflammatory and fibrotic consequences of established disease.16 Long-term outcome data are still emerging; however, BAFF/APRIL inhibition has the potential to represent one of the most diseasespecific therapeutic approaches in IgAN, given its direct effects on the

pathways responsible for aberrant IgA production.

The role of corticosteroids Historically, corticosteroids were the primary disease-modifying therapy available for patients with progressive IgAN. However, concerns regarding significant adverse effects and variable risk-benefit profiles have led to a reassessment of their role within contemporary treatment algorithms. The TESTING trial confirmed that corticosteroids can reduce the risk of major renal outcomes in IgAN – however, this benefit was associated with a significant increase in serious adverse events, most notably infections. Although lower-dose regimens improved safety, they did not fully eliminate concerns, and the overall balance between efficacy and toxicity remains an important consideration in clinical decision-making.17 The 2025 KDIGO guideline continues to acknowledge systemic corticosteroids as a treatment option for carefully selected high-risk patients – however, it places growing emphasis on the use of more targeted therapies where these are available. The development of diseasespecific agents, including targetedrelease budesonide and other emerging therapies, is expected to progressively reduce dependence on conventional systemic glucocorticoid regimens in clinical practice.1

Conclusion

The management of IgAN has undergone a profound shift over the past decade, fuelled by major advances in understanding disease pathogenesis and the identification of key therapeutic targets. This evolving knowledge has enabled the development of multiple diseasemodifying therapies that intervene at distinct stages of the pathogenic cascade, moving management

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KIDNEY DISEASE

beyond supportive care alone. The 2025 KDIGO guideline reflects this paradigm shift and reinforces a comprehensive strategy that integrates optimised nephroprotective therapy with emerging diseasespecific interventions. Targeted-release budesonide, endothelin receptor antagonists such as sparsentan and atrasentan, complement inhibitors including iptacopan, and emerging BAFF/ APRIL-directed therapies collectively represent a new generation of mechanism-based treatments. These

agents not only reduce proteinuria but also have the potential to modify longterm disease trajectory by directly targeting key biological drivers of glomerular injury. Despite these significant advances, important challenges remain. Key uncertainties persist regarding longterm safety, optimal sequencing and combination of therapies, equitable access, and cost-effectiveness across different healthcare systems. Full approval and reimbursement has yet to be granted for all of these therapies in Ireland. Nevertheless,

the therapeutic landscape of IgAN has changed fundamentally. For the first time, clinicians have access to an expanding portfolio of interventions that target the underlying immunological and inflammatory drivers of disease, rather than focusing solely on its downstream clinical consequences. As therapeutic innovation continues and precision medicine approaches become more refined, the prospect of substantially reducing progression to kidney failure in IgA nephropathy is becoming increasingly achievable. ✽

References

7. Theodorakopoulou M, Ortiz A, Fernandez-Fernandez B, et al. Guidelines for the management of hypertension in CKD patients: Where do we stand in 2024? Clin Kidney J. 2024;17(Suppl 2):36-50. doi:10.1093/ckj/sfae278.

13. Novartis. Investigational atrasentan phase III study in IgA nephropathy demonstrates clinically meaningful proteinuria reduction. 2023 Oct 30. Available at: https://www.novartis.com/news/ media-releases/novartis-investigationalatrasentan-phase-iii-study-demonstratesclinically-meaningful-and-highlystatistically-significant-proteinuria-reduction-patients-iga-nephropathy-igan.

1. Kidney Disease: Improving Global Outcomes (KDIGO) IgAN and IgAV Work Group, Rovin BH, Barratt J, et al. KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV). Kidney Int. 2025;108(4S):S1-S71. doi:10.1016/j. kint.2025.04.004. 2. Stamellou E, Seikrit C, Tang SCW, et al. IgA nephropathy. Nat Rev Dis Primers. 2023;9(1):67. doi:10.1038/s41572-02300476-9. 3. Jarrick S, Lundberg S, Welander A, et al. Mortality in IgA nephropathy: A nationwide population-based cohort study. J Am Soc Nephrol. 2019;30(5):866-876. doi:10.1681/ ASN.2018101017. 4. Daza JL, de la Cruz Y, Puello L, et al. IgA nephropathy: Are we doing enough? Open J Nephrol. 2023; 13:116-125. doi:10.4236/ ojneph.2023.132013. 5. Medjeral-Thomas NR, Cook HT, Pickering MC. Complement activation in IgA nephropathy. Semin Immunopathol. 2021;43(5):679-690. doi:10.1007/s00281021-00882-9. 6. Barbour SJ, Coppo R, Zhang H, et al. Evaluating a new international riskprediction tool in IgA nephropathy. JAMA Intern Med. 2019;179(7):942-952. doi:10.1001/jamainternmed.2019.0600.

8. Batyushin MM. Ter Arkh. 2021;93(6):713723. doi:10.26442/00403660.2021.6.2008 91. 9. The EMPA-KIDNEY Collaborative Group, Herrington WG, Staplin N, et al. Empagliflozin in patients withchronic kidney disease. N Engl J Med. 2023;388(2):117-127. doi:10.1056/NEJMoa2204233. 10. Lafayette R, Kristensen J, Stone A, et al. Efficacy and safety of a targeted-release formulation of budesonide in patients with primary IgA nephropathy (NefIgArd): Two-year results from a randomised phase 3 trial. Lancet. 2023;402(10405):859-870. doi:10.1016/S0140-6736(23)01554-4.

14. Barratt J, Eren N, Kashihara N, et al. Iptacopan in IgA nephropathy: Final 24-month data. N Engl J Med. Published online March 29, 2026. doi:10.1056/ NEJMoa2600743. 15. Perkovic V, Barratt J, Lafayette R, et al. Evaluating sibeprenlimab in IgA nephropathy: Rationale and baseline data from the VISIONARY trial. Kidney Int Rep. 2025;10(12):4207-4218. doi:10.1016/j. ekir.2025.09.031.

11. Kohan DE, Barratt J, Heerspink HJL, et al. Targeting the endothelin A receptor in IgA nephropathy. Kidney Int Rep. 2023;8(11):2198-2210. doi:10.1016/j. ekir.2023.07.023.

16. Lim RS, Yeo SC, Barratt J, Rizk DV. An update on current therapeutic options in IgA nephropathy. J Clin Med. 2024;13(4):947. doi:10.3390/jcm13040947.

12. Rovin BH, Barratt J, Heerspink HJL, et al. Efficacy and safety of sparsentan versus irbesartan in patients with IgA nephropathy (PROTECT): Two-year results from a randomised, active-controlled, phase 3 trial. Lancet. 2023;402(10417):2077-2090. doi:10.1016/S0140-6736(23)02302-4.

17. Lv J, Wong MG, Hladunewich MA, et al. Effect of oral methylprednisolone on decline in kidney function or kidney failure in patients with IgA nephropathy: The TESTING randomised clinical trial. JAMA. 2022;327(19):1888-1898. doi:10.1001/ jama.2022.536.

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

REFLECTIONS

✽

AUTHOR: Dr Jayanta B Sarma, Consultant Microbiologist and Infection Prevention Specialist

Bare above the wrist, bare below the elbow: What two infection prevention phrases taught about the culture of healthcare Guidelines are only one part of infection prevention; culture is the other

Image: iStock.com/sturti

hen people compare healthcare systems, they usually compare waiting lists, staffing levels, or funding. After spending more than two decades in the NHS, and the last two years working in the HSE, I have become fascinated by something altogether quieter – language. Sometimes an institution reveals its character not in policy documents or organisational charts, but in the ordinary words it chooses. One example has stayed with me. The

NHS speaks of ‘bare below the elbows’. The HSE asks staff to remain ‘bare above the wrists’. At first glance, they describe the same thing. Microbiologically, they largely do. Both seek effective hand hygiene, unobstructed wrists and forearms, and the removal of clothing and jewellery that interfere with patient safety. Yet I have often wondered why two neighbouring healthcare systems chose different words. Perhaps because they reveal something deeper than anatomy. Perhaps they reveal culture.

More than sleeves

When I began medical school in India, nobody wore a tie. The prized possessions of a young doctor were the long white coat and, if one could afford it, a good stethoscope. They were symbols of belonging. When I arrived in Britain to continue my training, I discovered another expectation; doctors wore ties. I learnt to knot one properly and bought several because that was simply what doctors did. Then,

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

REFLECTIONS

almost without anyone noticing, the culture changed. The white coats disappeared. The ties disappeared. Long sleeves disappeared. ‘Bare below the elbows’ became part of everyday professional life. Looking back, I think those practical infection prevention measures quietly redefined what professionalism looked like.

A revolution without speeches

The NHS never announced a cultural revolution, it simply changed everyday habits. Alcohol hand rub appeared outside every patient room; watches disappeared, bracelets disappeared. The tie quietly became unnecessary. Authority no longer resided in appearance. It increasingly resided in behaviour. Today, patients may not notice whether a doctor wears a tie. They are far more likely to notice whether the doctor cleans their hands.

The quiet leaders

During my time in Ireland, one observation has remained constant. The infection prevention and control nurses I have worked alongside have been remarkably diligent. They know the guidance thoroughly. They apply it consistently. They follow it faithfully, often in circumstances that are far from ideal. Yet guidelines are only one part of infection prevention. Culture is the other. Healthcare buildings evolve over decades. Clinical pressures rarely ease. Resources are never unlimited. Long-established professional habits do not disappear simply because a guideline has changed. That is where infection prevention becomes something much larger than compliance. It becomes leadership. Authority rarely comes from hierarchy. It comes from evidence, credibility, consistency, and the quiet confidence that patient safety must remain the same regardless

of who happens to be standing beside the bed. Healthcare remains a profession where seniority matters, where consultants, quite rightly, carry ultimate responsibility for patient care, and where established ways of working can be deeply embedded. Changing culture therefore requires something more persuasive than authority. It requires trust. The quiet leaders rarely command. They persuade, they educate, they remind. Then, they return the next day and begin again. Real cultural change seldom occurs because someone wins an argument; it happens because someone patiently wins confidence.

‘Does this patient still need one?’ Many younger doctors understand this instinctively, yet they often find themselves navigating between newer evidence and older habits. Evidence usually moves first, practice follows. Culture is often the last to arrive.

Evidence and authority

I still have the ties I bought when I first arrived in Britain. They have not been worn for more than 20 years. I have never added another. They remain carefully folded in a drawer, neither useful nor discarded. Looking at them now, I no longer see items of clothing. I see reminders that professions evolve quietly; not through dramatic declarations, not through sweeping reforms, but through thousands of ordinary decisions repeated every day by nurses, doctors, healthcare assistants, pharmacists, therapists, cleaners, and patients who gradually agree that there is a better way. By the time we notice the change, the culture has already moved on. Policies can be written overnight, evidence can be published in a journal, but culture changes only when people patiently help one another to see the world differently. That is the quiet revolution. ✽

Working in two health systems has also made me reflect on how professional authority evolves. One of the strengths I have observed in Irish hospitals is the respect afforded to consultants. Their leadership is visible, reassuring, and deeply valued. Their opinion often carries influence well beyond the immediate clinical decision. The NHS, too, remains consultantled. Yet over the past two decades that phrase has acquired a different flavour. Leadership increasingly feels shared. The consultant remains accountable, but decisions emerge through conversations involving nurses, pharmacists, microbiologists, therapists, advanced nurse practitioners, and junior doctors. Perhaps infection prevention has contributed quietly to that evolution. Microorganisms, after all, pay little attention to professional hierarchy. Evidence gradually acquires an authority of its own.

The courage to stop

Increasingly, my advice as a microbiologist is to recommend stopping antibiotics. The question is no longer simply: ‘What antibiotic should we prescribe?’ It has become:

Lessons from two phrases

‘Bare above the wrists’, ‘bare below the elbows’ – one defines the practical minimum required for effective hand hygiene, the other has come to symbolise an entire professional philosophy. Neither phrase is really about sleeves. Both are about culture.

A drawer full of history

Dr Jayanta B Sarma is a Consultant Medical Microbiologist and Infection Prevention Specialist. He served for more than two decades in the NHS before spending the last two years with the HSE at Letterkenny University Hospital, Co Donegal. This reflection draws on his experience of working across both healthcare systems.

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IAANMP NEWS

✽ EDITORIAL DIRECTOR: Theresa Lowry Lehnen

IN THIS ISSUE: Committee news ✽ Association news ✽ Showcasing excellence in research and innovation ✽ Meet the members

WELCOME FROM MELISSA AND THE TEAM

Melissa Hammond, Chairperson

Claire Kearney, PRO & GDPR Officer

Caroline Fraser, Vice-Chair

Sarah Daly, Membership Secretary

Fiona Colbert, Committee Officer

Louise Moore, Treasurer

Roisin Mullan, Committee Officer

Kathleen Canavan, Committee Officer

t is my pleasure, as Chair of the Irish Association of Nurse Midwife Practitioners (IAANMP), to introduce this September/October supplement. This edition reflects the continued growth, innovation, and impact of advanced nursing and midwifery practice across Ireland. We are delighted to welcome our newest committee officer, Anna Marie Kiernan, whose expertise in innovation and service redesign further strengthens our Association. The supplement also highlights

Theresa Lowry Lehnen, Editorial Officer, IAANMP supplement & website

Marcella Gavin, Committee Officer

Peter Livingstone, Committee officer

our upcoming Annual Conference 2026, which promises an exciting programme of speakers, discussions on the future of advanced practice, and opportunities to celebrate excellence, collaboration, and leadership within our profession. Members are encouraged to submit poster abstracts and share the outstanding work being undertaken across clinical practice, research, education, and quality improvement. Throughout this edition, you will see compelling examples of how ANMPs

Leena Rodrigues, Committee Officer

Anna Marie Kiernan, Committee officer

are transforming patient care through research, innovation, and service development. These achievements demonstrate the expertise, leadership and commitment of our members, and reinforce the vital contribution advanced practice continues to make to healthcare delivery in Ireland. On behalf of the IAANMP committee, thank you for your continued support and dedication. We hope you enjoy this edition, and we look forward to welcoming many of you to our Annual Conference in November.

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IAANMP NEWS

COMMITTEE NEWS

Welcome to Anna Marie Kiernan, new IAANMP committee officer

nna Marie Kiernan is a RANP in Pain Medicine and a National Nursing and Midwifery Innovation Fellow with the HSE Spark Innovation Programme. Based at Croom Orthopaedic Hospital, Limerick, she has co-led service redesign initiatives which significantly reduced patient wait times. With postgraduate qualifications in pain management, healthcare innovation, and service design, Anna Marie focuses on sustainable, human-

Anna Marie Kiernan

centred care. She has co-developed extended reality tools for chronic pain self-management in the areas of procedural pain and incidental pain management support, which she is currently working towards scaling to other fields. As a fellow with the HSE Spark Programme, Anna Marie is focused on advocating nationally for, while also supporting development of, innovation literacy and skills in healthcare, as well as supporting frontline staff-led innovation.

ASSOCIATION NEWS IAANMP Annual Conference 2026 ✽ Author: Theresa Lowry Lehnen, IAANMP Editorial Officer

Date: Friday, 6 November 2026, Midlands Park Hotel, Portlaoise. Theme: Advanced practice in Ireland – transforming care, measuring impact, expanding access, and shaping the future.

n Friday, 6 November 2026, advanced nurse practitioners (ANPs), advanced midwife practitioners (AMPs), healthcare leaders, policymakers, academics, and clinical innovators from across Ireland will gather at the Midlands Park Hotel, Portlaoise, for the Irish Association of Advanced Nurse

and Midwife Practitioners (IAANMP) Annual Conference 2026. Under the theme ‘Advanced practice in Ireland: Transforming care, measuring impact, expanding access, and shaping the future’, this year’s conference reflects the growing influence of advanced practice in shaping modern healthcare delivery. As healthcare systems continue to face increasing demands associated with population growth, chronic disease, workforce challenges, and rising service expectations, advanced practitioners continue to demonstrate their value through clinical leadership, innovation, research, and the delivery of highquality, patient-centred care. The conference programme has been

designed to explore the evolving role of advanced practice, while highlighting the significant contribution ANPs and AMPs make to healthcare delivery across Ireland. Bringing together nationally recognised experts and leaders from across healthcare, the event will provide delegates with opportunities to share knowledge, celebrate achievement, and engage in discussions on the future direction of advanced nursing and midwifery practice. The conference will be formally opened by Melissa Hammond, Chair of the IAANMP and RANP, whose welcome address will reflect on the continued growth of advanced practice and the Association’s commitment to supporting excellence in clinical practice, education,

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research, and leadership. The opening address will be delivered by Dr Colm Henry, Chief Clinical Officer of the HSE. As one of Ireland’s senior clinical leaders, Dr Henry has played a pivotal role in shaping national healthcare strategy, clinical governance, and service transformation. His address will provide delegates with an important overview of current healthcare priorities and the contribution of advanced practice to delivering safe, effective, and integrated patient care across Ireland. The morning programme will feature keynote presentations exploring education, innovation, and the development of advanced practice capability. Dr Jarlath Varley, RANP and Programme Director of the MSc in Advanced Practice at the Royal College of Surgeons in Ireland, will present ‘Impact by design: Building ANMP capability through advanced practice education’. His talk will examine how advanced education supports clinical excellence, leadership, and the continued development of the advanced practitioner workforce. Delegates will also hear from Clare Crowley, Nursing and Midwifery Fellow with the National Simulation Office, who will present on the role of simulation in advanced practice and quality improvement. As healthcare systems become increasingly complex, simulation-based education is playing an important role in strengthening clinical decision-making, enhancing patient safety, and supporting multidisciplinary team performance. Digital transformation remains a key priority across Irish healthcare. Prof Richard Greene and Loretto Grogan from HSE Technology and Transformation will provide delegates with an update on the National Electronic Health Record Programme. Their session will explore how digital innovation is transforming clinical practice, improving information

sharing, and supporting more integrated, efficient, and patientcentred models of care. Protecting and advancing the profession is another important theme within this year’s programme. Phil Ní Sheaghdha, General Secretary of the Irish Nurses and Midwives Organisation (INMO), will examine the importance of professional autonomy and scope of practice, highlighting the policy, workforce and professional issues influencing the continued development of advanced practice roles in Ireland. Supporting professional development, academic achievement, and the recognition of excellence remains central to the mission of the IAANMP. The conference will feature presentations from the recipients of the IAANMP Bernie Carpenter and Trisha McKeown Bursaries, recognising innovative work that advances research, education, and clinical practice. These prestigious bursaries reflect the Association’s continued commitment to fostering scholarship, supporting emerging leaders, and strengthening the evidence base underpinning advanced nursing and midwifery practice. Delegates will also hear from Carolyn Donohoe, Chief Executive Officer of the Nursing and Midwifery Board of Ireland (NMBI), who will provide an important update on professional regulation and developments within nursing and midwifery. Her address will highlight the NMBI’s ongoing role in supporting safe, effective, and contemporary professional practice. Measuring and demonstrating the impact of advanced practice continues to be a national priority. Patricia Minnock, RANP, will deliver a keynote presentation entitled ‘Capturing impact in advanced practice’, exploring the importance of evidencing clinical outcomes, service improvements, and patient benefits arising from

advanced practice roles. Demonstrating measurable impact is essential in supporting workforce planning, service expansion, and the continued evolution of advanced practice across Ireland. A highlight of the afternoon programme will be a multidisciplinary panel discussion chaired by Priscilla Lynch, award-winning journalist and clinical editor of the Medical Independent. The panel, entitled ‘Advanced nurse and midwife practitioners’ impact in Ireland: Unlocking opportunities, demonstrating benefits and overcoming challenge’, will bring together senior representatives from the Department of Health, the Office of the Nursing and Midwifery Services Director, the NMBI, HSE Technology and Transformation, practising ANPs, and the INMO. The discussion will explore how advanced practitioners are improving access to healthcare, delivering measurable patient outcomes, and contributing to service transformation across Ireland. Panel members will consider the opportunities and challenges associated with workforce expansion, digital innovation, professional regulation, leadership, and the future strategic development of advanced practice. The conference features a motivational address from Dr Brian Pennie, internationally recognised neuroscientist, author, lecturer, and entrepreneur. His presentation, ‘There is no magic wand, only powerful tools we forget to use!’, will explore the science of resilience, mindset, and sustainable personal change. Drawing on both his lived experience and extensive academic expertise, Dr Pennie has become a leading advocate for psychological resilience, adaptability, and high performance in challenging environments. His remarkable personal journey, from heroin addiction to earning a doctorate in neuroscience and psychology, has inspired audiences

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worldwide and underpins his unique approach to personal and professional development. As a lecturer at Trinity College Dublin, award-winning television presenter, bestselling author, and founder of Change is Possible, Dr Pennie works with individuals and organisations to foster meaningful and sustainable change. His keynote address is expected to provide delegates with valuable insights into leadership, innovation, wellbeing, and the importance of embracing change within increasingly complex healthcare environments. Through a compelling blend of science, storytelling, and practical strategies, he will challenge attendees to rethink limitations, build resilience, and unlock their full potential.

Throughout the day, delegates will have the opportunity to view poster presentations showcasing research, quality improvement initiatives, and examples of innovation from advanced practitioners across Ireland. These presentations continue to promote collaboration, evidence-based practice and the dissemination of new knowledge throughout the profession. The conference will conclude with the IAANMP Annual General Meeting, followed by networking opportunities during the closing reception. These sessions provide members with an opportunity to engage with colleagues, discuss future priorities for the profession, and strengthen professional networks across the

advanced practice community. As advanced practice continues to expand throughout Ireland, the IAANMP Annual Conference remains an important national platform for professional engagement, education, and collaboration. The conference reflects the continued progress of advanced nursing and midwifery practice and the growing influence of ANPs and AMPs in shaping healthcare delivery, policy development, and patient outcomes. The IAANMP looks forward to welcoming delegates from across Ireland for a day of innovation, knowledge exchange, professional networking, and celebration of excellence in advanced nursing and midwifery practice.

Call for poster presentation abstracts Conference theme: ‘Advanced Practice in Ireland: Transforming care, measuring impact, expanding access and shaping the future.’ Date: Monday, 6 November, 2026. Venue: Midlands Park Hotel, Portlaoise.

he Irish Association of Advanced Nurse and Midwife Practitioners (IAANMP) is delighted to announce a call for poster presentation abstracts for its upcoming Annual Conference 2026. This year’s conference offers a fantastic opportunity to showcase excellence, innovation, and leadership in advanced nursing and midwifery practice across Ireland. We invite abstract submissions for poster presentations from all members and healthcare professionals working in or alongside advanced practice roles.

Whether you are engaged in innovative clinical practice, research projects, quality improvement initiatives, audit, or service developments, we encourage you to share your work. Your contribution will help inspire and inform others, while also providing a platform to disseminate findings, receive feedback, and connect with peers from across the country.

Abstract submission details ✽ Deadline: Wednesday 30 September, 2026 ✽ Word count: Maximum 300 words ✽ Structure: • Title • Background • Aims/objectives • Methods/approach • Results/outcomes • Discussion • Conclusion/implications for Practice. ✽ Authors: (Include full name(s), job

title(s) and place of work) ✽ Eligibility: Open to all professionals involved in or supporting advanced practice in nursing or midwifery ✽ Submission format: PDF document ✽ Use the submission form on the IAANMP website to submit your poster abstract: www.iaanmp.com/submit-yourposters-here-for-2026-conference ✽ Notification of acceptance: By 30 September, 2026. Once your poster has been accepted, you will be asked to submit a digital version of the poster by 26 October, 2026.

Awards and recognition

Prizes will be awarded for 1st, 2nd, and 3rd place. For any queries, please contact: iaanmp@gmail.com. We look forward to receiving your submissions and to celebrating the outstanding work being carried out by ANPs, AMPs, and their colleagues across the country.

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SHOWCASING EXCELLENCE: HIGHLIGHTING IAANMP MEMBERS RESEARCH AND INNOVATION ✽ Author: Theresa Lowry Lehnen,

practice, demonstrating excellence in clinical care, research, education, service development, and healthcare innovation. Collectively, they highlight the significant and evolving role that ANPs and AMPs play in shaping and transforming healthcare delivery nationwide. The projects and publications presented demonstrate the contribution of advanced practice to patient care, service delivery, and healthcare development. They also

IAANMP Editorial Officer

e are delighted to showcase the outstanding work, research, innovation, and leadership undertaken by members of the Irish Association of Advanced Nurse and Midwife Practitioners across Ireland. These contributions reflect the breadth, depth, and diversity of advanced

illustrate the ongoing commitment of ANPs and AMPs to evidenceinformed practice, professional development, and the evaluation and improvement of healthcare services. This platform offers an opportunity to showcase the real impact of advanced practice on healthcare delivery and to inspire continued innovation, scholarship, and excellence in every area of advanced nursing and midwifery.

RECENT PUBLICATIONS Evaluating subcutaneous furosemide in an acute community collaborative, nurse-led heart failure service: A real-world pilot study Author: Norma Caples, ANP Heart Failure, University Hospital Waterford. Reference: Caples N. Evaluating subcutaneous furosemide in an acute community collaborative, nurseled heart failure service: A realworld pilot study. British Journal of Cardiac Nursing. 2026;21(5):1-7. doi. org/10.12968/bjca.2025.0057. Background: Subcutaneous furosemide offers an alternative to intravenous (IV) therapy for decompensated heart failure, but evidence for the standard formulation in integrated care models is limited.

Aim: Evaluate the feasibility, safety, tolerability, and clinical outcomes of standard subcutaneous furosemide within a nurse-led, acute-community, heart failure service. Methods: Eleven patients received nurse-prescribed subcutaneous furosemide with daily community monitoring and heart failure nurse oversight. Weight, NT-proBNP, renal function, and hospital admission were analysed. Results: NT-proBNP decreased by 43.6 per cent (median 2734 to 1542pg/ml; P=0.083). New York

Heart Association class improved (median 3 to 2; P=0.003) and weight decreased (81.0 to 77.0 kg; P=0.012). Electrolytes remained stable, renal function improved in eight patients, and no infusionsite reactions occurred. Hospital admission was avoided in 10/11 patients (90.9%). Conclusions: Standard subcutaneous furosemide was feasible, safe, and well tolerated within a nurse-led integrated pathway, supporting communitybased diuresis as an alternative consideration to IV therapy.

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The Irish COPD paradox and the promise of virtual care Authors: Emma Lynn Burke;1,2 Clare Connolly;2 Niki Byrne;2 Karolina Glomba;1 Ian McCabe;3 David Tiernan;3 Sheila Gleeson;3 Hemendra Worlikar;3 Derek O’Keeffe;3 and Sinead Walsh.2 1: Respiratory Department, Galway University Hospital, Galway 2: Respiratory Integrated Care, Galway City Hub, HSE West Northwest, Galway 3: HIVE Lab, University of Galway, Galway Reference: Burke EL, Connolly C, Byrne N, et al. The Irish COPD paradox and the promise of virtual care. Front Digit Health. 2026;8:1838140. doi:10.3389/ fdgth.2026.1838140. Introduction: Ireland has the highest chronic obstructive pulmonary disease (COPD) hospitalisation rate in the Organisation for Economic Cooperation and Development (OECD) – 315 per 100,000 vs an average of 190 – yet possesses the infrastructure and reform ambition – through Sláintecare – to deliver care differently. Virtual care pathways underpinned by remote patient monitoring offer one route out

of this costly, hospital-centric cycle, but the question is not simply whether they work. It is how, for whom, and at what cost to equity. Methods: We conducted a 20-month prospective mixed-methods feasibility study at Galway University Hospital, enrolling 85 adults with high-risk COPD (GOLD Group B/E) into a nurse-led, protocol-driven, virtual care pathway using tablet-based remote monitoring with 5G connectivity. Clinical outcomes were evaluated against historical baselines; patient experience was explored through focus groups and serial surveys, with findings interpreted through a critical realist lens and the NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework. Results: Of 152 exacerbation episodes managed on the platform, 148 (97.3%) were completed without hospital admission. Mean length of stay was 5.15 days – a 51.5 per cent reduction against the regional baseline of 11.8 days (p < 0.001) – translating to an estimated €949,000 in gross hospital

cost avoidance. Borg dyspnoea and CAT (COPD assessment test) scores improved significantly beyond minimal clinically important differences. However, the qualitative data complicates this picture. Discussion: Patients embraced the platform largely because hospital terrified them, not because the technology delighted them. The ‘digital safety net’ generated its own anxieties around device failure and clinical abandonment, and families – particularly daughters and grandchildren – absorbed a hidden burden of technical troubleshooting that the model depends on but does not account for. Most critically, every participant owned a smartphone. In a country where 37 per cent of over-65s are digitally excluded, and where COPD prevalence is itself socially patterned, the absence of digitally excluded patients from our sample is not a limitation to footnote; it is the finding. Without deliberate design of hybrid digital-analogue pathways, Ireland risks cementing an inverse digital care law in which the most effective care reaches those who need it least.

Clinical scope and workforce contribution of ANPs in general practice: A cross-sectional study Authors: Keye C, McCann P, Loftus Moran O, Hammond M, Deehan J, Nolan Ryan L, Lynch K, Kelly C. On behalf of the General Practice Advanced Nurse Practitioners Ireland Group. Reference: Keye C, McCann P, Loftus Moran O, et al. Clinical scope and workforce contribution of advanced

nurse practitioners in general practice: a cross-sectional study. Journal of Research in Nursing. 2026;0(0). doi:10.1177/17449871261452880. Aim: To examine the clinical activity and workforce contribution of Advanced Nurse Practitioners (ANPs) working in general practice.

Background: Primary care systems internationally are experiencing increasing demand due to ageing populations, rising multimorbidity, and workforce shortages. Advanced nursing practice has expanded globally as a strategy to strengthen service capacity, improve access, and maintain quality outcomes. Although there is

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substantial evidence regarding patient outcomes associated with advanced practice roles, there is comparatively limited empirical data describing the day-to-day clinical activity of ANPs in primary care settings. Methods: This national cross-sectional descriptive study, conducted in Ireland and reported in accordance with the STROBE Statement, involved a one-week activity capture of general practice ANPs (GP ANPs) and candidate ANPs (cANPs) working across general practice settings. Data collected included consultation type,

prescribing activity, complexity of care, and clinical outcomes. Data were analysed using descriptive statistics. Results: Twenty GP ANPs/cANPs recorded 1,659 consultations, including 757 full episodes of care (45.6%). Practice spanned acute illness (adults and children), chronic disease management, women’s health, and preventive services. Medication optimisation activity included 503 medication reviews, 251 prescriptions issued, and 59 medications deprescribed. About 15 per cent of consultations were

classified as complex and 14.8 per cent involved multiple presenting complaints. Most consultations were independently managed. Conclusion: GP ANPs demonstrate broad clinical capability and contribute substantially to general practice capacity. The findings highlight the value of a holistic nursing approach, which is well suited to chronic disease management, health promotion, patient education, and the management of multimorbidity, supporting access to care and strengthening primary care workforce capacity.

Making nursing visible in general practice: Responsible action research as an approach to developing nurse-sensitive metrics Authors: Orla Loftus Moran, Mary Casey, School of Nursing, Midwifery and Health Systems, University College Dublin. Reference: Loftus Moran O, Casey M. Making nursing visible in general practice: Responsible action research as an approach to developing nurse-sensitive metrics. Nurs Inq. 2026;33(3):e70130. doi:10.1111/ nin.70130. Abstract: This critical discussion paper argues that the development of nurse-sensitive metrics in general practice is not simply a technical task of selecting indicators, but an ethical and methodological process through which nursing contribution becomes known, named, and represented. Although health systems

increasingly prioritise measurement, accountability and performance data, important dimensions of nursing practice remain poorly captured, particularly in community and primary care contexts. In general practice, nursing care is characterised by generalist, relational, preventive, and cumulative forms of care, making the direct transfer of metrics developed outside this context problematic. General practice nurses represent a substantial workforce, yet their contribution remains only partially visible within existing healthcare data systems. This paper advances a Responsible Action Research approach to developing nursesensitive metrics grounded in everyday practice. Drawing on Action Research, implemented through Appreciative Inquiry and informed by

the Quality Action Research Checklist, the paper considers how collaborative inquiry can support general practice nurses to articulate dimensions of nursing quality that may otherwise remain tacit. Inclusion of perspectives from general practitioners, patients, and practice administrators further situates this inquiry within the broader ecology of care. The paper argues that responsible metric development requires attention not only to what is eventually measured, but to the transparency, reflexivity, and accountability of the process through which potential indicators are generated. By reframing metric development as a practiceengaged process of knowledge generation, it offers a methodological contribution to debates on how nursing work can be made visible without reducing its complexity.

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Mapping menopause education for healthcare professionals: A scoping review Authors: Catriona Keye, Margaret Murphy, Mohamad Saab, Michelle O’Driscoll. Reference: Keye C, Murphy M, Saab MM, O’Driscoll M. Mapping menopause education for healthcare professionals: A scoping review. Climacteric. 1-9. doi:10.1 080/13697137.2026.2676683. Published online: 22 Jun 2026 Abstract: Menopause is a natural life stage with substantial impacts on women’s quality of life and long-term health. Education on menopause for healthcare professionals (HCPs) remains limited and inconsistently embedded across health disciplines. This scoping review mapped current evidence on menopause education, including available

programmes, delivery approaches, and extent of curricular integration. Following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines, a search of six databases and grey literature (last searched May 2025) identified original research evaluating menopause-specific education for undergraduate and postgraduate HCPs. Data were synthesised using deductive and inductive analyses. Of 5034 records identified, 14 studies met the inclusion criteria: Nine evaluated educational interventions and five examined curricular provision. Most studies originated from the USA and focused on medical residents. Education formats varied widely, including structured curricula, case-based learning, online modules,

telemedicine encounters, and peersupported platforms. Core content commonly addressed menopause physiology, symptom management, and hormone therapy, while long-term health implications and equity-focused content were infrequently included. Interventions consistently improved knowledge, confidence, and preparedness for menopause care. Despite widespread recognition of its importance, menopause education remains inadequately integrated across healthcare training. Standardised, multidisciplinary and equity-focused menopause education frameworks are urgently required to strengthen clinical competence and improve care for midlife women.

POSTER PRESENTATION ABSTRACTS The simple lipid management algorithm: It works Author: Lorna Keating, ANP Cardiology Chest Pain, Naas General Hospital, Co Kildare Background: All patients on statin therapy require repeat lipid level within the first three months after initiation (European Society of Cardiology dyslipidaemia guidelines update 2025). An audit of statin therapy practices by the advanced nurse practitioner (ANP) (chest pain) in Naas General Hospital (NGH) in quarter 1 of 2024 identified that only 20 per cent of these patients had lipid monitoring (total cholesterol and low-density lipoprotein) performed within this timeframe. A statin therapy prescribing and lipid

management algorithm (incorporating a risk stratification tool) was designed to guide prescribers on statin prescribing standards and lipid targets based on primary and secondary prevention. An information leaflet was also developed to empower patients and inform them of their current lipid levels, targets, and monitoring dates.

targets, and monitoring.

Aims and objectives: This quality improvement aimed to design a tool to individualise and standardise lipid management of patients discharged from the ANP Chest Pain service in NGH to community services by June 2025. The objective was to empower patients through education on lipids,

Results: The statin therapy practices were re-audited in June 2025 identifying: ✽ 39 per cent of patients had lipids checked ≤ three months of starting statins versus 20 per cent initially. ✽ 37 per cent on target at three months ✽ >90 per cent are primary prevention patients

Method: The Model of Quality Improvement was used. This quality improvement was aligned with Framework for Improving Quality in Our Health Service (HSE 2016) and the HSE Code of Practice for Integrated Discharge Planning (HSE 2008).

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✽ 52 per cent scoring ‘high’ on SCORE2 risk stratification. Conclusion: This algorithm provided step by step approach assisting

clinicians with targeting high cholesterols and improving lipid management. The pathway allows for correct individualised prescribing, optimisation, monitoring, and

pathways to assistance with issues. Early detection and treatment of cholesterol is key in the prevention of primary and secondary disease.

Bridging primary and specialist care: An ANP-led GP reach-in initiative to improve respiratory management Authors: Aoife Bradley, ANP Respiratory, Peamount Healthcare; Dr Minesh Kooblall, Consultant Respiratory Medicine Peamount Healthcare/Tallaght Hospital Background: Respiratory diseases contribute significantly to Ireland’s healthcare burden. In 2023/2024, 34 per cent of out-of-hours GP consultations and over 100 per 1000 emergency department (ED) admissions were for respiratory conditions. Many could be avoided with earlier intervention in primary care, highlighting the need for improved community-based respiratory pathways. Aims/objectives: This ANP-led GP reach-in initiative aims to improve timely access to respiratory care, support GPs in managing patients, reduce acute sector burden, decrease outpatient referrals, and

enhance patients’ quality of life. Methods/approach: An ANP provides a direct-access pathway for registered GPs to refer patients for respiratory assessment, diagnostics, and linkage to specialist inpatient/outpatient support. Evaluation forms from GPs and patients assess perceived benefit, quality of life improvements, and potential avoidance of acute care. Results: To date, 21 patients across 12 of 18 participating GP practices have accessed the service. Of 18 completed care episodes, seven full evaluations were returned. ✽ 100 per cent of GPs and patients reported service benefit ✽ Four of seven GPs would have referred to ED if the service were unavailable

✽ GPs reported achievement of all service aims, including improved access, support, and patient outcomes. Discussion: The initiative illustrates the impact of advanced practice leadership in enhancing integrated care, preventing avoidable hospital presentations, and supporting primary care in managing complex conditions. Conclusion/implications for practice: This ANP-led model improves respiratory care access and coordination. It supports GPs, prevents unnecessary hospital attendances, enhances respiratory patients’ quality of life, and demonstrates how advanced practice can lead sustainable, high-impact service innovations. This model offers a blueprint for broader chronic disease management in primary care.

The impact of a respiratory RANP clinic in reducing time to initial assessment Author: R. Reilly Respiratory RANP, Department of Respiratory Medicine, Cavan Monaghan Hospitals, Co Cavan. Background: The respiratory RANP clinic was established in Cavan Monaghan Hospitals (CMH) in

February 2024. Prior to this, all patients referred by GPs/other hospital consultants were triaged by a respiratory consultant and added to the respiratory consultants waiting list for assessment, diagnosis, and treatment. In 2024, the waiting time

for initial assessment by a respiratory consultant was over one year. Objective: To expedite clinic review for a specific cohort of patients on the waiting list who require assessment, diagnosis, and treatment initiation.

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Implementation: The cohort of patients suitable for the RANP clinic was agreed with the relevant stakeholders. Policies were developed and approved by the CMH Medical Services Clinical Governance Committee. Seven clinics per fortnight were implemented in CMH. Outcomes: Between 1 February 2024 and 31 August 2025, 706 appointments (new and review) were issued, of which 486 (69%) patients attended. In 2024, 21 per cent of patients were waiting >12months for their initial appointment, reducing to 2 per cent in 2025. Furthermore in 2024, 67 per cent of

patients were seen in less than months, improving to 83 per cent in 2025. Confirmed diagnosis included asthma, asthma chronic obstructive pulmonary disease (COPD) overlap (ACO), COPD, bronchiectasis, interstitial lung disease, sinusitis, and gastro-oesophageal disease. A total of 84 patients (17%) required discussion with a respiratory consultant at the fortnightly multidisciplinary team (MDT) patient discussion meetings. Case management included referral for radiology (22), ordering and interpreting blood (174) and diagnostic (127) tests, writing prescriptions

(186), and completing appropriate referrals to MDT/respiratory integrated care (44). A sum of 84 patients were discharged to GP care or linked into other respiratory clinics/services for ongoing management. Conclusion: The respiratory RANP clinic provides a pathway to earlier diagnosis and treatment for patients on the respiratory consultant waiting list. This clinic reduces the patient’s time to diagnosis and treatment optimisation to less than nine months. Patients are discharged to appropriate care/clinic for ongoing management.

The respiratory post-discharge clinic reduces time to diagnosis and treatment optimisation Author: R Reilly Respiratory RANP; and M Togher Respiratory cANP, Dept of Respiratory Medicine, Cavan General Hospital Background: The respiratory postdischarge clinic was established in Cavan General Hospital in January 2024. Prior to this, patients who had an in-patient stay and who were assessed by clinical nurse specialist (CNS)/allied health professional (AHP) as having undiagnosed respiratory disease were referred to the respiratory clinic waiting list for formal diagnosis. The waiting time for review by respiratory consultant and diagnostics in 2024 was less than one year. Objective: To expedite clinic review for patients requiring diagnosis and/or confirmation of respiratory disease. Clinic appointment includes pulmonary function tests, allowing for diagnosis and treatment

initiation on same day. In addition, an oxygen therapy assessment and blood testing are included as necessary. This initiative reduces the number of patients referred to the respiratory consultant waiting list (waiting list avoidance). Implementation: The clinic is bimonthly and run by registered/ candidate ANP(RANP/cANP). Outcomes: Between 1 January 2024 – 11 August 2025: 101patients were referred. Seventy-eight patients were offered appointments – 58 per cent within 12 weeks and 86 per cent within 16 weeks of discharge. Seventy percent of new patients (55) attended their appointments. Confirmed diagnosis included asthma, asthma-chronic obstructive pulmonary disease (COPD) overlap, COPD, bronchiectasis, interstitial lung disease, and obstructive sleep apnoea.

A total of 22 patients (40%) were on the correct inhaler regime and had the correct inhaler technique, and 20 patients (36%) required an oxygen assessment. A total of 14 cases were discussed at the multidisciplinary team discussion meetings; eight patients (15%) were discharged following one review; and 47 per cent (26) were linked into other respiratory clinics/ services for ongoing management including consultant clinic; RANP clinic; cANP/CNS asthma clinic; ANP interstitial lung disease clinic,; oxygen clinic; sleep clinic; and integrated care. Conclusion: The respiratory postdischarge clinic provides a pathway to earlier diagnosis and treatment for patients identified during an inpatient stay with an undiagnosed respiratory disease. This clinic reduces the patient’s time to diagnosis and treatment optimisation to 16 weeks. Patients are cohorted into appropriate clinics for ongoing management.

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MEET THE MEMBERS Christina O'Rourke, ANP Dermatology, St James's Hospital Staff nurse to ANP: My journey in dermatology

My path to advanced nurse practitioner (ANP) status began at St James's Hospital 10 years ago, when I left behind the night duty and ‘on-call’ of the theatre department for a more family-friendly roster in skin cancer surgery. As a staff nurse in dermatology, I quickly became drawn to the specialty's blend of chronic disease management, acute intervention, and the profound psychological impact that skin conditions have on patients' lives. That early curiosity became the foundation for everything that followed: A deliberate, years-long progression from staff nurse to clinical nurse specialist (CNS), and ultimately to registered ANP, underpinned by a Master’s Degree in Advanced Practice Nursing and the gradual development of experience and competence. As a CNS, I joined an experienced medical dermatology team and began to focus on where nursing could add

Advanced practice nursing is not about replacing medical care, it is about designing better systems around the patient

Leadership, education, and autonomy

Christina O'Rourke

the most value to patients who were falling through gaps in traditional consultant-led pathways. This led myself and my job-sharing partner, RANP Deirdre Kennedy, to delivering a nurse-led Roaccutane (isotretinoin) clinic, giving patients with severe acne structured, closely monitored access to a treatment that demands rigorous safety oversight. I also joined my colleague Deirdre to expand the nurse-led biologic clinic for patients with psoriasis requiring ongoing biologic therapy management. Both services were built around patient safety: Robust pre-treatment screening, monitoring protocols, and continuity of care that reduces consultant wait lists, while improving the patient experience. These innovations reflected a wider truth I have carried throughout my career; advanced practice nursing is not about replacing medical care, it is about designing better systems around the patient.

Progressing to ANP level meant taking on clinical autonomy, including prescribing authority, but it also opened a leadership dimension I had not fully anticipated. Within St James's Hospital, Deirdre and I recognised a gap in structured, accessible education for nurses working in dermatology, so, together we established the annual dermatology study day, now a recurring fixture that brings nurses and doctors together for focused, practical learning. We felt it was important to ensure that skill development is not confined to a small group of specialists, but distributed across the wider nursing and primary care teams. Building on that, we are now working on additional nurse education courses designed to raise the baseline standard of dermatology nursing knowledge across national services. This conviction – that education and structured pathways are essential to the evolution and maturity of the profession – has also informed my work outside the hospital in my role as Chairperson of DANAI (Dermatology and Aesthetic Nurses Association of Ireland). Representing over 200 nurses nationally, I continue to advocate for clear training and education pathways for aesthetic and dermatology nurses up to Level 9 postgraduate standard, including ongoing discussions with third level institutions to develop a structured MSc-aligned pathway. My motivation

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has been consistency – every nurse working in dermatology, regardless of where they trained or which employer they work for, should have equal access to professional development that is recognised, regulated, and aligned with the Nursing and Midwifery Board of Ireland (NMBI) competencies. Patient safety is the primary motivation of my voluntary work in this area. In 2023, I led a team to establish a dedicated Dermatology Aesthetic Section within the Irish Nurses and Midwives Organisation (INMO) – a step taken because both nurses and patients were being exposed to inconsistent standards. As Secretary of the INMO section, I have supported Chairperson

Cora Murphy at the Annual Delegate Conferences over the last two years, with successful motions passed at each event. It has been a great endorsement for our dermatology aesthetic nurses to secure the support of our peers and colleagues. We now have sustained engagement with our regulator NMBI and continue moving towards the goal of safer practice for patients receiving aesthetic and dermatological treatments from nurses. Representing aesthetic and dermatology nurses at the national level, whether in direct engagement with NMBI on scope of practice guidance, in ongoing dialogue with the INMO, or in national media interviews addressing misinformation about nurse-led aesthetic care,

has demanded a particular kind of leadership. It requires evidence-based clarity under scrutiny, the composure to correct public misconceptions without becoming defensive, and the persistence to keep pushing even when progress is incremental. It also requires genuine collaboration and teamwork. It is enjoyable to work with nurses, professional bodies, and educational institutions who share the same conviction that safe, well-educated, appropriately regulated nursing practice benefits everyone, patients and the profession alike. That, ultimately, is what my journey to advanced practice has been about; not a single promotion, but a continuous effort to raise the standard of care and the standing of the nurses who deliver it.

TAKE A BREAK: SPOT THE DIFFERENCE Find the 10 differences between picture A and picture B

Answers to previous edition’s word scramble: 1. AUTONOMY 2. ASSESSMENT 3. DIAGNOSIS 4. PRESCRIBING 5. COLLABORATION 6. ADVOCACY 7. LEADERSHIP 8. EDUCATION 9. RESEARCH 10. ETHICS

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CPD MODULE

✽

AUTHORS: Catriona Keye, PhD candidate, RANP, MSc, RGN, Dip PN H Dip NS, RNP, MFTM RCPS (Glas), DiGP, Advanced Nurse Practitioner General Practice (Menopause)

Polyendocrine metabolic ovarian syndrome management for GPNs and ANPs People with PMOS frequently report seeing multiple healthcare professionals before receiving an explanation that connects their symptoms

To earn free CPD points, go to www.nurseCPD.ie and complete the quizzes based on this article.

published evidence base, guideline literature, and historical research continues to use the term PCOS. In this module, the updated term PMOS is used throughout the main text, while the term PCOS is retained where necessary within guideline titles, published study titles, and reference terminology.

PMOS

n international consensus statement published in 2026 proposed renaming polycystic ovary syndrome (PCOS) to polyendocrine metabolic ovarian syndrome (PMOS), reflecting broader recognition of its endocrine and metabolic features.1,2 This evolving terminology reflects increasing recognition that the condition extends beyond ovarian dysfunction alone, and involves complex endocrine, metabolic, reproductive, and cardiometabolic pathways. Historically, the term PCOS has been criticised as potentially misleading because many affected individuals do not have ovarian cysts in the conventional sense, while others experience substantial metabolic and endocrine dysfunction that is not adequately reflected by the older terminology. The proposed term PMOS aims to better represent the multisystem nature of the condition, including insulin resistance, androgen excess, ovulatory dysfunction, cardiometabolic risk, and broader endocrine involvement. At the time of writing, much of the

PMOS is a common endocrinemetabolic condition characterised by variable combinations of ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology.2 It is not simply a ‘period problem’ or a cosmetic condition – it is a lifelong syndrome with reproductive, dermatological, metabolic, and psychological implications.3 PMOS affects approximately 8-13 per cent of women and people assigned female at birth of reproductive age, although prevalence varies according to diagnostic criteria, age, ethnicity, and population studied.2,3 Symptoms may include irregular or absent periods, subfertility, hirsutism, acne, androgenic alopecia, weight gain or weight cycling, insulin resistance, acanthosis nigricans, fatigue, and psychological distress.2 The 2023 International Evidencebased Guideline for the Assessment and Management of PCOS2 was developed by the Monash Centre for Health Research and Implementation (MCHRI) alongside international societies like the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology, engaging multidisciplinary

experts and consumers across over 70 countries. It remains the most important contemporary clinical standard underpinning diagnosis and management of the condition. In Ireland, there does not currently appear to be a dedicated national clinical practice guideline for PMOS equivalent to the Irish national clinical practice guideline for endometriosis. Irish clinical practice therefore continues to draw on international guidance, HSE patient information, Irish GP and nursing education resources, and local referral pathways. 4,5 General practice nurses (GPNs) are well placed to support early recognition, provide clear education, reduce stigma, screen for metabolic risk, support contraception and fertility planning, and co-ordinate long-term follow-up.

Irish context and patient-facing resources

Irish patients commonly access initial information through the HSE website, which describes PMOS/PCOS as a common condition affecting how the ovaries work, and outlines symptoms including irregular periods, excess facial or body hair, weight gain, thinning hair, acne, and difficulty getting pregnant.4 The HSE treatment information emphasises that PMOS cannot currently be ‘cured’, but symptoms and longterm risks can be managed through lifestyle measures, medicines, and, where needed, fertility treatment. This is useful patient-facing language because it avoids unrealistic promises while

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supporting active management. In Irish professional education, the Irish College of GPs includes PCOS within its Community Gynaecology Certificate module on abnormal bleeding, oligomenorrhoea, amenorrhoea, and adolescent gynaecology. 5 This reflects the reality that many patients first present in primary care with symptoms, concerns, or fertility questions. The evidence base for this CPD module remains the 2023 International Guideline, HSE patient information, Irish professional education resources, and peer-reviewed academic literature.2,4 GPN practice point: Use HSE pages and credible Irish resources to support understanding after consultation, but base assessment, treatment, and referral on clinical guidelines and local pathways.

Epidemiology and public health impact

PMOS is one of the most common endocrine disorders affecting reproductive-aged individuals. The 2023 International Guideline estimates a prevalence of approximately 8-13 per cent, with many affected individuals remaining undiagnosed.2 This means that in a typical general practice population, PMOS is likely to be encountered regularly, although it may not always be coded, named, or managed as a single condition. Under-recognition is common because PMOS presents across several clinical domains. Menstrual irregularity may be managed as a period issue, acne as a dermatology concern, hirsutism as cosmetic, and infertility as a separate reproductive issue.2,3 Without a unifying diagnosis, patients may receive fragmented care and miss opportunities for metabolic screening, endometrial protection, and fertility counselling. There is no national Irish PMOS registry or robust publicly available dataset reporting the exact number of people diagnosed or treated for PMOS in Ireland. The main prevalence estimates used are generally extrapolated from

international data.4,5 A 2024 Irish professional education article reported an Irish prevalence figure of 128 per 100,000 women, but this is likely to reflect recorded or recognised disease rather than true population prevalence, as international population-based estimates are considerably higher.2,6,7 The absence of strong Irish epidemiological data is itself clinically important. It means that GPNs should not rely solely on coded prevalence or prior diagnosis, but should actively recognise symptom clusters and consider PMOS where irregular cycles, hyperandrogenic symptoms, infertility, or metabolic risk factors occur together.2,4

Diagnostic delay and fragmented care

People with PMOS frequently report seeing multiple healthcare professionals before receiving an explanation that connects their symptoms.2,8 Delayed diagnosis can lead to untreated irregular bleeding, prolonged distress about body changes, delayed fertility counselling, and missed opportunities to screen for cardiometabolic risk.2,9 Diagnostic delay may also contribute to worsening psychological wellbeing, reduced trust in healthcare encounters, and prolonged uncertainty regarding fertility and longterm health risks.2,8 International literature suggests that up to half of affected individuals may remain undiagnosed, highlighting the importance of proactive recognition in primary care.2

Ethnicity, symptom diversity, and weight diversity PMOS expression varies by ethnicity and clinical presentation2,3,6 Some individuals present predominantly with hyperandrogenic symptoms, while others present mainly with irregular cycles, infertility, or metabolic dysfunction.3 Metabolic risk may occur across body mass index (BMI) categories, and lean PMOS should not be dismissed.2,9 Conversely, weight stigma can worsen healthcare avoidance, disordered eating,

anxiety, and psychological distress.2,8 The international guideline specifically emphasises the importance of culturally sensitive, person-centred, and weightstigma-informed care.2 Differences in symptom presentation and metabolic risk between ethnic groups may also influence diagnosis, cardiometabolic risk assessment, and treatment priorities.2,6

Psychological burden

PMOS is associated with higher rates of anxiety, depression, body image distress, reduced quality of life, and disordered eating.2,8 Hirsutism, acne, scalp hair thinning, fertility concerns, and weight stigma can all affect self-esteem, intimate relationships, and overall quality of life.2,8 Psychological symptoms should therefore be actively assessed rather than treated as secondary or less important.

Fertility and reproductive impact at population level

PMOS is one of the leading causes of anovulatory infertility worldwide.2,3 Ovulatory dysfunction may contribute to delayed conception, cycle unpredictability, and fertility-related psychological distress.2,8 Importantly, PMOS should not be viewed as synonymous with infertility. Many individuals conceive spontaneously, while others conceive following ovulation induction or assisted reproductive treatment.2,10,11,12 Fertility concerns may significantly affect quality of life, relationships, and emotional wellbeing, highlighting the importance of early recognition, evidence-based counselling, and timely referral, where appropriate.2,8

Long-term health burden

PMOS is associated with increased risk of insulin resistance, impaired glucose tolerance, type 2 diabetes, gestational diabetes, hypertensive disorders of pregnancy, dyslipidaemia, obstructive sleep apnoea, and endometrial hyperplasia.2,9,13,14 It should therefore be understood as a chronic condition requiring long-term health surveillance.

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The evolving terminology of PMOS reflects increasing recognition that cardiometabolic dysfunction is not simply a secondary association, but a core component of the condition for many individuals. Contemporary evidence demonstrates important links between insulin resistance, endothelial dysfunction, dyslipidaemia, chronic inflammation, altered glucose metabolism, and increased long-term cardiometabolic risk.9,13 Large population-based data from the UK demonstrate increasing recorded incidence and prevalence of PMOS over time, alongside higher healthcare utilisation compared with controls.15 Although UK data cannot be directly applied to Ireland, these findings support the view that PMOS is an important primary-care and public health condition, rather than a niche reproductive diagnosis.

Normal menstrual cycle: Foundation for understanding PMOS

Understanding normal menstrual physiology helps explain why PMOS causes irregular periods, abnormal bleeding patterns, and subfertility. 2,3 The menstrual cycle is regulated by the hypothalamic-pituitary-ovarian (HPO) axis. 2,3 The hypothalamus releases gonadotropin-releasing hormone (GnRH) in pulsatile patterns. GnRH stimulates the pituitary gland to release follicle-stimulating hormone (FSH) and luteinising hormone (LH). FSH supports follicular growth and oestradiol production, while LH stimulates androgen production by ovarian theca cells. Oestradiol and progesterone feed back to the hypothalamus and pituitary to regulate the cycle. 2,3

✽ Follicular phase: In a typical ovulatory cycle, FSH stimulates development of a group of ovarian follicles. One dominant follicle matures and produces rising oestradiol. Oestradiol thickens the endometrium and prepares the reproductive system for ovulation.2

✽ Ovulation: Sustained high oestradiol triggers an LH surge, leading to release of an oocyte from the dominant follicle. Ovulation is the key event supporting predictable menstrual cyclicity and fertility. 2

✽ Luteal phase: After ovulation, the corpus luteum produces progesterone. Progesterone stabilises the endometrium and prepares it for potential implantation. If pregnancy does not occur, progesterone levels fall and menstruation follows.2,14 What changes in PMOS?: In PMOS, many follicles begin development but do not consistently progress to dominant follicle selection and ovulation. Increased LH activity, insulin resistance, and androgen excess contribute to this follicular arrest.2,3,9 As ovulation becomes irregular or absent, progesterone exposure is reduced or absent for prolonged periods. This may lead to prolonged cycles, unpredictable bleeding or amenorrhoea, and increases endometrial exposure to unopposed oestrogen.2,14 Patient explanation: “PMOS is not only an ovarian condition, it also affects metabolism and hormone regulation throughout the body. The ovaries may receive mixed hormonal and metabolic signals, meaning eggs can begin developing but may not release regularly, leading to irregular periods. Changes in insulin and androgen hormones can also affect skin, hair growth, weight regulation, energy levels, fertility, and long-term cardiometabolic health. This broader endocrine and metabolic understanding is one of the reasons the terminology changed from PCOS to PMOS.”

Pathophysiology of PMOS

The exact cause of PMOS is not fully understood. Current evidence suggests that genetic predisposition interacts with environmental and metabolic influences to disrupt hormonal signalling pathways. Many patients have a family history

of PMOS, type 2 diabetes, or metabolic disease, suggesting inherited susceptibility. However, clinical presentation varies considerably between individuals.2,3

Insulin resistance and hyperinsulinaemia

In PMOS, elevated insulin levels contribute directly to ovarian androgen production. Insulin acts synergistically with LH on ovarian theca cells, increasing androgen synthesis. High insulin levels also suppress hepatic production of sex hormonebinding globulin (SHBG), resulting in increased free testosterone levels.¹³ This explains why insulin resistance contributes not only to metabolic dysfunction, but also to acne, hirsutism, ovulatory dysfunction, and fertility problems.2,3,9 Importantly, insulin resistance can occur across all BMI categories. While adiposity may worsen insulin resistance, lean individuals with PMOS can also experience significant metabolic dysfunction.2,9

Hyperandrogenism

Hyperandrogenism refers to excess androgen activity. Clinically, this may present as hirsutism, acne, scalp hair thinning, or androgenic alopecia. Biochemically, elevated testosterone or free androgen index may be detected.2,3 Androgens are normally present in all women and are important for physiological function. However, excess androgen activity affects hair follicles, sebaceous glands, and ovarian follicle development. Increased androgen exposure can disrupt normal ovulation and perpetuate the hormonal cycle underlying PMOS.2,3

Ovulatory dysfunction and follicular arrest

In a normal ovulatory cycle, one dominant follicle matures and releases an oocyte following the LH surge. In PMOS, follicles often begin development but fail to reach full maturation.2,3 This follicular arrest results in accumulation of multiple small follicles within the ovaries. Importantly,

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these are not true ovarian cysts in the conventional sense. The historical term PCOS can therefore be misleading and contributed to the rationale for the updated terminology PMOS.2,3 Ovulatory dysfunction results in irregular cycles, oligo-ovulation, or anovulation. Reduced ovulation also means reduced progesterone exposure, leading to prolonged endometrial exposure to oestrogen without regular shedding.2,14

Diagnosis of PMOS

The modified Rotterdam criteria remain the most widely used international diagnostic framework for PMOS and are supported by the 2023 guideline.2 Diagnosis requires the presence of two of the following three features, after exclusion of alternative causes: ✽ Clinical or biochemical hyperandrogenism ✽ Ovulatory dysfunction ✽ Polycystic ovarian morphology on ultrasound.2 Importantly, PMOS remains a clinical diagnosis rather than a diagnosis based solely on ultrasound or laboratory findings. Symptoms, metabolic profile, menstrual history, and broader endocrine assessment should always be interpreted together.2,3

PMOS phenotypes

The modified Rotterdam criteria recognise four main phenotypes of PMOS.2 These phenotypes help explain why clinical presentation varies substantially between individuals and why some patients present primarily with reproductive symptoms while others demonstrate more prominent metabolic, dermatological, or psychological features.6 Recognition of phenotypic variation is clinically important because PMOS is a heterogeneous condition rather than a single uniform disorder.2 Some individuals experience significant insulin resistance and cardiometabolic dysfunction, while others may present predominantly with infertility, acne, hirsutism or menstrual irregularity, despite relatively limited metabolic features.2,6,9

Phenotype A (classic PMOS): This phenotype includes hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology.2 Individuals with this phenotype may demonstrate more significant metabolic dysfunction, insulin resistance, and reproductive symptoms.6,9 Hirsutism, acne, irregular cycles, and infertility concerns are often prominent. Phenotype B: This phenotype includes hyperandrogenism and ovulatory dysfunction without polycystic ovarian morphology on ultrasound.2 Patients may still experience significant endocrine and fertility symptoms despite normal ovarian imaging. Phenotype C: This phenotype includes hyperandrogenism and polycystic ovarian morphology with apparently preserved ovulation.2 Menstrual cycles may appear relatively regular, which can delay diagnosis and contribute to under-recognition of androgen-related symptoms like acne, hirsutism, or scalp hair thinning. Phenotype D: This phenotype includes ovulatory dysfunction and polycystic ovarian morphology without clear hyperandrogenism.2 Patients may present primarily with irregular periods, subfertility, or abnormal bleeding patterns rather than acne or excess hair growth.

Biochemical assessment

Biochemical assessment in PMOS has two important aims: Supporting diagnosis of hyperandrogenism and ovulatory dysfunction, and excluding alternative endocrine or metabolic conditions which may mimic PMOS.2,3 Common investigations may include: ✽ Total testosterone and calculated free testosterone or free androgen index ✽ SHBG ✽ DHEAS (dehydroepiandrosterone sulphate) ✽ Androstenedione ✽ LH and FSH

✽ Oestradiol ✽ Thyroid function tests ✽ Prolactin ✽ 17-hydroxyprogesterone ✽ HbA1c (glycated haemoglobin) and/or oral glucose tolerance testing

✽ Fasting glucose and lipid profile ✽ Fasting insulin in selected cases.2,9 Markedly elevated testosterone, rapidly progressive virilisation, or very high DHEAS levels should prompt consideration of androgen-secreting ovarian or adrenal tumours.2,3

Ultrasound and AMH

Ultrasound may identify polycystic ovarian morphology, typically characterised by increased follicle number and/or increased ovarian volume.2 However, ultrasound findings alone are not diagnostic of PMOS and must be interpreted within the wider clinical context. In adults, transvaginal ultrasound is generally preferred, where appropriate and acceptable, because it provides superior assessment of ovarian morphology and follicle number compared with transabdominal imaging.2 AntiMüllerian hormone (AMH) levels are often elevated in PMOS because of increased small follicle number. However, AMH should not be used as a standalone diagnostic test for PMOS in routine clinical practice.2

Diagnosis in adolescents

Diagnosis in adolescence requires particular caution because irregular cycles, acne, and multi-follicular ovarian appearance may occur during normal pubertal maturation.2 The international guideline recommends that adolescent diagnosis requires both persistent ovulatory dysfunction and evidence of hyperandrogenism after exclusion of other causes.2 Ultrasound is not recommended for diagnosis in adolescents because ovarian morphology may overlap substantially with normal puberty.2

Differential diagnoses

Important differential diagnoses include pregnancy, thyroid dysfunction,

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hyperprolactinaemia, non-classic congenital adrenal hyperplasia, Cushing syndrome, androgensecreting ovarian or adrenal tumours, hypothalamic amenorrhoea, primary ovarian insufficiency, and medicationrelated hyperandrogenism. 2,3 Routine cortisol testing is not recommended in all individuals with suspected PMOS. Investigation for Cushing syndrome should be reserved for patients with clinical features suggestive of hypercortisolism, such as proximal muscle weakness, facial plethora, wide purple striae, dorsocervical fat pad, easy bruising, or rapid central weight gain. 2,3

Red flags requiring urgent or specialist referral

Although most patients with PMOS present with gradual symptom progression over time, certain clinical features require urgent assessment because they may indicate alternative endocrine or malignant pathology. 2,3 Rapid onset androgenic symptoms are particularly important because uncomplicated PMOS typically develops gradually across adolescence or early adulthood. Sudden or severe virilisation raises concern for androgen-secreting tumours or significant endocrine pathology. 2,3 Persistent abnormal uterine bleeding or prolonged amenorrhoea with heavy bleeding may also indicate endometrial hyperplasia or malignancy associated with chronic anovulation and prolonged unopposed oestrogen exposure.2,14 The following features should prompt urgent investigation or specialist referral: ✽ Rapid onset hirsutism or virilisation ✽ Deepening voice, clitoromegaly, or rapidly progressive androgenic alopecia ✽ Very high testosterone or DHEAS ✽ Pelvic mass ✽ Postmenopausal androgen excess ✽ Prolonged amenorrhoea with abnormal bleeding or suspected endometrial pathology.2,3,14

Non-pharmacological management

Lifestyle and behavioural interventions are considered first-line management for many individuals with PMOS. However, modern PMOS care emphasises that lifestyle support should be collaborative, realistic, evidence-based and nonstigmatising.2,16 Historically, consultations often focused narrowly on weight loss. This approach can be harmful, particularly for individuals who have experienced repeated dieting, body shame, weight stigma, or disordered eating. For GPNs, non-pharmacological management represents one of the most important aspects of PMOS care. Nurses are often central to continuity of care, behaviour-change support, psychological assessment, metabolic screening, education, and long-term follow-up.

Education and validation

Many individuals with PMOS report years of feeling dismissed, misunderstood, or blamed for symptoms such as weight gain, acne, irregular periods, fatigue, or infertility. Some patients describe previous consultations focused solely on body weight without broader discussion of endocrine or metabolic health. Others report being told that symptoms are simply part of being female or that fertility problems are inevitable.1,8 Providing a clear explanation of the condition can reduce shame, improve health literacy, and support engagement with treatment plans. The international guideline emphasises person-centred care, shared decision-making, and awareness of the psychological impact of PMOS.2 Education should therefore emphasise that PMOS is a hormonemetabolic condition influenced by genetics, insulin resistance, and ovarian signalling, rather than a failure of willpower or lifestyle.2,3 Many patients experience relief when symptoms are finally linked together within a coherent diagnosis. Explaining how insulin resistance, androgen

excess, ovulatory dysfunction, and metabolic changes interact may help individuals understand why symptoms such as fatigue, hunger changes, weight fluctuation, acne, irregular cycles, and fertility difficulties often occur together. Consultation language nurses can use: “PMOS affects metabolism as well as hormones, so fatigue, hunger changes, and weight fluctuation are not simply about willpower. “The goal is not perfection or rapid weight loss. Small sustainable changes in sleep, movement, nutrition, and stress can significantly improve symptoms and longterm health. “Even modest improvements in insulin sensitivity can positively affect periods, ovulation, energy levels, and long-term cardiometabolic health.” Many individuals with PMOS have already attempted multiple lifestyle interventions before presentation. Previous negative experiences with dieting, shame-based messaging, unrealistic goals, or repeated weight cycling may affect confidence and engagement with healthcare.2,8 GPNs are well placed to support realistic goal setting, self-management, and sustainable behavioural change. Motivational interviewing techniques, collaborative planning, and nonjudgemental communication may improve long-term adherence and therapeutic relationships. Importantly, behaviourchange conversations should avoid framing the patient as non-compliant or unmotivated. PMOS involves biological drivers affecting appetite regulation, satiety, insulin signalling, fatigue, and energy regulation.9 This means lifestyle change may feel considerably more difficult for some individuals than simplistic public health messaging often suggests. Helpful consultation approaches may include exploring what has or has not worked previously, identifying barriers to change, discussing emotional responses to food and movement, and recognising

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social or financial factors affecting health behaviours. Useful approaches may include: ✽ Collaborative goal setting ✽ Exploring barriers to change ✽ Identifying achievable behavioural targets ✽ Focusing on health outcomes rather than appearance ✽ Encouraging gradual habit formation ✽ Recognising relapse as part of long-term behaviour change rather than ‘failure’. Long-term consistency is generally more clinically meaningful than short periods of highly restrictive behaviour.

Nutrition

There is no single PMOS diet. Current evidence supports healthy eating principles tailored to individual preferences, culture, metabolic risk, and eating behaviours.2,16 Reducing highly processed foods and improving dietary quality may support insulin sensitivity, satiety, glycaemic control, and energy regulation.2,9,16 Some individuals find lower glycaemic-load approaches helpful, particularly where insulin resistance or prediabetes are present.2,9 However, excessively restrictive diets may increase risk of disordered eating behaviours, food preoccupation, and psychological distress.2,8 General dietary strategies may include: ✽ Increasing fibre intake ✽ Prioritising protein intake ✽ Reducing ultra-processed foods ✽ Supporting stable blood glucose patterns ✽ Encouraging regular meal patterns ✽ Limiting sugar-sweetened beverages ✽ Supporting realistic and culturally

appropriate food choices. Referral to a dietitian may be particularly useful where complex metabolic dysfunction, obesity, disordered eating, fertility planning, or diabetes risk are present.

Physical activity

Exercise improves insulin sensitivity, cardiovascular health, mood, and body composition independent of major weight loss.2,16 Both aerobic and resistance exercise are beneficial. Movement should be framed positively as supporting energy, strength, metabolic health, and wellbeing rather than solely weight reduction. Sustainable and enjoyable activity is more likely to be maintained long-term and may reduce shame-based relationships with exercise.2 Practical advice may include: ✽ Encouraging gradual increases in movement ✽ Promoting enjoyable and sustainable activity ✽ Combining aerobic and resistance exercise where possible ✽ Reducing prolonged sedentary time ✽ Supporting realistic activity goals in individuals with fatigue or obesity ✽ Recognising barriers such as pain, body image concerns, caring responsibilities, or financial limitations. Resistance exercise may be particularly beneficial for insulin sensitivity, metabolic health, and preservation of lean muscle mass.

Weight stigma and weight-neutral care

Excessively restrictive diets may increase risk of disordered eating behaviours and psychological distress

Weight stigma is increasingly recognised as a major issue within PMOS care. Repeated exposure to shame-based healthcare interactions may worsen anxiety, disordered eating, healthcare avoidance, and low self-esteem.2,8 Clinicians should therefore use respectful, personcentred and weight-stigma-informed communication. Weight should not be

treated as a measure of personal worth, motivation, or compliance. Practical approaches include: ✽ Asking permission before discussing weight ✽ Using neutral terminology ✽ Avoiding moralising language around food or body size ✽ Focusing on health behaviours rather than appearance ✽ Recognising that metabolic dysfunction occurs across BMI categories ✽ Avoiding assumptions regarding lifestyle habits. Lean individuals with PMOS should not be falsely reassured that metabolic risk is absent simply because BMI is within normal range.2,9

Psychological support

Anxiety, depression, body image distress, and eating disorders occur more frequently in PMOS.2,8 Psychological symptoms may be amplified by infertility, hirsutism, acne, weight stigma, social isolation, or repeated unsuccessful dieting attempts.2,8 For some individuals, PMOS symptoms affect identity, confidence, sexuality, intimate relationships, and social participation. Visible symptoms such as facial hair growth, scalp hair thinning, or severe acne may lead to embarrassment, avoidance behaviours, or reduced self-esteem. Psychological distress may also be worsened by delayed diagnosis or previous healthcare encounters in which symptoms were minimised or attributed solely to weight.2,8 Psychological assessment should therefore form part of routine PMOS care rather than being treated as a secondary issue. GPNs should consider:

✽ Mood assessment ✽ Anxiety screening ✽ Eating disorder awareness ✽ Assessment of emotional eating patterns ✽ Body image concerns ✽ Social isolation and relationship impact ✽ Fertility-related distress

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✽ Impact on self-esteem and quality of life. Cognitive behavioural therapy (CBT) and psychological support may improve coping, self-esteem, emotional eating patterns, anxiety, and adherence to treatment plans.2,8

Sleep and circadian health

Sleep disturbance and obstructive sleep apnoea are more common in PMOS, particularly where metabolic dysfunction and higher BMI are present.2 Poor sleep may worsen insulin resistance, appetite regulation, fatigue, and daytime function.2,9 Shift work, chronic stress, and circadian disruption may also negatively affect metabolic health and hormonal regulation. Assessment should therefore include: ✽ Sleep quality ✽ Snoring or witnessed apnoea ✽ Daytime sleepiness ✽ Shift work patterns ✽ Fatigue ✽ Sleep duration ✽ Sleep hygiene practices. Sleep optimisation strategies may include regular sleep routines, reduction of evening screen exposure, stress

management, and referral for sleep assessment where indicated.

may improve confidence and long-term self-management.

Stress management and self-management support

Pharmacological management

Stress may contribute to hormonal and metabolic dysregulation through neuroendocrine and behavioural pathways. Chronic stress may also worsen emotional eating, sleep disturbance, fatigue, and psychological distress. Nurses can support stress reduction through: ✽ Relaxation strategies ✽ Mindfulness approaches ✽ Breathing exercises ✽ Encouraging restorative activities ✽ Signposting psychological supports ✽ Supporting realistic self-management expectations. Self-monitoring tools such as symptom tracking, cycle monitoring, wearable devices, or health apps may help some individuals recognise progress and improve engagement with care. Peer support and long-term engagement: Many individuals with PMOS feel isolated or misunderstood. Peer support groups, reputable educational resources, and ongoing nurse follow-up

INTERVENTION

WHY IT HELPS

CLINICAL TARGET

Education and validation

Reduces shame and improves engagement

Diagnosis acceptance; adherence

Nutrition support

Improves metabolic risk and insulin sensitivity

Prediabetes; metabolic dysfunction; energy

Exercise

Improves insulin sensitivity and cardiovascular health

Fatigue; metabolic risk; mood

CBT/psychological support

Supports mood, body image, and behaviour change

Anxiety; depression; disordered eating

Sleep optimisation

Improves metabolic and psychological health

Fatigue; obstructive sleep apnoea symptoms

Stress management

Supports neuroendocrine regulation and wellbeing

Emotional distress; burnout

Peer support

Reduces isolation and stigma

Confidence; selfmanagement

TABLE 1: Non-pharmacological approaches

Treatment should be individualised according to symptoms, fertility goals, metabolic risk, contraindications, and patient preference.2

Combined hormonal contraception

Combined hormonal contraception is commonly used for menstrual regulation, endometrial protection, and hyperandrogenic symptoms. It suppresses LH-driven ovarian androgen production and increases SHBG, reducing free testosterone.2 Choice of formulation may be influenced by the patient’s predominant symptoms, cardiovascular risk profile, tolerability, metabolic profile, and contraceptive needs. Examples commonly used in practice include: ✽ Ethinylestradiol with drospirenone, which may be particularly helpful where acne, fluid retention, or mild hirsutism are prominent because drospirenone has anti-androgenic activity.2 ✽ Ethinylestradiol with cyproterone acetate may be considered for more significant hirsutism or acne, although thromboembolic risk profile should be considered carefully.2 ✽ Ethinylestradiol with desogestrel or norgestimate, which may be useful where acne predominates and a lower androgenic progestogen is preferred.2 ✽ Levonorgestrel-containing combined oral contraceptives, which may provide effective menstrual regulation and endometrial protection, but may be less beneficial for androgenic symptoms in some individuals.2 Patients should be counselled that improvement in acne and hirsutism may take several months because androgen-sensitive hair follicles and sebaceous glands respond gradually to hormonal change.2 Newer formulations such as estetrol/drospirenone (Drovelis)

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EAACI: European Academy of Allergy & Clinical Immunology; GER: Gastroesophageal Reflux; GERD: Gastroesophageal Reflux Disease EAACI: European Academy AllergyAllergy & Clinical Immunology; GER: Gastroesophageal Reflux; GERD: PMID: Gastroesophageal Reflux Disease References: 1. Meyer R et al.,ofPediatr Immunol. 2022 Oct;33(10):e13856. doi: 10.1111/pai.13856. 36282131. 2. Bellaiche, et al. Pediatr Gastroenterol Hepatol Nutr.1.2023;26(5):249-265. 3. Vandenplas Y et al.2022 Eur JOct;33(10):e13856. Pediatr 1994;153:419–23. 4. Nutricia Research. Artificial digestion model. onGastroenterol file. References: Meyer R et al., Pediatr Allergy Immunol. doi: 10.1111/pai.13856. PMID: 36282131. 2. Bellaiche, et al. Data Pediatr Hepatol Nutr. 2023;26(5):249-265. 3. Vandenplas Y et al. Eur J Pediatr 1994;153:419–23. 4. Nutricia Research. Artificial digestion model. Data on file.

IMPORTANT NOTICE: Breastfeeding is best. Aptamil Anti-Reflux is a food for special medical purposes for the dietary management NOTICE: of frequent reflux and regurgitation. It should only be used medical supervision, after full consideration of IMPORTANT Breastfeeding is best. Aptamil Anti-Reflux is a under food for special medical purposes for the dietary the feeding options available including breastfeeding. Suitable for as under the sole sourcesupervision, of nutrition after for infants from birth and management of frequent reflux and regurgitation. It should only beuse used medical full consideration of EAACI: European Academy of Allergy & Clinical Immunology; GER: Gastroesophageal Reflux; GERD: Gastroesophageal Reflux Disease as part of a options weaningavailable diet fromincluding 6-12 months. This product should not beasused in combination with antacids or other the feeding breastfeeding. Suitable for use the sole source of nutrition for infants fromthickeners birth and References: 1. Meyer R et al., Pediatr Allergy Immunol. 2022 Oct;33(10):e13856. doi: 10.1111/pai.13856. PMID: 36282131. 2. Bellaiche, et al. Pediatr Gastroenterol andpart is not suitable fordiet premature infants. Refer toproduct label forshould details.not be used in combination with antacids or other thickeners as of a weaning from 6-12 months. This Hepatol Nutr. 2023;26(5):249-265. 3. Vandenplas Y et al. Eur J Pediatr 1994;153:419–23. 4. Nutricia Research. Artificial digestion model. Data on file. and is not suitable for premature infants. Refer to label for details.

Date Breastfeeding of Publication: July Deansgrange Deansgrange, Dublin. for the dietary IMPORTANT NOTICE: is 2025. best. Nutricia AptamilIreland, Anti-Reflux is a Business food forPark, special medicalCo. purposes Date of Publication: July 2025. Nutricia Ireland,only Deansgrange Park, Deansgrange, Co.after Dublin. management of frequent reflux and regurgitation. It should be used Business under medical supervision, full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth and as part of a weaning diet from 6-12 months. This product should not be used in combination with antacids or other thickeners

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may be considered in selected patients with PMOS. Drospirenone has antiandrogenic properties which may support improvement in acne, fluid retention, and mild hirsutism. Emerging evidence suggests estetrol-containing combined pills may offer favourable cycle control and tolerability, although long-term comparative data in PMOS populations remain limited.2,17

Progesterone-based management and endometrial protection

Individuals with infrequent periods may require progesterone therapy or other forms of endometrial protection to reduce the risk of endometrial hyperplasia associated with prolonged unopposed oestrogen exposure.2,14 This is particularly important where menstrual cycles are prolonged, highly irregular, or amenorrhoea persists. The 2023 guideline recommends consideration of regular withdrawal bleeding, combined hormonal contraception, or cyclical progestogen therapy where menstrual cycles are infrequent.2 The aim is to ensure adequate endometrial protection and reduce prolonged endometrial proliferation.2,14 Commonly used approaches in clinical practice may include: ✽ Micronised progesterone 200mg nightly for 12-14 days in cyclical regimens ✽ Medroxyprogesterone acetate 10mg daily for 10-14 days every one to three months ✽ Levonorgestrel intrauterine system ✽ Progesterone-only oral contraceptives ✽ Combined hormonal contraception where appropriate.2 Micronised progesterone may be preferred by some clinicians because of its more physiological profile and favourable tolerability for some patients, although treatment choice should remain individualised. 2 Continuous progestogenic methods may also provide effective endometrial protection through suppression and stabilisation of the endometrium and

do not necessarily require scheduled withdrawal bleeding. 2 Progesteroneonly contraception may be particularly appropriate for individuals who cannot use oestrogen-containing contraception because of migraine with aura, hypertension, venous thromboembolism risk, smoking history, obesity-related cardiovascular risk, or intolerance of combined hormonal contraception. 2 Traditional progesterone-only pills are generally less effective for androgenic symptoms because they do not increase SHBG to the same extent as combined hormonal contraception. However, the drospirenone-only pill (Slynd) may offer additional benefits in selected patients because drospirenone has antiandrogenic and anti-mineralocorticoid activity.2,18 Slynd uses a 24/4 regimen, which may provide more predictable bleeding patterns than traditional progesterone-only pills, and may improve acceptability for some individuals.2,18 Slynd may therefore provide contraception and endometrial protection while also offering some improvement in acne, bloating, or mild hirsutism in selected individuals.2,18 Although evidence remains more limited than for combined anti-androgenic contraceptive formulations, Slynd may be particularly useful where oestrogen is contraindicated or poorly tolerated. Patients should also be advised that prolonged amenorrhoea should not simply be ignored because persistent endometrial proliferation may increase long-term risk of endometrial hyperplasia and malignancy.2,18

Metformin

Metformin reduces hepatic glucose production and improves peripheral insulin sensitivity, helping lower circulating insulin levels.2,9 Because hyperinsulinaemia contributes directly to ovarian androgen production, metformin may also indirectly reduce androgen excess and support improved ovulatory function.2,9 Metformin may support: ✽ Improvement in insulin resistance and

hyperinsulinaemia ✽ Reduction in impaired glucose tolerance and type 2 diabetes risk ✽ Improvement in menstrual regularity and ovulation in some individuals ✽ Cardiometabolic risk reduction ✽ Modest support for weight management, particularly when combined with lifestyle interventions.2,9,16 Although metformin is not primarily a weight-loss medication, some individuals experience modest reductions in weight, appetite, or weight regain patterns, particularly where insulin resistance contributes to metabolic dysfunction.2,9,16 Expectations should remain realistic and treatment should not be framed solely around weight reduction. Metformin may be particularly useful where impaired glucose tolerance, prediabetes, insulin resistance, higher metabolic risk, or features of metabolic syndrome are present.2 It may also be considered in selected patients with menstrual irregularity who cannot tolerate or do not wish to use hormonal contraception.2 Gastrointestinal side effects such as nausea, bloating, abdominal discomfort, and diarrhoea are common, particularly during initiation. Gradual dose titration and use of modified-release preparations may improve tolerability.2 Long-term treatment may also be associated with vitamin B12 deficiency and periodic review should therefore be considered.2

Spironolactone and anti-androgen therapy

Spironolactone is an anti-androgen medication commonly used to reduce hirsutism, acne, and androgen-related scalp hair thinning in PMOS.2 It works primarily by blocking androgen receptor activity and reducing androgen effects at the hair follicle and sebaceous gland.2 Spironolactone is generally considered when hyperandrogenic symptoms persist despite combined hormonal contraception, or where combined hormonal contraception is

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contraindicated or declined.2 Improvement in hirsutism is gradual and patients should be counselled that several months of treatment may be required before meaningful clinical improvement becomes apparent because terminal hairs must complete their growth cycle before reduction is visible.2 Potential adverse effects may include dizziness, breast tenderness, menstrual irregularity, fatigue, and hyperkalaemia.2 Because spironolactone may affect foetal development, effective contraception is recommended during treatment.2 Monitoring may include renal function, potassium levels where clinically indicated, blood pressure assessment, and review of treatment tolerability and adherence.

Dermatological treatments

Topical acne therapies, oral antibiotics, isotretinoin pathways, and hair removal strategies may be relevant depending on symptom severity and patient preference.2,8 Cosmetic concerns should not be minimised. Some patients may experience substantial psychological distress despite relatively mild clinical findings.8 Hair reduction approaches such as laser therapy, electrolysis, and cosmetic hair removal may therefore form an important part of holistic management.2

GLP-1 receptor agonists

Glucagon-like peptide-1 (GLP-1) receptor agonists may support weight and metabolic management in selected patients with PMOS, particularly where insulin resistance, obesity, or broader cardiometabolic dysfunction are significant contributors.2 These medications work by mimicking the GLP-1 hormone, helping the body release insulin only when glucose levels are elevated, slowing gastric emptying and reducing appetite signals. In PMOS, this may support weight management, insulin resistance and broader metabolic health. Treatment requires individualised prescribing, contraception counselling,

side effect discussion, and awareness of licensing and local prescribing policy. Patient explanation: “These medicines can help regulate appetite and improve how the body handles blood sugar and energy signals. For some people with PMOS, this may reduce food noise, improve fullness, and support healthier metabolic signalling. Improvements in insulin resistance and weight regulation may also positively affect ovulation, energy levels, and long-term cardiometabolic health.”

PMOS and fertility

PMOS is one of the leading causes of anovulatory infertility worldwide.2,3 Ovulation may occur unpredictably or not at all, making cycle timing difficult and contributing to delayed conception.2,3 Importantly, patients with PMOS are sometimes incorrectly told that they are ‘infertile’, which can cause significant psychological distress. In reality, many individuals with PMOS can conceive spontaneously or with relatively simple ovulation induction strategies.2,10,11,12 A large Swedish population-based study involving 45,395 women with PMOS and 217,049 controls found the cumulative probability of childbirth after spontaneous conception was approximately 55 per cent in women with PMOS.11 The same study found

the overall cumulative probability of childbirth, including assisted conception, was 80.2 per cent in women with PMOS compared with 78.2 per cent in women without PMOS.11 Another longitudinal cohort study involving 291 women with PMOS reported that 73.6 per cent conceived spontaneously.12 These findings are important in helping clinicians provide realistic reassurance and avoid catastrophic or inaccurate language regarding fertility potential. Subfertility in PMOS is multifactorial. Ovulatory dysfunction is central, but insulin resistance, obesity, inflammation, and metabolic dysfunction may also affect reproductive outcomes and pregnancy risk.2,9,13,14

Fertility counselling in primary care

GPNs should ask routinely about reproductive goals because management priorities differ significantly depending on whether or not pregnancy is desired. If pregnancy is desired, management should shift from ovulation suppression and contraception towards ovulation optimisation, metabolic assessment, preconception counselling, and timely referral where appropriate.2 Preconception counselling should include: ✽ Folic acid supplementation ✽ Medication review

TREATMENT

MECHANISM

CLINICAL TARGET

Combined hormonal contraception

Suppresses ovarian androgen production; increases SHBG

Irregular cycles; acne; hirsutism

Cyclical progestogen

Protects endometrium

Infrequent bleeding; amenorrhoea

Metformin

Improves insulin sensitivity

Prediabetes; metabolic risk; cycle irregularity

Spironolactone

Blocks androgen receptor activity

Hirsutism; acne

Letrozole

Induces ovulation

Anovulatory infertility

GLP-1 receptor agonists

Appetite and metabolic effects

Selected weight/ metabolic indications

TABLE 2: Treatment options

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✽ Smoking cessation support

contributors.2,9 It may occasionally be used alone or alongside ovulation induction therapy depending on metabolic profile and fertility pathway.

where relevant

✽ Optimisation of metabolic health ✽ HbA1c or glucose assessment where indicated

Gonadotropins and assisted reproduction

✽ Weight-stigma-informed lifestyle support ✽ Discussion of cycle tracking and ovulation awareness.2

Ovulation induction and fertility medications

The 2023 guideline recommends letrozole as first-line pharmacological ovulation induction for anovulatory infertility associated with PMOS where no other infertility factors are present.2,10 Letrozole is an aromatase inhibitor which transiently lowers oestrogen levels, increasing pituitary FSH secretion and promoting follicular development and ovulation.2,10 Compared with clomiphene citrate, letrozole is associated with higher ovulation rates, higher live birth rates, and a lower risk of multiple pregnancy.2,10 In the landmark New England Journal of Medicine trial, cumulative ovulation rates were approximately 62 per cent with letrozole compared with 48 per cent with clomiphene citrate, while live birth occurred in approximately 28 per cent versus 19 per cent respectively.10 Clomiphene citrate was historically first-line therapy for ovulation induction in PMOS and may still be used in some fertility pathways. It acts as a selective oestrogen receptor modulator, increasing endogenous gonadotropin release and stimulating ovulation.2,10 However, clomiphene is associated with a higher risk of multiple pregnancy compared with letrozole and may be less effective in some patients with insulin resistance or obesity.2,10

Metformin and fertility

Metformin may improve ovulatory function in some individuals with PMOS, particularly where insulin resistance and metabolic dysfunction are significant

Some individuals may require gonadotropin therapy or assisted reproductive technologies such as in vitro fertilisation (IVF), particularly where additional infertility factors are present or first-line ovulation induction is unsuccessful.2 Patients with PMOS may have increased risk of ovarian hyperstimulation syndrome during assisted reproduction because of high follicle sensitivity. Fertility management should therefore remain individualised and carefully monitored.

Pregnancy risks in PMOS

PMOS is associated with increased risk of gestational diabetes, hypertensive disorders of pregnancy, pre-eclampsia, miscarriage, preterm birth, and adverse metabolic outcomes during pregnancy.2,9,13 Insulin resistance and metabolic dysfunction likely contribute significantly to these risks.9,13 Preconception care should therefore include folic acid supplementation, medication review, diabetes screening where appropriate, blood pressure assessment, and realistic lifestyle support delivered in a nonstigmatising manner.2

Psychological aspects of fertility in PMOS

Fertility concerns may significantly affect self-esteem, relationships, and mental wellbeing in individuals with PMOS.2,8 Patients may experience shame, anxiety, grief, uncertainty, or fear regarding future fertility potential. Repeated exposure to messages suggesting inevitable infertility may further worsen psychological distress and hopelessness. Many patients report significant emotional burden associated with cycle unpredictability, delayed conception, or

fear of needing fertility treatment.8 The international guideline highlights the importance of psychological assessment and person-centred communication within PMOS care.2 GPNs can therefore play an important role in providing realistic reassurance, avoiding catastrophic language, supporting emotional wellbeing, and ensuring timely fertility referral where appropriate.

Glucose metabolism and diabetes risk

Insulin resistance is highly prevalent in PMOS and contributes to increased risk of impaired glucose tolerance and type 2 diabetes.2,9 Hyperinsulinaemia may precede overt hyperglycaemia for many years.9 The 2023 guideline recommends ongoing metabolic surveillance because diabetes risk may increase across the reproductive lifespan.2 This is particularly important where additional risk factors are present, including family history of diabetes, previous gestational diabetes, higher BMI, sedentary lifestyle, or ethnic backgrounds associated with increased diabetes prevalence.2 HbA1c may be useful in ongoing monitoring, but oral glucose tolerance testing may be more sensitive in selected high-risk groups, particularly preconception or during fertility assessment.2 GPNs play an important role in reinforcing longterm metabolic follow-up, supporting lifestyle interventions and recognising progression toward impaired glucose tolerance or type 2 diabetes.

Long-term cardiometabolic risk

PMOS should be understood as a longterm endocrine-metabolic condition rather than solely a reproductive disorder. Contemporary evidence demonstrates increased prevalence of insulin resistance, impaired glucose tolerance, type 2 diabetes, dyslipidaemia, and cardiovascular risk factors in individuals with PMOS.2,9,13

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Metabolic risk is not confined to individuals with obesity. Lean individuals with PMOS may also demonstrate impaired glucose metabolism and increased cardiovascular risk markers.2,9 Patients may also experience increased central adiposity, elevated triglycerides, and reduced HDL cholesterol.2,9,13 Chronic inflammation, insulin resistance, and adverse metabolic signalling likely contribute to long-term cardiovascular risk in PMOS.9,13 The international guideline therefore recommends regular assessment of blood pressure, glucose metabolism, and lipid profile as part of ongoing care.2

NAFLD

Non-alcoholic fatty liver disease (NAFLD) appears more common in individuals with PMOS, particularly where insulin resistance, obesity, and metabolic syndrome are present.9 Chronic hyperinsulinaemia and adverse metabolic signalling are thought to contribute to hepatic fat accumulation and metabolic dysfunction.9 Patients may present with abnormal liver function tests, fatigue or incidental imaging findings, although many remain asymptomatic in early disease stages. Recognition of NAFLD is clinically important because progression may contribute to steatohepatitis, fibrosis, and broader cardiometabolic risk over time.9 GPNs should therefore remain aware of liver health within long-term metabolic surveillance, particularly in individuals with obesity, impaired glucose tolerance, dyslipidaemia, or other features of metabolic syndrome.

Obstructive sleep apnoea

Obstructive sleep apnoea is more common in PMOS, particularly in the context of obesity and insulin resistance.2 Symptoms may include snoring, witnessed apnoea, morning headaches, poor concentration, and excessive daytime sleepiness.2 Sleep disruption may further worsen insulin

resistance, appetite regulation, fatigue, and metabolic dysfunction through neuroendocrine and inflammatory pathways.2,9 This can contribute to a cyclical pattern of worsening metabolic health and daytime functioning.

Endometrial health and cancer risk

PMOS is associated with increased risk of endometrial hyperplasia and endometrial cancer, primarily because chronic anovulation may expose the endometrium to prolonged unopposed oestrogen stimulation without regular progesterone-mediated shedding. 2,14 In ovulatory menstrual cycles, progesterone stabilises the endometrium after ovulation and supports organised shedding during menstruation.² In PMOS, irregular or absent ovulation means that progesterone exposure may be reduced or absent for prolonged periods. 2,14 This can result in persistent endometrial proliferation and unpredictable bleeding patterns.²,¹² Patients may therefore present with prolonged amenorrhoea followed by heavy, prolonged, or irregular bleeding. 2,14

Clinical implications for practice

Individuals with infrequent periods should not simply be reassured that irregular cycles are ‘normal for PMOS’ without consideration of endometrial protection. 2,14 The 2023 guideline recommends consideration of regular withdrawal bleeding, combined hormonal contraception, or cyclical progestogen, where appropriate, to reduce the risk of endometrial hyperplasia. 2 GPNs should therefore: ✽ Assess menstrual frequency and bleeding pattern regularly ✽ Identify prolonged amenorrhoea ✽ Reinforce the importance of endometrial protection ✽ Support adherence to prescribed hormonal treatment

✽ Recognise abnormal bleeding patterns requiring further investigation. Further assessment or referral should be considered in individuals with: ✽ Persistent abnormal uterine bleeding ✽ Prolonged amenorrhoea followed by heavy bleeding ✽ Intermenstrual bleeding ✽ Failure to respond to treatment ✽ Additional endometrial cancer risk factors. 2,14 Timely recognition is important because prolonged unopposed oestrogen exposure may increase long-term endometrial risk if left untreated. 2,14

Monitoring and follow-up

PMOS is a lifelong condition requiring ongoing monitoring rather than episodic treatment alone. Follow-up should be individualised according to symptoms, metabolic risk, fertility goals, age, and treatment type. 2 Monitoring should extend beyond menstrual regulation and include psychological wellbeing, metabolic health, cardiovascular risk, and quality of life.

Role of the GPN

GPNs are central to continuity of care in PMOS. They are often the healthcare professionals who have the most regular contact with patients over time and are therefore well placed to identify changing symptoms, reinforce education, and support long-term engagement with care. GPNs can support education, metabolic screening, behaviour change, contraception counselling, fertility discussions, medication monitoring, and psychological support. Nurse-led consultations may also provide opportunities to identify concerns that patients do not initially disclose during brief medical appointments, including body image distress, emotional eating, fertility

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anxiety, sexual wellbeing concerns, or previous negative healthcare experiences. The therapeutic relationship is particularly important because many patients report previous experiences of dismissal, stigma, or fragmented care.2,8 A validating, non-judgemental, and evidence-based approach can significantly improve engagement and long-term outcomes. GPNs may also play an important role in: ✽ Coordinating referrals to dietetics, fertility services, endocrinology, or psychology ✽ Reinforcing metabolic monitoring and cardiovascular prevention

References 1. Teede HJ, Khomami MB, Morman R, et al. Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: A multistep global consensus process. Lancet. 2026;407(10545):2329-2339. doi:10.1016/ S0140-6736(26)00717-8. 2. Teede HJ, Tay CT, Laven J, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Fertil Steril. 2023;120(4):767-793. doi:10.1016/j. fertnstert.2023.07.025. 3. Azziz R, Carmina E, Chen Z, et al. Polycystic ovary syndrome. Nat Rev Dis Primers. 2016;2:16057. doi:10.1038/ nrdp.2016.57. 4. Health Service Executive. Polycystic ovary syndrome. Dublin: HSE; 2025. Available at: www2.hse.ie/conditions/polycystic-ovarysyndrome/. 5. Irish College of General Practitioners. Community Gynaecology Certificate. Dublin: ICGP; 2025.

✽ Supporting adherence to hormonal therapy and endometrial protection ✽ Providing culturally sensitive and weight-stigma-informed care ✽ Encouraging sustainable long-term self-management rather than shortterm restrictive approaches ✽ Supporting transition between reproductive, fertility, and later-life health stages.

Conclusion

The terminology shift from PCOS to PMOS reflects a broader contemporary understanding of the condition as

hospitalprofessionalnews.ie/2024/10/02/ polycystic-ovary-syndrome-pcos/. 8. Cooney LG, Lee I, Sammel MD, Dokras A. High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: A systematic review and meta-analysis. Hum Reprod. 2017;32(5):1075-1091. doi:10.1093/humrep/ dex044. 9. Diamanti-Kandarakis E, Dunaif A. Insulin resistance and the polycystic ovary syndrome revisited: An update on mechanisms and implications. Endocr Rev. 2012;33(6):9811030. doi:10.1210/er.2011-1034. 10. Legro RS, Brzyski RG, Diamond MP, et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med. 2014;371(2):119-129. doi:10.1056/ NEJMoa1313517. 11. Persson S, Elenis E, Turkmen S, et al. Fecundity among women with polycystic ovary syndrome (PCOS) – a populationbased study. Hum Reprod. 2019;34(10):20522060. doi:10.1093/humrep/dez159.

6. Wolf WM, Wattick RA, Kinkade ON, Olfert MD. Geographical prevalence of polycystic ovary syndrome as determined by region and race/ethnicity. Int J Environ Res Public Health. 2018;15(11):2589. doi:10.3390/ ijerph15112589.

12. Joham AE, Teede HJ, Ranasinha S, et al. Prevalence of infertility and use of fertility treatment in women with polycystic ovary syndrome: Data from a large communitybased cohort study. J Womens Health (Larchmt). 2015;24(4):299-307. doi:10.1089/ jwh.2014.5000.

7. Byrne R, Phelan N. Polycystic ovary syndrome. Hospital Professional News Ireland. 2024. Available at: https://

13. Tay CT, Mousa A, Vyas A, et al. 2023 International Evidence-Based Polycystic Ovary Syndrome Guideline update: Insights

a multisystem endocrine-metabolic syndrome rather than a predominantly ovarian disorder alone. Insulin resistance, metabolic dysfunction, and cardiometabolic risk are now recognised as central components of the condition for many individuals, alongside reproductive and androgenic features. By combining evidence-based pharmacological management with realistic lifestyle support, validation, and long-term follow-up, general practice nurses can help improve both short- and long-term outcomes for people living with PMOS. ✽

from a systematic review and meta-analysis on elevated clinical cardiovascular disease in polycystic ovary syndrome. J Am Heart Assoc. 2024;13(16):e033572. doi:10.1161/ JAHA.123.033572. 14. Barry JA, Azizia MM, Hardiman PJ. Risk of endometrial, ovarian, and breast cancer in women with polycystic ovary syndrome: A systematic review and meta-analysis. Hum Reprod Update. 2014;20(5):748-758. doi:10.1093/humupd/dmu012. 15.Berni TR, Morgan CL, Rees DA. Rising incidence, health resource utilisation, and costs of polycystic ovary syndrome in the United Kingdom. J Clin Endocrinol Metab. 2025;110(5):e1580-e1589. doi:10.1210/ clinem/dgae518. 16. Lim SS, Hutchison SK, Van Ryswyk E, et al. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2019;3(3):CD007506. doi:10.1002/14651858.CD007506.pub4. 17. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Drovelis (drospirenone 3 mg/estetrol 14.2 mg): New product review. London: FSRH; 2022. Available at: www.cosrh.org/Public/ Public/Documents/fsrh-ceu-product-reviewdrovelis-estetroldrospirenone.aspx. 18. Slynd: Does a drospirenone progestogenonly pill offer an advantage? Drug and Therapeutics Bulletin. 2024;62:5559. Available at: https://dtb.bmj.com/ content/62/4/55.

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DERMATOLOGY

✽

AUTHOR: Dr Johnny Loughnane, retired GP with a specialist interest in dermatology, Newcastlewest, Co Limerick

Getting the diagnosis right when faced with disc-shaped dermatology lesions

Overlapping clinical signs can result in confusion and misdiagnosis, leading to incorrect treatment, so getting an accurate diagnosis is essential

kin diseases often present with overlapping clinical signs. This can result in confusion and misdiagnosis, which in turn can lead to choosing the incorrect treatment. When it comes to managing disease, an accurate diagnosis is an essential starting point. Disc-shaped lesions present one such conundrum for the diagnostician. As a clinician, when faced with a disc-shaped lesion, one has to ask: Is it a fungal infection, discoid eczema, psoriasis, or perhaps something else? In my experience these three entities are easily confused, and I hope these illustrations will help improve your diagnostic accuracy. Before reading this article, consider having a look at the clinical cases illustrated and before you read the captions, ask yourself: Is it a fungal infection, discoid eczema, psoriasis, or perhaps something else?

Discoid eczema

Discoid eczema is a common eczematous disorder characterised by scattered, circular or oval, exudative plaques with well-defined borders. With its coin-like shape it is often referred to as nummular eczema (derived from the Latin word for coin). Similar lesions can occur with atopic eczema (Figure 8), asteatotic eczema, and stasis eczema, leading some to question whether discoid eczema is an independent clinical entity. It may be complicated by secondary bacterial infection, and seems to be particularly susceptible to

Staphylococcus aureus colonisation. However, although the exact relation between Staphylococcus aureus colonisation and discoid eczema remains unknown, it does seem to flare the eczema lesions. Pruritus is usually severe. All age groups can be affected, especially older adults. Eczema lesions usually start as small papules and papulovesicles on a red base. Over time, more and more papules and papulovesicles develop and become confluent to form the characteristic plaques of discoid eczema. Vesicles are thin walled and rupture easily, producing a prominent exudate which dries, leaving a crusted surface over the eczema plaques (exudative acute discoid eczema). Over time, plaques become less vesicular and are dry with a covering of scale (dry discoid eczema). Some plaques develop central clearing to produce annular lesions that may be confused with tinea infection, especially as distribution of discoid eczema can sometimes mimic the asymmetrical distribution of tinea. Discoid eczema most commonly affects

the extremities, but involvement may be widespread. Distribution is usually bilateral. Most cases follow a relapsing/ remitting course over months or years. In darker skin, clearance may leave patches of post-inflammatory hyperpigmentation or hypopigmentation. All phases of eczema may be seen. Lesions may be acute (vesicles and weeping) or chronic (lichenified, scaling, and hyperkeratotic). Subacute lesions (combining oozing and scaling) are common.

Management

Emollients: Patients with discoid eczema tend to have a dry background skin and a defective skin barrier function. Irritants such as soaps, shower gels, shampoos, detergent, washing-up liquid, and polish need to be avoided. When washing hair in the shower, suds should be allowed to run down the plughole directly, avoiding contact with the body as much as possible. If taking a bath, the hair should be washed separately, not allowing bathing in water mixed with shampoo. Before a bath or a shower, a greasy moisturiser might be applied if the skin

MILD (CLASS I)

HYDROCORTISONE

Moderate (Class II)

Clobetasone butyrate (Eumovate), alclometasone dipropionate (Modrasone)

Potent (Class III)

Betamethasone butyrate (Betnovate), betamethasone dipropionate (Diprosone), hydrocortisone butyrate (Locoid), mometasone furoate (Elocon)

Very potent (Class IV)

Clobetasol propionate (Dermovate)

TABLE 1: Classification of TCSs

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DERMATOLOGY

is particularly dry. For the body, a liquid moisturiser should be substituted for soap and shower gel. Following a shower or bath, the skin should be moisturised. A regular moisturising regimen, outside bath or shower time, should be started. Topical corticosteroids: Topical corticosteroids (TCSs) have potent anti-inflammatory effects and constitute the first-line therapy for acute flares of discoid eczema. TCSs are safe when the appropriate potency is employed, depending on the body area being treated (Table 1). Most discoid eczema occurs in adults and involves the limbs and trunk. Potent or very potent TCSs are needed to get control. Clobetasol propionate ointment (or as a cream if lesions are very wet – creams tend to dry oozing lesions) may be applied daily. After about a week you will hopefully have had a good response and may step down the potency to betamethasone butyrate ointment once daily. In the event of frequent recurrences, consider suppressive TCS use combining betamethasone butyrate ointment daily for two days each week with ongoing irritant avoidance and moisturisation.

Tinea corporis

Tinea corporis is a superficial fungal infection of the trunk and limbs. It presents as ring-shaped lesions with an advancing, scaly, and a slightly raised edge. As the advancing edge looks like a worm, it is commonly referred to as

‘ringworm’. The causative dermatophytes constitute a group of fungi that produce keratinases, which break down keratin, allowing the dermatophytes to penetrate keratinised human tissue such as hair, nail, and skin. Tinea corporis starts as a single red patch with a raised scaly leading edge that gradually advances from the centre to give the classic ringshape rash with central clearing. The clinical signs of tinea skin infection vary, depending on the degree of inflammatory host response. Trichophyton rubrum (from humans) induces a mild response. Trichophyton verrucosum (from cattle) induces a vigorous inflammatory response, while in Trichophyton tonsurans (from humans), the response may vary from mild to severe. Microsporum canis (from cats and dogs) does not usually give a brisk inflammatory response, although a high infection load may. The case illustrated in Figure 13 was associated with a prod from a sharp piece of hedging associated with a cat spending a lot of time in the patient’s lap.

Tinea incognito

If tinea skin infection is misdiagnosed (as dermatitis, psoriasis, etc) and treated with a topical steroid, the clinical features are markedly modified (Figure 10). As the name suggests, tinea is in disguise, and is sometimes called ‘steroid-modified tinea’. It was first described and named by Dr Adrian Ive and Prof Ronnie Marks. Those of you who participated in the early years of the Diploma in Practical Dermatology

If tinea skin infection is misdiagnosed (as dermatitis, psoriasis, etc) and treated with a topical steroid, the clinical features are markedly modified

in Cardiff will remember Prof Marks, who was quite a character. They later admitted that their classical education had let them down. They should have termed it tinea incognita as tinea is feminine. When we examine a rash, we rely on the inflammatory reactions provoked in the skin by tinea infection. This inflammatory reaction may be suppressed by corticosteroids. In addition, steroids may have an immunosuppressive effect, leading to spreading of the rash. Suppression of inflammation leads to relief of pruritus, encouraging the patient to continue steroid use. You end up with a rash that feels better, but is spreading, and as it extends it may mimic other skin diseases. Clinically, the extending rash with a raised, continuous edge is broken up and is less raised. Scaling at the rash margins is lost, nodules and, more rarely, pustules may develop and concentric arcs are common. All potencies of TCSs may induce tinea incognito with potent, and very potent, TCSs carrying a higher risk. The mild potency, hydrocortisone, may lead to tinea incognito, especially on the face (Figure 11). With loss of scaling, scrapings may be difficult to obtain. Stopping the TCSs for a few days prompts a rapid return of inflammation and scale production. The clinical appearance may again resemble tinea and scrapings are more easily collectable. The diagnosis should always come to mind when faced with a unilateral or asymmetric, scaly or pustular rash with an irregular border that is spreading with the application of a topical steroid. Management Tinea incognito is best managed with oral terbinafine or itraconazole. The topical steroid may be continued for the first few days of oral antifungal to reduce the risk of a severe flare.

Kerion

As outlined, the clinical signs of tinea skin infection vary depending on the degree

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DERMATOLOGY

of inflammatory host response. With a milder response, the typical picture of circular lesions with a scaly, advancing edge are seen. If the immune response to the dermatophyte is dramatic, a severe inflammatory reaction called a kerion may result. Trichophyton verrucosum, the most common culprit, is not unusual in rural Ireland. It presents as an inflammatory mass, sometimes studded with pustules or a boggy abscess discharging puss. With this appearance it is often misdiagnosed as a bacterial infection (Figure 14). It arises most commonly on the scalp, but can occur on the face, upper limbs, and other body sites. This is usually caused by one of the zoophilic species (from animals), typically Trichophyton verrucosum, Microsporum canis, Trichophyton tonsurans, or Trichophyton mentagrophyte.

Management: Six to eight weeks of oral terbinafine or itraconazole.

Palmoplantar pustulosis

Palmoplantar pustulosis is a chronic, and often relapsing, dermatosis affecting typical sites on the palms and soles (Figures 15 and 16). It is still sometimes referred to as palmoplantar pustular psoriasis, but it is now accepted as representing a distinct clinical entity. The rash has a sharp, non-raised margin. Sterile pustules resolve to leave distinctive, brown macules, a most useful diagnostic clue. Scaling and peeling may be evident on the background, over the erythematous plaques. Itch is not usually prominent, and many complain of a more stinging discomfort. It usually presents between the ages of 20 and 60 years, and is more common

in females. About 80 per cent of patients are cigarette smokers. Stopping smoking may benefit. Management: Emollients containing keratolytics (salicylic acid or urea) to moisturise and help break down thickened keratin. Topical potent or very potent steroid ointment formulations are first-line. After application at night, they may be covered with cling film or polyethylene gloves, left on overnight. This increases the potency of the topical steroid by a factor of five, and occlusion should be stopped after one week, while the steroid may be continued. Morning application of tar or calcipotriol added to the topical steroid at night may impact to the therapeutic response. Response to topical treatment is frequently disappointing. Early referral to secondary care is encouraged. ✽

FIGURE 1

FIGURE 2

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

FIGURE 8

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DERMATOLOGY

FIGURE 9

FIGURE 10

FIGURE 11

FIGURE 12

FIGURE 13

FIGURE 14

FIGURE 15

FIGURE 16

FIGURE 1: Early discoid eczema with scaling and oozing from ruptured vesicles.

FIGURE 6: Close-up of lesions

FIGURE 2: Same patient (Fig 1) with papules and vesicles coalescing to form a patch of subacute eczema with marked redness and oozing.

in the same patient (Fig 5). Note the inflammatory papules of spreading eczema beyond the margins. FIGURE 7: Lower limb discoid eczema with oozing, crusting, and papules coalescing beyond

FIGURE 3: Discoid eczema mistaken for tinea. One month of oral terbinafine ineffective. The picture is of a more chronic eczema with less redness and no vesicles or oozing.

the margins and forming new

FIGURE 4: Lichenification, lack of central clearing, and lack of a raised advancing edge suggest discoid eczema rather than tinea.

Honey-coloured crusts suggest

FIGURE 5: Extensive discoid eczema. Staphylococcal infection.

canis in a young boy. Note the

patches. FIGURE 8: Two-year-old with a history of atopic eczema, now presenting with discoid pattern near the shoulders. staphylococcal infection. FIGURE 9: Typical early tinea corporis due to Microsporum advancing, raised, inflamed edge

with central clearing. FIGURE 10: Look what happens when a mild potency topical steroid was applied to a similar rash (Fig 9), but different patient – tinea incognito. FIGURE 11: Tinea incognito on the face may be difficult to appreciate. Think of it if faced with inflamed nodules in a spreading rash while applying a topical steroid. FIGURE 12: Tinea incognito. Groin rash misdiagnosed as psoriasis. Betamethasone plus calcipotriol applied and followed by rapid spread over buttock and leg. FIGURE 13: A rapidly advancing, vesicular edge.with

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

pustules. Mistaken for cellulitis. Micrisporum canis was the suprising cause. A puncture wound facilitated fungal entry. FIGURE 14: Trichophyton verrucosum causing a kerion on the forearm. Remember if you find pustules or a boggy swelling think kerion. FIGURE 15: Early palmoplantar pustulosis on hands. More lesions develop and coalesce to a plaque. There may be only a few pustules and brown macules, so always examine carefully. FIGURE 16: Palmoplantar pustulosis. Note pustules fade to brown macules. Margin is discrete and without a raised edge.

INFECTION PREVENTION AND CONTROL

✽

AUTHOR: Grace Kinahan, MSc, RGN, RM, ANP, RNP Assistant Director of Nursing Infection Prevention and Control, Midlands Regional Hospital, Tullamore

Reducing the rate of Staph aureus bloodstream isolates associated with PVCs

A retrospective review of a quality improvement project implemented over a three-year period in a Model 3 hospital

eripheral intravenous catheters (PVCs) are the most commonly used invasive device in nursing practice but are frequently linked to complications.¹ Up to 60 per cent of hospitalised patients receive at least one cannulation during an admission.² PVC-related bloodstream infections (PVC-BSIs) can significantly impact patients by increasing morbidity and mortality, prolonging hospital stays, and leading to serious complications such as intensive care admission and death. 3,4, Infection prevention and control (IPC) measures have evolved to reduce PVCBSI rates and include the introduction of aseptic non-touch technique (ANTT); care bundles; visual infusion phlebitis scores; and intravenous (IV) care teams. In Model 4 hospitals in Ireland, IV teams have been established in eight sites, in collaboration with the HSE Antimicrobial Resistance and Infection Control (AMRIC) Team, to improve surveillance and national practice. One of the core objectives of the HSE’s RESIST campaign for prevention of peripheral and central venous catheter (CVC)-related infection is to reduce the use of venous catheters in situations where they are not strictly required. The Health Protection Surveillance Centre Point Prevalence Study (2023) reported that 19.7 per cent of 12,650 patients had at least one invasive device in situ, an increase from 18.7 per cent in 2017 and 16.3 per cent in 2012 – indicating that the

prevalence of invasive device use among Irish hospital inpatients has increased over time. 5 Quality improvement projects (QIPs)/initiatives that implement, measure, and monitor outcomes are essential to sustain improvements. However, factors such as hospital model, organisational structure, leadership, patient acuity, and practice gaps must be addressed to improve patient outcomes. This study examines the impact of an IPC QIP, implemented over three years to decrease the incidence of PVC-BSIs, with specific emphasis on Staphylococcus aureus (S aureus), in a Model 3 hospital serving the Midlands region of Tullamore, Co Offaly.

PVCs and BSI

Peripheral vascular catheterisation is a fundamental component of modern hospital care – however, it carries a recognised risk of BSI if not managed optimally. PVC-BSIs contribute significantly to patient morbidity but are largely preventable through adherence to evidence-based insertion and maintenance practices.6,7,8 With increasing emphasis on healthcare-associated infections (HAIs), surveillance has become a core function of IPC. Authors highlight the importance of sustained institutional efforts to maintain HAIs – including PVC-related bacteraemia – at the lowest achievable levels. 8,9,10 Healthcare organisations now

routinely collect standardised HAI data to monitor internal performance and benchmark outcomes against national and international standards. Robust surveillance systems facilitate early trend detection, inform targeted interventions, and strengthen accountability and patient safety. 8 Key performance indicators (KPIs) for acute hospital HCAIs are closely monitored, including structured review processes for rates exceeding targets. These reviews require hospital commentary, root cause analysis where appropriate, and documentation of corrective actions undertaken by the IPC team. Sustained improvement depends on continuous monitoring, visible leadership support, multidisciplinary collaboration, and the integration of IPC practices into routine clinical care. Embedding these strategies within organisational culture promotes long-term compliance, reinforces quality improvement, and supports the maintenance of low

Peripheral vascular catheterisation carries a recognised risk of BSI if not managed optimally

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INFECTION PREVENTION AND CONTROL

infection rates over time.6 This QIP aimed to review PVCassociated infection rates over a threeyear period. It compared outcomes before and after the introduction of a comprehensive multimodal prevention strategy that maintained a constant focus on improving infection rates at every quarter (Q).

The QIP

The project took place in a Model 3 hospital (Midlands Regional Hospital Tullamore [MRHT]) that provides a broad range of acute and regional services to the population of the midland region in Ireland. A retrospective review of hospital infection surveillance data was conducted from January 2022 to December 2025. Aims of the QIP were as follows: ✽ To reduce the number of hospitalacquired and healthcare-associated S aureus BSI ✽ To reduce the use of venous catheters

✽ To reduce the incidence of other adverse effects resulting from use of venous catheters ✽ To promote the use of the review tool for hospital acquired S aureus BSI. ✽ To educate staff on ANTT and PVC care ✽ To update the care bundle process. Implementation of the multimodal interventions began in Q4 2022 (Table 1) with the introduction of the following actions: ✽ Structured staff education and competency ✽ Standardised skin antiseptic and PVC insertion packs ✽ Audit and feedback mechanisms and surveillance. The evaluation occurred in cycles as each new action was introduced.

Staff education and competency

The staff education component of the QIP was implemented over a three-month period inclusive of February 2023 to April 2023 and occurred in a series of steps:

RECOMMENDATION

RESPONSIBLE PERSON

Ensure medical staff are appropriately trained

Clinical Director

Action plan to IPCN from CNM's following circulation of care bundle results

CNM'S

Full completion of PVC documentation on all patients to include insertion/ongoing maintenance details

NCHD/S/N

Incident form to be completed on all patients who develop a SABSI

IPCN/CNM/NCHD

Education of staff on ANT relating to PVC insertion

IPCN

Sharing of learning from RCA recommendations

Clinical Director/IPC committee

Promote HSeLanD modules on ANTT

IPCN/Clinical Director

Risk assessment of risks associated with PVC

IPCN/IPC Committee

Quarterly validation in all areas of care bundle compliance

IPCN

Display of AMRIC PVC poster in all wards

IPCN

Display of patient information poster on PVC care

IPCN

TABLE 1: IPC strategy including roles and responsibilities

STEP 1: February 2023 was

designated as ‘PVC and ANTT Awareness Month’ across the hospital to raise awareness of best practices in PVC care and ANTT. Educational materials and guidance on best practices from HSE eLearning portal on hand hygiene, aseptic technique, and prevention of PVC- and CVCrelated infections were recommended to all staff to support this training. STEP 2: In February 2023, a hospitalwide awareness day was also held to promote the initiative and highlight the importance of preventing PVCBSIs. The IPC team held an education stand outside the canteen at the start and middle of February to discuss and promote ANTT with all staff. Over 100 healthcare professionals engaged with the stand and feedback was positive. STEP 3: Ward-based nursing staff received ANTT training, focusing on aseptic practice during PVC insertion and ongoing catheter care during this initial period.

Introduction of standard skin antiseptic, PVC packs, and trolleys

STEP 1: In Q1 2023, a business case

was submitted to the drugs and therapeutics department for approval for chlorhexidine 2 per cent in 70 per cent alcohol (ChloraPrep) as the standard skin antiseptic for blood culture collection, PVC insertion, and CVC insertion, in line with national AMRIC guidance. While no financial support was received from the providers of ChloraPrep, the company did assist with the rollout of this initiative by providing education and support to all nursing and medical teams across the hospital. The business case was approved in Q1 of 2023, and Nursing Grand Rounds – formal learning forums that bring together nursing and healthcare

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INFECTION PREVENTION AND CONTROL

professionals to analyse challenging clinical cases, share evidence-informed approaches, and engage in professional development discussions – was scheduled for Q2 in April to introduce this to all healthcare professionals that had a role in PVC insertion and its management in MRHT. STEP 2: The key personnel in clinical

areas were then contacted to arrange training on best practice in skin antisepsis for all nursing and medical teams. This education ran from April to July (2023). A refresher day was then held in MRHT in October to support IPC Awareness Day. STEP 3: Standardised PVC insertion packs were then introduced to ensure that all staff had access to the required equipment (Q3 2023 – Q4 2023). The packs contained the following: ✽ Single use tourniquet ✽ Sterile drape ✽ Sterile gauze ✽ Transparent semi-permeable dressing.

STEP 4: Existing blood culture packs were aligned with the new PVC packs to promote a consistent approach to skin disinfection and aseptic practice across all vascular access procedures. STEP 5: (Q2 2023 - Q4 2023) Each ward was provided with a PVC trolley to ensure ease of access for staff inserting cannulas and taking blood cultures. Managers were provided with advice about ordering the ChloraPrep and PVC/ blood culture packs. Images of what the trolleys should look like with appropriate labels attached were provided to each ward manger and the IPC team assisted in the setup of the trolley also. STEP 6: (Q2 2023) With the support of the patient safety nurse, a patient information poster was also developed on how to care for their own cannula. The images were created and shared to the wards for patients and staff to view.

Audit, feedback, and surveillance

The audit and feedback component of

the QIP was implemented as follows: The previous audits and surveillance rates were reviewed for every Q for years 2022, 2023, 2024, and 2025. All results were reported to the IPC committee and to the business intelligence unit, where results are compared with data from the Dublin Midland Hospital group for further learning, and surveillance rates were recorded as a KPI. STEP 1 : To gain an understanding of how

many PVCs were in use, a PVC audit was completed in MRHT in September 2022 (Figure 1). A total of nine inpatient wards housing 157 patients were included in the audit. Results: 90 patients had a PVC inserted on the day of the audit (57%). Other concerns noted at the time of the audit were signs of infection and soiled dressings, which highlighted the need to review current practices and the care bundle process that was already in place. STEP 2: The existing PVC insertion

care bundle was reviewed and updated to ensure alignment with current

MRHT IVC SURVEY

FIGURE 1: PVC audit results

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INFECTION PREVENTION AND CONTROL

evidence-based practice and infection prevention guidelines (Q1 2023 and Q1 2024). This required daily assessment of catheter necessity, inspection of the insertion site for signs of infection or complications, assessment of dressing integrity, documentation of ongoing catheter care, and prompt removal of PVCs that were no longer clinically required. STEP 3: The PVC care bundle audit process was revised for nursing staff (Q1 2023). Staff nurses were responsible for completing care bundle audits, while clinical nurse managers implemented an action plan if their ward did not achieve 100 per cent compliance. STEP 4: In Q2 2024, the MEG audit tool was introduced to the nursing staff to electronically record audit findings, monitor compliance trends, and facilitate data collection. STEP 5: Audit results were reported

quarterly to the IPC committee. Quarterly reports were, and still are, also communicated to the ward managers. The results are discussed with their teams and displayed on the notice boards. Areas of non-compliance were identified, and feedback was provided to clinical teams to support quality improvement and sustained adherence to best practice. STEP 6: Working closely with the

surveillance scientists, an enhanced observation of PVC-BSIs was

maintained throughout the project to monitor outcomes and evaluate the impact of the interventions.

Interventions and the evidence base

PVC care bundle process

Although the care bundle process was already established within the hospital, a review identified opportunities to strengthen compliance monitoring, documentation, feedback mechanisms, and staff engagement. As a result, the existing process was updated as part of the QIP. RATIONALE: Evidence has demonstrated

that the implementation of PVC care bundles, together with staff education, audit, and feedback, can reduce catheter-related BSIs and improve patient safety.6,7 Effective measures include hand hygiene compliance, staff education and training, surveillance and monitoring, audit and feedback, use of evidence-based care bundles, and improved catheter and device management.7 Therefore, the rationale for reviewing and strengthening the PVC care bundle process at MRHT was to reduce variation in practice, improve compliance with evidence-based care, enhance patient safety, and ultimately reduce the incidence of PVC-BSIs.

Skin asepsis

The introduction of 2 per cent chlorhexidine in 70 per cent alcohol for pre-procedure skin asepsis formed an important component of the prevention strategy.

Using 2 per cent chlorhexidine in 70 per cent alcohol for pre-procedure skin asepsis is an important part of the prevention strategy

RATIONALE: Research indicates that appropriate skin preparation or cutaneous antisepsis prior to PVC insertion plays a key role in preventing PVC-BSIs. 9,10,11 The microorganisms most frequently associated with cannula-related infections are those naturally present on the skin, particularly staphylococci.11 Evidence supporting the use of chlorhexidinealcohol has continued to grow. Findings of the CLEAN randomised controlled trial, involving 1,181 patients and 2,612 catheters, demonstrated that chlorhexidine-alcohol was associated with a lower incidence of catheterrelated infections when compared with povidone-iodine alcohol.11 Current best practice guidance therefore recommends the use of a single-use application of 2 per cent chlorhexidine in 70 per cent alcohol isopropyl to disinfect the skin at the insertion site. 9,11

Dressing and catheter securement

Transparent sterile dressings replaced gauze dressings to secure PVCs post insertion. Images of the appropriate dressings were displayed in clinical areas. RATIONALE: Gauze dressings do not

facilitate observation of the insertion site. Transparent dressings allow healthcare staff and patients to easily inspect the site and help to control moisture.12,13,

Education and documentation

Evidence-based cannulation training was delivered to appropriate staff. Approaches included Centre for Nurse and Midwifery education delivered by the IPC team and evidence-based cannulation training with simulation and supervised practice. The patient information poster was developed to teach patients and carers to recognise early signs of infection. They were distributed to patients with a PVC in situ and outlined how to recognise signs of infection such as

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INFECTION PREVENTION AND CONTROL

redness, swelling, pain, or discharge, and when to seek medical review.11 RATIONALE: Staff education and training are key strategies in reducing PVC-BSIs. Cannulation training which includes theoretical teaching, simulation practice, and supervised competency assessment supports safe insertion practices and adherence to aseptic technique.11,12 Patient education about signs of infection, and advising that the cannula insertion site should be covered with a sterile dressing to prevent contamination and reduce the risk of infection, is also important for early detection of infection.10,13,14,15

Hand hygiene

The emphasis on hand hygiene within this QIP was intended to strengthen compliance with evidence-based infection prevention practices and minimise the risk of PVC infection. Additional measures to minimise infection risk included the consistent presence of IPC nurses (IPCNs), monthly hand hygiene audits, and consistent and strong support from hospital management and director of nursing on the ‘bare above the wrist’ policy. RATIONALE: Hand hygiene is the most effective measure for preventing healthcare-associated infections and reducing the transmission of micro-organisms between patients.15 Inadequate hand hygiene among healthcare workers is a wellrecognised risk factor for PVCassociated infections.12 When hand decontamination is not performed effectively, healthcare workers’ hands can act as vectors for the transmission of micro-organisms between patients.15

PVC replacement

The introduction of clinically indicated PVC replacement, supported by a standardised care bundle, aimed

to reduce PVC-BSI by ensuring that catheters were inserted, maintained, and removed according to best practice. No further changes were recommended apart from the ongoing use of the PVC care bundle process. RATIONALE: Recent evidence suggests that routine replacement does not significantly reduce infection rates and may lead to unnecessary procedures and patient discomfort. Current guidance from HSE-AMRIC recommends that PVCs should not be routinely replaced at fixed intervals, but instead removed or replaced when clinically indicated, such as in the presence of phlebitis, infiltration, occlusion, suspected infection, or when the device is no longer required. 9 This change coincided with the introduction of a PVC care bundle process at MRHT.

Results

The baseline PVC audit demonstrated variation in both device utilisation and maintenance practices across the hospital. Of the 157 patients audited prior to implementation of changes, 90 (57%) had a PVC in situ (Figure 1). The findings suggested opportunities to reduce unnecessary catheter use, as some PVCs remained in place without a clear ongoing clinical indication. Of the patients with a PVC in situ, 28 (31.1%) exhibited signs of local infection, including redness and pain at the insertion site. In addition, 14 patients (15.6%) had a soiled or compromised dressing, indicating deficiencies in catheter

maintenance and ongoing monitoring. Variation in these findings between wards highlighted inconsistencies in adherence to best practice. These baseline audit results informed the development of targeted interventions, including staff education, enhanced surveillance and audit processes, regular feedback to clinical teams, and reinforcement of the PVC care bundle. Collectively, these measures aimed to improve adherence to evidence-based practice, reduce variation in care, and minimise the risk of PVC-associated complications and BSI. Following a detailed review of the infection prevention measures, PVC-related S aureus BSI incidence decreased from 14.8 per cent in 2023 to 5.7 per cent in 2025 per 1,000 PVC days. This resulted in reduction of 9.1 percentage points. In 2023, there was a significant decline in hospitalacquired BSI from 202214 to 2023. 4 The target rate was at 0.5 which is below the newly revised national target rate of 0.7. This number has stayed consistently low throughout 2024 4 and 2025 4 . The current number for Q1 2026 is 0. In addition to these improvements, compliance with hand hygiene and aseptic insertion practices improved significantly. The hand hygiene compliance audit results increased from 85.5 per cent in 2023 to 87.9 per cent in 2024, and then up to 92.1 per cent in 2025. This represents a total improvement of 6.6 percentage points over three years. A positive finding from the care bundle audit was that

Hand hygiene is recognised as the single most effective measure for preventing healthcare-associated infections

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INFECTION PREVENTION AND CONTROL

the wards were achieving compliance rates of over 90 per cent. The care bundle audits also demonstrated that there were no signs of infection at the time the assessment was completed. In addition, substantial improvements in PVC care bundle audit results were also demonstrated. PVC audit results increased from 64 per cent compliance in 2022 to 87 per cent in 2025. No other major confounders or environmental changes were observed, suggesting direct correlation with the QIP.

Conclusion

re-adjust, and adapt interventions to achieve desired results, sustain improvements in patient outcomes, and investigate reasons for nonadherence as keys to achieving desired outcomes. Sustained implementation and ongoing reinforcement of these interventions are vital to maintaining improvements. Continued education, leadership, good governance, regular audit and feedback, and organisational support should be embedded into routine practice to ensure long-term compliance and patient safety outcomes. ✽

References

6. Ray-Barruel G, Xu H, Marsh N, et al. Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: A systematic review. Infect Dis Health. 2019;24(3):152-168. doi:10.1016/j. idh.2019.03.001.

11. Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidinealcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheterrelated infection (CLEAN): An open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet. 2015;386(10008):2069-2077. doi:10.1016/ S0140-6736(15)00244-5.

1. Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of short peripheral intravenous catheters: Characteristics, management, and outcomes worldwide. J Hosp Med. 2018;13(5):10.12788/jhm.3039. doi:10.12788/jhm.3039. 2. Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6 Suppl):S1-S40. doi:10.7326/M15-0744. 3. Drugeon B, Guenezan J, Pichon M, et al. Incidence, complications, and costs of peripheral venous catheter-related bacteraemia: A retrospective, single-centre study. J Hosp Infect. 2023;135:67-73. doi:10.1016/j.jhin.2023.02.012. 4. Marsh N, Larsen EN, Ullman AJ, et al. Peripheral intravenous catheter infection and failure: A systematic review and metaanalysis. Int J Nurs Stud. 2024;151:104673. doi:10.1016/j.ijnurstu.2023.104673. 5. Health Protection Surveillance Centre. Point prevalence survey of healthcareassociated infections and antimicrobial use in Irish hospitals: National Report 2023. Dublin: Health Protection Surveillance Centre; 2024. Available at: www.hpsc. ie/a-z/microbiologyantimicrobialresistance/ infectioncontrolandhai/surveillance/ hospitalpointprevalencesurveys/2023/.

The IPC team in MRHT successfully implemented a quality improvement initiative to optimise patient safety and quality of care for patients with PVCs. This multimodal quality improvement approach significantly reduced the incidence of PVC-associated S aureus BSIs, demonstrating the effectiveness of policy, targeted education, procedural, and monitoring-based interventions in promoting patient safety. There is a requirement to continuously monitor, evaluate,

7. World Health Organisation. Guidelines for the prevention of bloodstream infections and other infections associated with the use of intravascular catheters. Part 1: Peripheral catheters. Geneva: WHO; 2024. ISBN: 97892-4-009382-9. Available at: www.who.int/ publications/i/item/9789240093829. 8. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: An overview of published reports. J Hosp Infect. 2003;54(4):258-321. doi:10.1016/s0195-6701(03)00150-6. 9. Health Service Executive. Antimicrobial Resistance and Infection Control (AMRIC) Action Plan 2022-2025. Dublin: HSE; 2021. Available at: catalogue.nli.ie/Record/ vtls000906521. 10. Health Information and Quality Authority. National standards for the prevention and control of healthcareassociated infections in acute healthcare services. Dublin: HIQA; 2017. Available at: www.hiqa.ie/hiqa-news-updates/hiqapublishes-revised-national-standardsprevention-and-control-healthcare.

12. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86 Suppl 1:S1-S70. doi:10.1016/S0195-6701(13)60012-2. 13. Rickard CM, Webster J, Wallis MC, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: A randomised controlled equivalence trial. Lancet. 2012;380(9847):1066-1074. doi:10.1016/ S0140-6736(12)61082-4. 14. Gorski LA, Hadaway L, Hagle ME, et al. Infusion Therapy Standards of Practice, 8th Edition. J Infus Nurs. 2021;44(1S Suppl 1):S1-S224. doi:10.1097/ NAN.0000000000000396. 15. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis. 2006;6(10):641-652. doi:10.1016/S14733099(06)70600-4.

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PROFESSIONAL INSIGHTS

The lived experience of an ANP working in a nurse-led university medical centre ANP in General Practice, Dr Theresa Lowry Lehnen, talks about her role in a nurse-led university medical centre and the complexities of delivering care to a diverse student population

ithin her role as an advanced nurse practitioner (ANP), Theresa’s scope of practice is broad and diverse. It spans undifferentiated acute presentations; chronic disease management; sexual and reproductive health; mental health; prescribing; diagnostics; minor injuries; emergency response; and clinical governance and quality improvement. This interview explores the breadth, autonomy, and impact of advanced practice nursing in delivering safe, accessible, and comprehensive primary care within a third-level education healthcare setting.

How would you describe your role within the university medical service?

I am GP employed to manage a nurseled medical centre for a large thirdlevel university student population. I am the first point of contact for clinical presentations, delivering assessment, diagnosis, prescribing, investigation, and treatment and management of care independently. I work 40 hours per week – 34 hours as a lone practitioner, with GP presence on site for six hours weekly. I manage approximately 3,000 consultations during term-time, with over 80 per cent of complete episodes of care delivered independently, without GP involvement, reflecting a high level of advanced clinical autonomy and decision-making responsibility. The operational and clinical integrity of the service is grounded in autonomous ANP practice. All advanced practice nursing care and procedures, including

presentations may evolve over time or where multiple contributing factors are present, including physical illness, stress, mental health concerns, and lifestyle influences. This requires not only diagnostic skill, but also the ability to review, reassess, and adjust management plans appropriately. This level of autonomy reflects both the scope and extent of advanced practice nursing, in a real-world primary care setting, where clinical accountability, diagnostic responsibility, and ongoing management are held independently within a structured and supported service framework. Theresa Lowry Lehnen

tests and investigations, are free, which is fundamental to ensuring equity and encouraging early engagement with healthcare.

How extensive is your clinical autonomy in day-to-day practice?

For 34 hours each week, I am the sole on-site clinical decisionmaker, responsible for managing the full patient journey, from initial presentation through to diagnosis, treatment, and followup. This includes undifferentiated presentations that require rapid clinical reasoning and structured risk assessment, as well as complex decision-making across acute and chronic conditions. A significant part of my workload involves managing uncertainty in a primary care context, where

What does your clinical workload typically involve? The clinical workload reflects the breadth and complexity of general practice within a busy third-level student health setting. Presentations range from acute respiratory and infectious conditions such as upper respiratory tract infections and influenza-like illness, sore throat, sinusitis, otitis media and tonsillitis, through to urinary tract infections, dermatological conditions including rashes, eczema, acne, fungal infections, and gastrointestinal complaints such as abdominal pain, gastroenteritis, reflux symptoms, and altered bowel habit. There is a substantial volume of musculoskeletal presentations, particularly sports-related injuries, including sprains, strains, ligament injuries, joint pain, back and neck pain, and overuse injuries associated with training or increased physical activity.

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

PROFESSIONAL INSIGHTS

Ophthalmic presentations such as conjunctivitis and eye irritation are regularly encountered, alongside ENT-related issues including ear pain, wax impaction, and sore throat presentations requiring differentiation between viral and bacterial causes. Workload also includes a range of general systemic presentations such as fatigue, headache, dizziness, and non-specific viral illnesses, all of which require careful clinical assessment to exclude more serious underlying pathology. Minor injuries, wound care, and post-trauma presentations are a regular feature. In addition to acute illness, there is a significant component of chronic disease management. This involves the ongoing, coordinated care of individuals with long-term conditions and includes regular review, medication management, clinical monitoring, lifestyle advice, and patient education. This includes the management of conditions such as type 1 and 2 diabetes, asthma, chronic obstructive pulmonary disease, epilepsy, mental health conditions, as well as hypertension, chronic kidney disease, coronary vascular disease, osteoarthritis, osteoporosis, inflammatory bowel disease, thyroid disorders, chronic liver disease, and oncological follow-up care. In a context where university students engage intermittently with healthcare services, continuity of care and structured follow-up is important. Supporting self-management and preventing complications are key components of the clinical workload. Each consultation requires a thorough and systematic clinical assessment, including history- taking, examination, and the formulation of differential diagnoses. Management is guided by clinical findings, current evidence, and relevant guidelines, with appropriate safety- netting and escalation where necessary.

Student populations frequently present with conditions influenced by a complex interplay of biopsychosocial factors, including psychological stress, maladaptive coping mechanisms, poor lifestyle behaviours, and the sustained pressures associated with academic performance and assessment demands. These determinants of health can both contribute to the onset of illness and exacerbate existing conditions, meaning clinical presentations are often multifaceted rather than straightforward. As a result, symptoms may overlap between physical and psychological causes, requiring careful history taking, holistic assessment, and sound clinical judgement to ensure accurate diagnosis and safe management. The service also supports a large and diverse international student population, contributing to a high consultation volume and added complexity in clinical care. Variations in health profiles, vaccination histories, and cultural health beliefs, along with potential language barriers, can influence communication, assessment, and adherence to management, requiring clear communication and culturally responsive, patient-centred care. In many cases, reassessment and follow-up are necessary to monitor progress, evaluate response to treatment, and identify any evolving

As university students engage intermittently with healthcare services, continuity of care and structured follow-up is important

or underlying pathology. This requires a flexible and responsive approach to care delivery within a primary care setting, with an emphasis on continuity, patient education, and timely escalation where appropriate. Effective management depends on advanced clinical reasoning, proactive decisionmaking, and the ability to deliver safe, individualised care within complex and changing presentations.

How do you manage urgent care and emergency presentations on campus?

A significant part of my role involves urgent and unscheduled care, including direct response to call outs and emergencies across the university campus. These presentations are highly variable and include acute collapse, seizures, syncope, trauma, sportsrelated injuries, allergic reaction/ anaphylaxis, or sudden medical deterioration. In these situations, response is immediate and the clinical focus is on rapid assessment, stabilisation, and ensuring patient safety. This often occurs outside the clinical environment, where the nurse is the first healthcare professional on scene and is required to take full clinical responsibility from the outset. Initial management is guided by structured clinical assessment, prioritisation of immediate risk, and timely intervention based on presenting findings. Decision-making in this context is prompt and safety-orientated, with continuous evaluation of the need for escalation and transfer to emergency services. Clear communication with ambulance services, campus staff, and where appropriate, family members, forms an important part of the process, ensuring coordinated and effective care delivery. These episodes require a high level of clinical confidence, situational awareness, and the ability to remain calm under pressure while managing potentially life-threatening

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

PROFESSIONAL INSIGHTS

presentations. It also reinforces the importance of autonomous advanced practice in providing immediate, skilled clinical intervention within a community-based setting where traditional emergency resources are not immediately available.

What is your approach to sexual and reproductive health within the service?

Sexual and reproductive health forms a large part of the service and is delivered with a strong emphasis on accessibility, confidentiality, and continuity of care. The service provides comprehensive management of sexual health needs, including contraceptive counselling, initiation, and ongoing review of the full range of contraceptive methods, alongside screening, diagnosis, and treatment of sexually transmitted infections. Care is structured to ensure there are no barriers at the point of access for students, which supports timely presentation and encourages engagement with preventative health services. This is particularly important within a student population, where healthcare may otherwise be delayed due to uncertainty around access. Consultations are conducted in a private, and non-judgemental environment, allowing space for open discussion of often sensitive or personal concerns. The focus is on informed choice, with clear, balanced information provided regarding available options so that individuals can make decisions appropriate to their own needs and circumstances. Continuity of care is maintained through follow-up review, ongoing contraceptive management, and repeat sexual health screening where clinically indicated. This ensures that care is not delivered in isolation, but as part of an ongoing, responsive approach to individual health needs. The approach is grounded in

confidentiality, patient autonomy, and preventative care, with an emphasis on early engagement and sustained access to high-quality sexual and reproductive health services.

Mental health is a significant aspect of student care. How is this managed? Mental health presentations account for a substantial proportion of clinical workload within the service and commonly include anxiety, depression, stress-related conditions, adjustment difficulties, and emotional distress linked to academic, social, and personal pressures. These presentations often require time-sensitive, structured clinical assessment alongside careful exploration of contributing factors and overall level of distress. Each presentation is managed with a systematic clinical approach that includes comprehensive assessment, identification of risk, and evaluation of safeguarding concerns where relevant. This includes consideration of self-harm risk, vulnerability, and any indicators that may require urgent escalation or additional supports. Where appropriate, short-term medical management is provided alongside ongoing review and follow-up. A key strength of the service is the close integration with the college counselling service. A well-established reciprocal referral pathway exists between the nurse-led medical service and counselling supports, enabling timely and appropriate transfer of care depending on clinical presentation,

complexity, and psychological need. This ensures that students are not managed in isolation but are supported through a coordinated model of care that bridges medical and psychological services. This collaborative approach allows for shared understanding of patient needs, reduces fragmentation of care, and supports more timely escalation where required. It also facilitates a more holistic response to mental health presentations, recognising the interaction between physical health, psychological wellbeing, and social stressors. The accessibility of medical and counselling services, both delivered free at the point of access, is central to early engagement and intervention. This reduces barriers to seeking help, supports earlier identification of emerging mental health concerns, and plays an important role in reducing the likelihood of crisis-level presentations.

What is your role in diagnostics, prescribing, and clinical procedures?

As a registered nurse prescriber, I independently initiate, titrate, and review pharmacological treatments across a broad range of acute and chronic presentations. This includes responsibility for clinical prescribing decisions within my scope of practice, ensuring that treatment is appropriate, evidence-based, and safely monitored over time. Prescribing decisions are made in conjunction with clinical assessment, ongoing review, and clear safety-netting, particularly in presentations that may evolve or

Mental health presentations account for a substantial proportion of clinical workload within the service

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

PROFESSIONAL INSIGHTS

require reassessment. In relation to diagnostics, I am responsible for clinical decision-making regarding selection and interpretation of appropriate investigations. This includes requesting laboratory tests and radiological imaging where indicated, as well as interpreting results and integrating them into ongoing management plans. Diagnostic reasoning is a central component of the role, particularly within a primary care setting where presentations are often undifferentiated and require structured clinical judgement to guide appropriate investigation and management pathways. Alongside prescribing and diagnostics, I provide a comprehensive range of clinical services as part of routine practice. These include phlebotomy, vaccination, ear irrigation, wound assessment, management and follow-up care, and general health screening. I provide certification for illness, driving medicals and eyesight testing, as well as medical assessments for sports club medicals. My practice also includes smoking cessation and weight management services, and the provision of health promotion, advice, and patient education, ensuring a holistic and preventative approach to care delivery. Together, these competencies support an integrated model of care in which assessment, diagnosis, prescribing, treatment, and follow-up care are delivered within a single point of access. This contributes to continuity of care, reduces fragmentation of services, and allows for timely clinical decision-making within a busy primary care environment.

Do you have responsibilities beyond direct clinical care?

In addition to direct clinical practice, I contribute to the operational and clinical governance of the student medical centre. This extends beyond day-to-day consultations and involves oversight of

the systems and structures that ensure the service functions safely, efficiently, and in line with best practice standards. A key aspect of this responsibility is the development, review, and implementation of policies, procedures, protocols, and guidelines, ensuring that practice is evidence-based, consistent, and aligned with relevant national guidance and professional standards. Medication governance forms an important component of this, particularly in relation to safe prescribing systems, audit processes, and maintaining appropriate safeguards around medication use within a high-volume service. Operational responsibilities also include procurement and stock control, ensuring that essential clinical supplies, medications, and equipment are available and appropriately managed. This requires ongoing planning and coordination to maintain continuity of service delivery in a busy clinical environment with a high patient volume. Alongside these operational functions, service development and continuous quality improvement are integral to the role. This includes reviewing service demand, identifying areas for improvement, implementing changes in practice, and adapting service delivery to meet the evolving healthcare needs of the university student population. There is a constant focus on maintaining responsiveness, efficiency, and accessibility within the service model. This aspect of the role ensures that the service is not only clinically effective at point of care, but also structurally sound, sustainable, and aligned with contemporary models of integrated primary care delivery.

What is the overall impact of this model of care?

The service delivers approximately 3,000 consultations during term-time, with over 80 per cent of complete episodes of care managed independently by

the ANP without GP involvement. This level of activity reflects both the scale of demand within a busy third-level setting and the capacity of advanced practice nursing to safely and effectively deliver comprehensive primary care at a high level of autonomy. The model demonstrates that ANPs can function as principal clinical decision-makers within a primary care service, managing a broad spectrum of presentations while maintaining continuity, safety, and clinical accountability. The consistency of independent management across such a high volume of consultations also reflects the robustness of advanced clinical assessment, diagnostic reasoning, and evidence-based decision-making within the role. A defining feature of the service is that all advanced practice nursing care is delivered free at the point of access. This is central to its effectiveness. It removes financial barriers that might otherwise delay or prevent students from seeking care, and it supports timely presentation when symptoms first arise. In practice, this contributes to earlier diagnosis, more straightforward management, and reduced escalation of illness or distress. Within a student population, where health needs are often shaped by time pressures, academic demands, financial constraints, irregular routines, and high levels of stress, accessibility is a key determinant of engagement with healthcare services. The ability to attend an ANP-led service without financial constraint encourages engagement with both acute and preventative services, supports continuity of care, and reduces reliance on fragmented or delayed healthcare pathways. This approach demonstrates a sustainable and effective method of primary care delivery, combining advanced clinical autonomy with universal access. It illustrates how ANP-delivered services can operate safely while enhancing accessibility, responsiveness, and equity within a real-world healthcare environment. ✽

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

PRODUCTS

Irish scientist wins European Inventor Award for groundbreaking malaria vaccine The European Patent Office (EPO) has awarded Irish scientist Sir Adrian Hill the European Inventor Award 2026 in the research category for developing the R21/Matrix-M malaria vaccine. The European Inventor Award is one of Europe’s most prestigious innovation prizes. Launched by the EPO in 2006, the award honours individuals and teams who have come up with solutions to some of the biggest challenges of their time. “I am delighted to accept this prestigious award on behalf of the many hundreds of people who have contributed to the discovery, development, and licensure of our malaria vaccine over the past 12 years,” said Sir Hill. The EPO presented the award at a recent ceremony in Berlin, honouring a vaccine that achieved 75-80 per cent protection in clinical trials – a result that exceeded the World Health Organisation (WHO) target of 75 per cent efficacy for malaria vaccines. Until now, traditional malaria vaccines have achieved only modest protection, particularly in young children. Malaria remains a major global health challenge. According to the WHO, there were an estimated 282 million malaria cases and 610,000 malaria deaths worldwide in 2024, with children under five accounting for about 75 per cent

Sir Adrian Hill

of malaria deaths in the WHO African Region.

Improving vaccine design

Scientists have been attempting to develop a malaria vaccine for more than a century, yet more than 150 vaccine candidates entered human trials before only two finally succeeded. Sir Hill’s team redesigned the vaccine structure to include more of the key malaria protein segments recognised by the immune system, while removing components that could divert the immune response. The vaccine forms nanoparticles approximately 25 nanometres in size, helping the immune system recognise and respond more effectively. Combined with the Matrix-M adjuvant, it generates a substantially stronger antibody response than earlier approaches. The vaccine was also

designed for practical deployment. It can be produced at large scale, costs less than €3 per dose, and remains stable for up to two years under standard refrigeration conditions, helping make vaccination programmes more accessible in regions where malaria remains endemic. Sir Hill’s long-term commitment to malaria research was shaped by his 1988 experience in The Gambia, where he witnessed the devastating impact of the disease on young children. Over the following three decades, his team at Oxford’s Jenner Institute investigated multiple vaccine candidates before developing R21/Matrix-M. The project brought together partners including the University of Oxford, the Serum Institute of India, Novavax, and leading African research centres in Burkina Faso, Kenya, Mali, and Tanzania. A key milestone came in 2021, when Phase 2b trial results showed up to 77 per cent efficacy. Ghana became the first country to approve the vaccine in 2023, followed by Nigeria. Later that year, the WHO formally recommended R21/Matrix-M for widespread use. Today, malaria vaccination is being integrated into routine immunisation programmes in more than 20 African countries, providing a new tool to reduce malariarelated illness and deaths.

NURSING IN PRACTICE IRELAND | SEPTEMBER-OCTOBER 2026

CROSSWORD

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Across

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1 - Esteem (6)

ACROSS 7 - Plan of action (8) DOWN 1 Lower (6) 1 Esteem (6) 7 Plan of action (8)8 - Eg oxygen (3) 2 Creative act (6) 8 Eg oxygen (3) 3 English homework 9 - Whole (6) 9 Whole (6) assignment (5) 10 Type of golf club10 (4) - Type of golf club (4)4 Male sibling (7) 11 Move to music (5) 5 Manner; mental state (8) 13 Exile; fugitive (7)11 - Move to music (5) 6 Refuse to acknowledge (6) 15 Lack of success (7) 12 Eg Gregorian or Julian (8) 13 (5) - Exile; fugitive (7) 14 Derived from living matter (7) 17 Measure heaviness 21 Link a town with another (4) 16 Forever (6) 15 - Lack of success (7)18 Within a space (6) 22 ___ the board: applying to all (6) 23 Not well (3) 17 - Measure heaviness19(5) Well-being (6) 24 Branch of mechanics (8) 20 Squeeze (5) 25 Spoken form of communication (6) 21 - Link a town with another (4)

2 - Creative act (6)

SCRIBBLE BOX

3 - English homework assignment (5) 4 - Male sibling (7) 5 - Manner; mental state (8) 6 - Refuse to acknowledge (6) 12 - Eg Gregorian or Julian (8) 14 - Derived from living matter (7) 16 - Forever (6) 18 - Within a space (6)

22 - ___ the board: applying to all (6)

19 - Well-being (6)

23 - Not well (3)

20 - Squeeze (5)

24 - Branch of mechanics NURSING (8) IN PRACTICE IRELAND 25 - Spoken form of communication (6)

| SEPTEMBER-OCTOBER 2026

Now Available in a 2 mg dose

1,2

for adults with Type 2 Diabetes1

HSE reimbursement effective from 01 May 2026

Start on Ozempic®, Stay on Ozempic® Safety profile comparable across all doses1,2 Abbreviated Prescribing Information Ozempic® (semaglutide). Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Ozempic® 0.25 mg solution for injection in pre-filled pen, Ozempic® 1 mg solution for injection in pre-filled pen: One ml of solution contains 1.34 mg of semaglutide (human glucagon-like peptide-1 (GLP-1) analogue). Ozempic® 0.5 mg solution for injection in pre-filled pen: One ml of solution contains 0.68 mg of semaglutide. Ozempic® 2 mg solution for injection in pre-filled pen: One ml of solution contains 2.68 mg of semaglutide. Indication: Ozempic® is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise • as monotherapy when metformin is considered inappropriate due to intolerance or contraindications • in addition to other medicinal products for the treatment of diabetes. For trial results with respect to combinations, effects on glycaemic control, cardiovascular disease and kidney events and the populations studied, see sections 4.4, 4.5 and 5.1 of the Ozempic® SmPC. Posology and administration: Administered once weekly at any time of the day, with or without meals. Injected subcutaneously in the abdomen, thigh or upper arm. Starting dose: 0.25 mg once weekly. After 4 weeks the dose should be increased to 0.5 mg once weekly. After at least 4 weeks with a dose of 0.5 mg once weekly, the dose can be increased to 1 mg once weekly to further improve glycaemic control. After at least 4 weeks with a dose of 1 mg once weekly, the dose can be increased to 2 mg once weekly to further improve glycaemic control. If a dose is missed: administer as soon as possible and within 5 days after the missed dose. If more than 5 days have passed, the missed dose should be skipped, and the next dose should be administered on the regularly scheduled day. In each case, patients can then resume their regular once weekly dosing schedule. The day of weekly administration can be changed, as long as the time between two doses is at least 3 days. After selecting a new dosing day, onceweekly dosing should be continued. When Ozempic® is added to existing metformin and/or thiazolidinedione therapy or to a sodium-glucose co-transporter-2 inhibitor (SGLT2) inhibitor, the current dose of metformin and/or thiazolidinedione or SGLT2 inhibitor can be continued unchanged. When Ozempic® is added to a sulfonylurea (SU) or insulin, a reduction in dose of SU or insulin should be considered to reduce the risk of hypoglycaemia. Blood glucose self-monitoring is necessary to adjust the dose of SU and insulin, particularly when Ozempic® is started and insulin is reduced. A stepwise approach to insulin reduction is recommended. Children: No data available. Elderly: No dose adjustment required. Renal impairment: No dose adjustment is required for patients with mild, moderate or severe renal impairment. Experience in patients with end-stage kidney disease is limited. Hepatic impairment: No dose adjustment is required for patients with hepatic impairment. Experience with severe hepatic impairment is limited. Caution should be exercised when treating these patients with semaglutide. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: Should not be used for the treatment of diabetic ketoacidosis (DKA). Not a substitute for insulin. DKA has been reported in insulin-dependent patients whom had rapid discontinuation or dose reduction of insulin. There is no experience in patients with congestive heart failure NYHA class IV and is therefore not recommended in these patients. Pulmonary aspiration has been reported in patients receiving GLP-1 receptor agonists undergoing general anaesthesia or deep sedation. Therefore, the increased risk of residual gastric content due to delayed gastric emptying should be considered prior to performing procedures with general anaesthesia or deep sedation. Use of GLP-1 receptor agonists (RAs) may be associated with gastrointestinal adverse reactions. This should be considered when treating patients with impaired renal function as nausea, vomiting, and diarrhoea may cause dehydration which in rare cases can lead to a deterioration of renal function. Patients treated with semaglutide should be advise of the

potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion. Acute pancreatitis has been observed with the use of GLP-1 RAs. Patients should be informed of the characteristic symptoms of acute pancreatitis. If pancreatitis is suspected, semaglutide should be discontinued; if confirmed, semaglutide should not be restarted. Exercise caution in patients with a history of pancreatitis. Use of semaglutide in combination with a SU or insulin may have an increased risk of hypoglycaemia; consider reducing the dose of SU or insulin when initiating treatment with Ozempic®. In patients with diabetic retinopathy treated with insulin and semaglutide, an increased risk of developing diabetic retinopathy complications has been observed. Exercise caution when using semaglutide in patients with diabetic retinopathy treated with insulin, monitor such patients closely and treat according to clinical guidelines. Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy, but other mechanisms cannot be excluded. Ozempic® 2 mg is not recommended in patients with type 2 diabetes with uncontrolled or potentially unstable diabetic retinopathy. Data from epidemiological studies indicates an increased risk for non-arteritic anterior ischaemic optic neuropathy (NAION) during treatment with semaglutide. There is no identified time interval for when NAION may develop following treatment start. A sudden loss of vision should lead to ophthalmological examination and treatment with semaglutide should be discontinued if NAION is confirmed. Semaglutide treated patients with gastroparesis may experience more serious or severe gastrointestinal adverse events. Semaglutide should be used with caution in these patients, and semaglutide is not recommended if gastroparesis is severe. When semaglutide is used in combination with a SU or insulin, patients should be advised to take precautions to avoid hypoglycaemia while driving and using machines. Fertility, pregnancy and lactation: Women of childbearing potential are recommended to use contraception when treated with semaglutide. Should not be used during pregnancy or breastfeeding. Discontinue at least 2 months before a planned pregnancy. Effect on fertility unknown. Undesirable effects: Very common (≥1/10): Hypoglycaemia when used with insulin or sulfonylurea, nausea, diarrhoea. Common (≥1/100 to <1/10): Hypoglycaemia when used with other oral antidiabetic medications, decreased appetite, dizziness, headache, diabetic retinopathy complications, vomiting, abdominal pain, abdominal distension, constipation, dyspepsia, gastritis, gastro-oesophageal reflux disease, eructation, flatulence, cholelithiasis, fatigue, increased lipase, increased amylase, weight decreased. Uncommon (≥1/1 000 to <1/100): Hypersensitivity, dysgeusia, increased heart rate, acute pancreatitis, delayed gastric emptying, injection site reactions. Rare (≥1/10 000 to <1/1 000): Anaphylactic reaction. Very rare (<1/10 000): Non-arteritic anterior ischaemic optic neuropathy (NAION). Not known (cannot be estimated from available data): Angioedema, intestinal obstruction, dysaesthesia. The SmPC should be consulted for a full list of side effects. MA numbers: Ozempic® 0.25 mg pre-filled pen EU/1/17/1251/002. Ozempic® 0.5 mg pre-filled pen EU/1/17/1251/012. Ozempic® 1 mg pre-filled pen EU/1/17/1251/005. Ozempic® 2 mg pre-filled pen EU/1/17/1251/010. Each pre-filled pen delivers 4 doses and includes 4 disposable NovoFine® Plus needles. Legal Category: POM. For complete prescribing information, please refer to the SmPC which is available on www.medicines.ie or by email from infoireland@novonordisk.com or from the Medical and Regulatory Department, Novo Nordisk Limited, 1st Floor, Block A, The Crescent Building, Northwood Business Park, Santry, Dublin 9. Date last revised: April 2026. Adverse events should be reported to the Health Products Regulatory Authority. Information about adverse event reporting is available at www hpra.ie. Adverse events should also be reported to Novo Nordisk on Tel: 01 8629 700 or complaintireland@novonordisk.com

References 1. Ozempic® Summary of Product Characteristics www.medicines.ie 2. Frías JP, et al. Efficacy and safety of once-weekly semaglutide 2.0 mg versus 1.0 mg in patients with type 2 diabetes (SUSTAIN FORTE): a doubleblind, randomised, phase 3B trial. Lancet Diabetes Endocrinol. 2021;9(9):563–574. Ozempic® is a prescription only medication. Ozempic® and the Apis bull logo are registered trademarks owned by Novo Nordisk A/S. May 2026. IE26OZM00040

Novo Nordisk Limited, First Floor, Block A, The Crescent Building Northwood Business Park, Santry, Dublin 9, D09 X8W3, Ireland Tel: 01 862 9700 Fax: 01 862 9725 Email: infoireland@novonordisk.com Web: www.novonordisk.ie