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World of Irish Nursing & Midwifery


Journal of the

Irish Nurses and Midwives Organisation g5.75

Vol 21 No 9 November 2013


Budget cuts will damage health service page 7

All-Ireland Midwifery Conference page 22

5 Editorial Despite its focus on health service reform, the HSE refuses to increase the number of midwifery-led units in Ireland, writes INMO general secretary, Liam Doran 6 News Reinstatement of senior grade secured… Budget cuts will damage health service… INMO hosts ICN 2013 workforce forum… Professional social media guide released... Refurbishment continues at Letterkenny... Interim north east maternity deal ends... Employment tribunal win for practice nurse... LRC resolves Wexford acting up dispute... St James’s Hospital announces directorate restructuring... Plus: Section news, page 17; Branch news, page 52 48 From the President INMO president Claire Mahon rounds up news from the Executive Council and beyond

FEATURES 19 Quality and safety Maureen Flynn explains the benefits of clinical audit 20 Questions and answers Bulletin board for industrial relations queries

Rhona Mahony interview page 34

21 Private sector update Private sector organiser Sheila Dickson updates members on the latest developments in the sector 22 Midwifery conference Report from the INMO/RCM Northern Ireland All-Ireland Midwifery Conference in Dublin last month 25 European conference report Mary Higgins reports on a meeting of the European Midwives Association, hosted by the Croatian Chamber of Midwives

Midwifery services

26 Day in the life We look at the role of Mary Reilly, clinical midwife manager in the midwifery-led unit at Cavan General Hospital 27 Midwifery matters Midwives should support the parents of a stillborn infant with compassionate care and communication, writes Kiera Fisher

34 Interview National Maternity Hospital Master Rhona Mahony spoke to Niall Hunter on her role and the issues facing the hospital 36 Productive ward The productive ward initiative piloted in the Rotunda Hospital is a driver for change and improvement, writes Ajita Raman 39 Library The library team provides a practical guide to academic writing 51 Student focus Student and new graduate officer Dean Flanagan updates us on the pay issue facing pre-registration nurses and midwives 57 Update Round-up of news items with an Irish and international interest

CLINICAL 41 Brain disease Sinéad Boland discusses the issues affecting treatment adherence in relation to bipolar affective disorder 45 Child health Good nutrition in the toddler years supports physical, cognitive and social development, writes Jessica Schram

HEALTH & LIVING 55 Book review Caring for the Nation is a lavishly-illustrated account of how the Dublin hospital developed, writes Niall Hunter Plus: Monthly crossword competition 56 Finance Ivan Ahern offers some practical tips for saving money on your car this autumn

JOBS & TRAINING 28 Professional development Courses run by the INMO Professional Development Centre 58 Diary Listing of meetings and events around the country 59 Recruitment & training Latest jobs and training opportunities

WIN – World of Irish Nursing & Midwifery, is distributed by controlled circulation to over 36,000 members of the INMO. It is published monthly (10 issues a year) and is registered at the GPO as a periodical. Its contents in full are Copyright© of MedMedia Ltd. No articles may be reproduced either in full or in part without the prior, written permission of the publishers. The views expressed in this publication are not necessarily those of the INMO. Annual Subscription: €130 incl. postage paid. Editorial Statement: WIN is produced by professional medical journalists working closely with individual nurses and officers on behalf of the INMO. Acceptance of an advertisement or article does not imply endorsement by the publishers or the Organisation.

INMO calls for nationwide staffing review WIN

November 2013 Vol 21 Iss 9



Midwifery: a profession of quality IN RECENT years a great deal of attention has focused upon the reform and reorganisation of the health service. Much of which is driven by the need to save money rather than improve quality, with much focus on management structures, trolley waits, elective waiting times and the continuing privatisation of significant areas of our health service. Throughout this period, Ireland has continued to have the highest birth-rate in the European Union and the midwifery profession and individual midwives have endeavoured to continue to provide safe care, through best practice, while suffering a significant drop in staffing levels and other cutbacks. It was for this reason that, at our annual conference earlier this year, delegates adopted a motion, proposed by the Executive Council, that our midwifery services be subject to review, by an independently chaired commission, to ensure best practice exists in all of our maternity hospitals/units across the country. The INMO has now written to the Minister in relation to this motion, asking that he would establish this commission, without delay, and immediately agree the terms of reference and a timeframe, with the Organisation, for this comprehensive examination of midwifery staffing and practice right across the country. This commission could form part of the wider review of maternity services recently announced. It is a simple reality that, despite this supposed focus on reform, our health service

has refused to expand on the number of midwifery-led units, across the country. We continue to see the profession exist within a medical model of care that under utilises the skills, practices, expertise and excellence of our midwives. It is unforgivable that in 2013 we do not have more quality assured and cost effective midwifery-led units across the country providing accessible, professional and personal services to the low risk mother and baby. We have examples of the excellence, of these midwifery-led services in such places as Cavan and Drogheda and it is imperative that similar type units are established in other areas of the country. Recently midwifery, and in particular, independent midwifery, has come into public scrutiny arising from the findings of a coroner following an inquest. These recommendations need to be the subject of immediate discussion between the HSE, the INMO and our Midwives Section. The State has an obligation to ensure that a mother, who is assessed as low risk, has the choice of a home birth, safe in the knowledge that the service provided to her is quality assured, stress tested and delivered by highly qualified midwives. Our Midwives Section, in partnership with the Royal College of Midwifery in Northern Ireland, recently held their annual conference, with the theme ‘Maternity Care - Everyone’s Affair: Practices, Partnerships, Policies and Possibilities’. The conference, which had an excellent agenda and list of

(ISSN: 2009-4264)

Volume 21 Number 9 November 2013 EDITORIAL & ADVERTISING ENQUIRIES: WIN, MedMedia Publications, 25 Adelaide Street, Dun Laoghaire, Co Dublin. Tel: 01-280 3967 Fax: 01-280 7076 Email: Website:

ADVERTISING MANAGER Leon Ellison PUBLISHER Geraldine Meagan WIN – World of Irish Nursing & Midwifery, is published in conjunction with the Irish Nurses and Midwives Organisation by MedMedia Group, Specialists in Healthcare Publishing & Design.

Reinstatement of senior grade secured THE ).-/ HAS SECURED THE

speakers, was the 19th joint collaboration with our RCM colleagues. The theme aptly sums up what needs to be done to maximise the potential of midwifery in this country. However, a cornerstone of high standards and a quality assured service is that there are adequate numbers of midwives across the country, and that is why this independently chaired review must commence its work immediately. The new Nurses and Midwives Act legally recognises the independent profession of midwifery for the first time. This is long overdue and our midwives are ready to lead the way in ensuring innovative best practice, which is quality assured and cost effective. However the HSE must recognise the pressures on the system, at the moment, which cannot be ignored and must be addressed without delay. Liam Doran General Secretary, INMO

EDITORIAL Editor: Alison Moore Assistant Editor: Gillian Tsoi Production Editor: Kennas Fitzsimons Sub-Editor: Sharon Murphy Designer: Paula Quigley


reinstatement of the senior staff nurse and midwife grade with effect from the July 1, 2013. Health employers have not appointed any nurses or midwives with 20 years service to the grade of senior staff nurse ORMIDWIFESINCE 4HE ).-/ HAS CONSISTently sought to have this corrected and the issue was subject to a full Labour Co u r t h e a r i n g. H owe ve r, health employers declined to implement the Labour Court finding and the matter remained unresolved. 4HEISSUEWASTHENRAISEDAS part of the Haddington Road NEGOTIATIONS ANDTHEFINALTEXT of the agreement confirmed

THE HSE has established the

process for regularising acting positions, and set out the new arrangements regarding the filling of short-term vacancies. Long-term actors will now be appointed to the posts they have been acting in under the following conditions: s4 HE POST HOLDER HAD BEEN in that acting position for

THE).-/CONTINUESTOENGAGE with the HSE in relation to all matters arising from the commencement of the staff nurse and midwife graduate programme. 4HE/RGANISATIONHASSCHEDuled further discussions with MANAGEMENTTHISMONTH4HESE discussions will focus particularly on service-related issues. A full update will be issued to members immediately thereafter.

INMO Editorial Board: Claire Mahon, president; Geraldine Talty, first vice-president; James Geoghegan, second vice president; Ann Burke; Eileen Kelly; Martin McCullough; David O’Brien, Allison O’Connell INMO Journal Co-ordinator: Ann Keating, Tel: 046-954 9315 Email INMO correspondence to: Irish Nurses and Midwives Organisation, Whitworth Building, North Brunswick Street, Dublin 7. Tel: 01-664 0600 Fax: 01-661 0466 Email: Website:


November 2013 Vol 21 Iss 9


)NACIRCULAR THE(3%ALSO stated that, in future, staff nurses and midwives who accrue 20 years service should be appointed to this senior nurse/midwife grade with EFFECTFROM.OVEMBEREACH year. 4HISISAVERYPOSITIVEDEVELopment as the difference in

Health service finally regularises long-term acting posts

Graduate placement update Editor-in-Chief: Liam Doran

that it would be reinstated from July 1 this year. 4HE(3%HASCONFIRMEDTHAT all nurses and midwives, who have accrued 20 years service and who should have been appointed senior staff nurse/ MIDWIFESINCE SHOULD now be appointed with effect from that date.

SALARYISSIGNIFICANT4HERESTOration of the senior staff nurse and midwife grade is long overdue and welcome particularly as it secures appointment, into the future, for all staff nurses and midwives who accrue the 20 years service REQUIREMENT All members who accrued T H E R E Q U I R E M E N T O F   years service, but were not appointed in the past four years, should immediately contact their director of nursing/midwifery to ensure they are placed on the senior staff nurse/midwife salar y with effect from July 1, 2013. -EMBERS SHOULD CONTACT THE).-/IFTHEYREQUIREANY clarification or assistance in relation to this matter.



at least two years up to 31st December 2012 (including periods spent on maternity leave) s4HEPOSTINQUESTIONISVACANT s4HEREISNOBACKFILLINGOFCONSEQUENTIALVACANCY s4 HE APPOINTMENT WILL BE made to the promotional salary scale by adding any allowance received to current salary and rounded to the nearest point, not below, on the promotional scale s) TWILLNOTBEAREQUIREMENT to have been in receipt of an acting allowance. However, documentary evidence confirming that the employee was in an acting role will be REQUIRED ANDSIGNOFFOFSAME at senior HSE management level is stipulated. Short-term vacancies 4HENEWARRANGEMENTSFOR filling posts on a short-term basis are: s3HORT TERMVACANCIESUNDER three months) will see EMPLOYEESBEINGASKEDTO


TAKEONTHEPOSTOFHIGHER responsibility to cover annual LEAVE AND SHORT TERM SICK leave and other absences 4HISPERIODWILLNOTATTRACT a payment unless the period IN QUESTION EXCEEDS THREE MONTHS)FTHETHREE MONTH PERIODISEXCEEDED THENPAYment on the appropriate point of the higher scale will be made retrospective to the first day of the absence s&ORLONGERTERMGREATERTHAN three months) absences, appointment to the actual post, with appropriate remuNERATION WHICHISREQUIREDTO be filled on a temporary basis (eg. maternity leave, longTERMSICKLEAVE CAREERBREAK etc) will occur s4HESELECTIONPROCESSWILLBE in accordance with the rules of recruitment as set out in the code of practice relevant to appointment to shortterm higher posts. Any employee who is acting, but who does not meet

the criteria for regularisation, will be temporarily assigned to the higher post in accordance with the new criteria. As a result of these new arrangements, many nurses and midwives who have been acting for over two years in vacant posts, will now be appointed to these higher grade posts. ).-/ GENERAL SECRETAR Y L i a m D o ra n , co m m e n te d : h4HISISAVERYIMPORTANTAND beneficial outcome to the ).-/SLONG HELDPOLICYTHAT the previous long-term acting ARRANGEMENTSREQUIREDSIGNIFIcant correction. h 4HE ISSUE OF LONG TERM acting up has been a major grievance for nursing and midwifer y staff and other grades, particularly in recent YEARS-ANYMEMBERSHAVE BEENACTINGUPFOREXTENDED periods without recognition and/or any real prospect of being confirmed in the higher post.�


Budget cuts will damage health service THE ).-/HASSAIDTHATTHE

further â‚Ź666 million to be cut from the health service as part of the Budget will “severely compromise“ patient care. 4HIS REPRESENTS THE SIXTH CONSECUTIVEYEAROFCUTBACKS for the public health service. ,IAM$ORAN ).-/GENERAL SECRETARY SAIDh4HEGOVERNment, while imposing these cuts, has refused to introduce targeted, revenue raising, public health measures in areas SUCHASSMOKING ALCOHOLAND SUGAR SWEETENEDDRINKS 4HE).-/BELIEVESTHATTHE GOVERNMENTSAPPROACHISILL advised because: Health service capacity s4HEHEALTHBUDGETHASBEEN re d u ce d by â‚Ź 3 . 3 b i l l i o n (20%) in the past five years s3 TAFFINGHASBEENREDUCED by 10,000 (10%) with 4,500 (45%) coming from cuts to nursing/midwifery posts s PUBLICBEDSACUTENON acute) remain closed s4HENUMBEROFPATIENTSINAP-

propriately placed on trolleys, in emergency departments O R A S E X T R A P A T I E N T S O N already full wards is up by FROM-ARCHTO3EPtember 2013 as compared to the same period in 2012. Despite these cuts the health service has increased its productivity and stands above the international average for best practice. -R $ORAN SAIDh 4HE 'OVernment, in demanding this fur ther ₏ 666 million cut, which may run to ₏1 billion ACCORDINGTOTHE#%/OFTHE HSE, continues to insist on another 2,000 cuts in staffing NUMBERS4HISISSIMPLYIMPOSSIBLE4HEONLYRESULTFROMTHIS budget will be compromised care.� Revenue raising 4HE).-/BELIEVESTHATTHE government could generate the revenue needed to maintain the public health service by: s!DDING₏ONAPACKOF

Liam Doran, INMO general secretary, said the budget cuts in health were flawed

cigarettes which would result in â‚Ź20 million in revenue s!DDINGCENTONAPINTOF beer/cider would generate â‚Ź100 million s!DDINGALEVYONSUGAR SWEETENED DRINKS WOULD amount to â‚Ź60 million, while reducing medium-term costs to the health service from obesity-associated illnesses could save â‚Ź200 million per annum. -R$ORANSAIDh4HEVESTED interests behind these industries cannot be allowed to

obstruct proper health planNING4HEREISNOEXCUSEFOR these damaging but avoidable cuts being imposed on the health service while these sources of revenue, which will bring about long-term benefits to society, are left untouched.� 4HE ).-/ IS SEEK ING AN immediate meeting with THE /IREACHTAS #OMMITTEE on Health to establish why THE GOVERNMENT HAS TAKEN THIShFLAWED APPROACHv4HE /RGANISATIONISCALLINGONTHE government to revise its policies in these areas. 4HE /RGANISATION IS ALSO SEEKING ALLIANCES WITH THE OTHERPROFESSIONALANDEXPERT groups who have previously argued for these public health measures. -R$ORANCONCLUDEDh)TWILL never be acceptable for any GOVERNMENTTORAISETHE6!4 on a bottle of wine by just 50 cents while increasing the cost for each item on a medical card prescription by ₏1.

Concession days and days in lieu granted for immunisation THE HSE has announced that concession and immunisation days are to be reinstated to those who were in receipt of them up to January 2012. After that time, the HSE IMPLEMENTEDTHEGOVERNMENTS decision to reduce annual leave FOREXISTINGEMPLOYEES4HE MAXIMUMANNUALLEAVEFROM that date was set at 32 days. &ROMTHENON ALLCONCESSION days were to be incorporated INTOTHISMAXIMUM BUT'OOD &RIDAYWOULDBEALLOWEDASAN EXTRADAY WHEREITWASALREADY in place for employees. 4HE(3%TOOKTHERELEVANT government instruction one step further by refusing to allow all staff that were in receipt of concession days to incorpoRATETHEM4HISAFFECTEDPUBLIC

health nurses, community general nurses, and nurse and MIDWIVESWORKINGINHOSPITALS ON-ONDAYTO&RIDAYADMINISTRATIVE TYPEROSTERS4HESE nurses and midwives always received concession days up to this action by the HSE. 4H E CO N CE S S I O N D AYS I N QUESTIONWEREUSUALLYONEAT Christmas and one at Easter. 4HE (3% ALSO SOUGHT TO remove the days in lieu granted to public health nurses as part of a previous agreement relatING TO TAKING ON ADDITIONAL roles in immunisation. 4HE).-/STRONGLYOBJECTED to this interpretation of the GOVERNMENT S DECISION ) T WASSUBSEQUENTLYAGREED AS part of the Haddington Road Agreement, that any employee

who held concession days up to January 1, 2012, would be ALLOWEDTOMAINTAINTHEM4HIS would be done by incorporating them into their annual leave allocation provided they DONOTEXCEEDTHEOVERALLMAXimum of 32 days. )NADDITIONTOTHEMAXIMUM DAYSLEAVE THETWODAYSIN LIEUFOR0(.GRADES RELATINGTO the immunisation agreement, WILLCONTINUETOAPPLY4HESE immunisation days will not be subjected to the cap of 32. 'OOD&RIDAYWILLALSOCONtinue to be given in addition to the cap of 32, to all grades WHOHELDIT4HEIMPLEMENTAtion of all of these changes SHOULDBEBACKDATEDTOTHE commencement of the annual leave year, 2012.

Commenting on the issue, ).-/GENERALSECRETARY ,IAM $ORAN SAIDh4HE).-/ISVERY pleased that we were able to correct this situation, and obviously, this is good news for all members and grades INVOLVED4HEREAREOBVIOUSLY significant benefits, accruing to affected members.� - R $ O RA N CO N C L U D E D h ) stress again that members SHOULDCONSULTWITHTHE).-/ IFTHEYREQUIREANYCLARIFICATION or assistance.� 4HE).-/WILLCONTINUETO engage in discussions with the HSE to ensure the smooth implementation of these developments and to address any anomalies that remain outstanding, or that may arise in the future.�



Pictured on the steps of Dublin’s Mansion House were the attendees at the ICN Workforce Forum with (front row l-r) Dave Hughes, INMO deputy general secretary; Óisin Quinn, Lord Mayor of Dublin; and Clare Mahon, INMO president Pictured below were members of the Forum hard at work in INMO HQ

INMO hosts ICN 2013 workforce forum Pay and conditions of nurses across the world under scrutiny IN LATE September the INMO hosted the International Council of Nurses (ICN) Workforce Forum for 2013. The ICN, – the worldwide professional representative body for nurses – has held this workforce forum, on an annual basis, for a number of years and this was the third time the event was held in Ireland. The Lord Mayor of Dublin Óisín Quinn hosted a reception for Forum participants to mark the gathering of nurse leaders from across the world, in Dublin. The Forum saw representatives from nursing associations including the US, Canada, Australia and across Europe, come together to discuss the trends and developments with regard to the pay and conditions of nurses. The meeting, which took place over three days, disc us s e d a ra n g e o f i ssu e s. Country reports, from all associations, that identified all



developments in the working conditions of nurses across the globe were presented. The global nursing workforce profile - which identifies a growing shortage of nurses following a worldwide survey by the ICN was also discussed. Other topics that featured included: s 4 HEIMPACTOFAUSTERITY AND changes in labour conditions, upon the delivery of healthcare s !DVANCEDPRACTICEINNURSing and what does it mean s 3 OCIAL MEDIA AND NURSES and its implications s 4HEIMPACTONTHEQUALITYOF patient care, arising from the introduction of guaranteed minimum staffing levels s 4 HE IMPACT ON NURSES OF changes in the age of retirement and their implications. The objective of the meeting was to examine trends and developments, in different countries, and to collectively agree appropriate responses,

November 2013 Vol 21 Iss 9

to meet these challenges, on h h ll behalf of the nurse members of each individual nursing association and the wider nursing population of ICN. Speaking during the conference, Forum chairperson, INMO deputy general secretary, Dave Hughes said: “This forum, which brings together the representatives of literally hundreds of thousands of nurses across the world, ensures we have an indepth awareness of changes i n l a b o u r c o n d i t i o n s, fo r nurses, and allows us to plan an appropriate response.

Mr H Hughes M h added dd d that h the h Forum was taking place at a particularly challenging time, for all healthcare systems, “arising from the sustained period of austerity, which sees the delivery of frontline services, primarily performed by nurses, severely challenged due to a reduction in resourcesâ€?. Following the Forum, Leslie Bell, director of the ICN, ISSUEDACOMMUNIQUĂ?CALLING on nurse leaders to speak out and take action in the interests of patients and nursing care to MAINTAINQUALITYASSUREDCARE across the world.


Professional social media guide released THE latest professional advice

from the Nursing and Midwifery Board of Ireland (NMBI), which addresses the use of social media by nurses and midwives, was launched by the Minister for Health, Dr James Reilly, during Nurses’ Week last month. The NMBI has published two sets of guidelines, which a r e e n t i t l e d ‘Guidance to Nurses and Midwives on Social Media and Social Networking’, and the accompanying, ‘Top Tips for Nurses and Midwives’. The development of the guidance was a collaborative effort over the past year between the NMBI, the Irish Nurses and Midwives Organisation (INMO), the Psychiatric y

Nurses Association (PNA) and the Services Industrial Professional and Technical Union (SIPTU). An advisor y group with representatives from nursing informatics, nursing management, clinicians, students and educators also contributed to the project. With social media use and social networking practice increasing all the time, this guidance should provide timely advice. The suite of information on social media and social networking includes: s'UIDANCETO.URSESAND -IDWIVESON3OCIAL-EDIA AND3OCIAL.ETWORKING This is a 21-page booklet with information about

what social media and social networking is about, including their benefits for professional practice and key messages about how to appropriately and confidently use it. Prac tice examples from n u r s e s a n d m i d w i ve s a re shared in the document along with professional advice. s4OP4IPSFOR.URSESAND -IDWIVES This is published as a poster for easy viewing. It focuses on 11 top tips for registrants in maintaining their professionalism and staying safe with regard to their online activity. The poster has been reproduced on the page opposite in a handy cut out and keep format for your ease of reference. s,ITERATUREREVIEW This ser ves as the foundation for the aforementioned booklet and poster, and examines the common and shared themes from national and international regulators and professional bodies on the subject. o Within hours of their l a u n c h i n I r e l a n d, t h e guidance documents we re a l s o l a u n c h e d a t w tthe World Health Organization Europe Chief Nursing Officer Meeting N in Vilnius, Lithuania, which

was attended by the most senior nursing and midwifery leaders and key policy makers from across Europe and beyond. E l i z a b e t h Ad a m s, I N M O director of professional development, launched the document on behalf of the NMBI, the INMO and other unions involved in its development. The WHO meeting provided a significant opportunity to highlight the appropriate use of social media. The INMO, together with NMBI and other unions, encourages nurses and midwives to engage in social media and social networking acknowledging its benefits and also being aware of safe professional practices. To view and download the guidance, visit WWWINMOIE If you have any comments or require further information, please contact NMBI at email: professionalguidance@ The board extends its gratitude to the Social Media Working and Advisory Groups. Special thanks go to Muriel Haire, the INMO web administrator and IT manager, and Helen Farrell from the NMBI for their professionalism and direction of the project.

Social Media & Social Networking Top Tips for Nurses and Midwives abc

Understand the basic concepts before you go online Respect boundaries: keep your personal life and professional life separate online Respect patient/client privacy and confidentiality



Use Social Media websites and Social Networking for your professional development Pause before you post Imagine your post ‘going viral’ Use ‘Netiquette’ when you are online Regularly check your settings and accounts online Remove any links between you and inappropriate content online Report any inappropriate content Understand and follow your organisation’s ICT policies

News in Brief V

 ( 3%3OUTH An ongoing dispute with the HSE-South regarding their failure to pay the acting-up allowance to INMO members who act-up in a higher nursing post has been referred by the INMO to the Labour Relations Commission for resolution. A conciliation conference to hear the dispute has been provisionally scheduled for the end of November. ,IZ#URRAN)2/


3T#OLUMCILLES(OSPITALA dispute following changes to breaks on night duty in introducing the Haddington Road Agreement has been referred to the LRC. Management have changed paid breaks to unpaid breaks on night duty. 0HILIP-C!NENLY )2/


4ALLAGHT(OSPITALWith the onset of the winter season Tallaght has seen a record number of patients placed on trolleys both in the Emergency Department and throughout the wards in the Hospital. This is compounded by an acute shortage of staff. Derek Reilly, Industrial Relations Officer, and hospital Reps have had a number of meetings with management in an attempt to address the situation. $EREK2EILLY )2/

The bottom line is – if you have a social media presence, keep it separate from your profession, keep it positive, and most importantly, keep it patient/client free and colleague-free! For further information, please refer to Guidance on Social Media and Social Networking (NMBI, 2013) on

Bord Altranais agus Cnåimhseachais na hÉireann Nursing and Midwifery Board of Ireland



November 2013 Vol 21 Iss 9




Interim north east maternity deal ends

Tony Fitzpatrick, INMO industrial relations officer for the north east

W O R K continues on the reinstatement of services at Letterkenny General Hospital, which suffered serious structural damage when flooding obliterated 40% of its floor space in July. A portable kitchen has been put in place to provide patient meals and an interim staff dining area, located adjacent to the closed outpatient department at the hospital, is now operational. This has been welcomed by the staff. A location has been earmarked to facilitate the return of all outlaying OPD clinics to the hospital, which will enable the delivery of services under one roof. The haematology/oncology Ward remains temporarily accommodated on medical 4,


November 2013 Vol 21 Iss 9

a nd lif ting, p e n s i o n s a n d superannuation. 3LIGO #YCLE 0SYCHOLOGIcal Support Services and the ).-/AND)-0!#4UNIONSALSO set up stands at the event. Members of the committee secured various raffle prizes FROM 3LIGO 2EGIONAL (OSPITAL THE 2ADISSON "LU (OTEL

the Southern Hotel, the Sligo Bike shop and Sligo County Council. This is the first time this event was run at Sligo 2EGIONAL (OSPITAL AND IT IS envisaged that, following a review, it may become an annual occurrence. - Maura Hickey, IRO

and welcomes the commitment by the Health Minister to ensure that Letterkenny General Hospital will be restored to the operational level it was at before the flood, which will enable the

delivery of acute services to the population of Donegal. The INMO commends its members for their ongoing commitment to the hospital and their tireless work at LGH. - Maura Hickey, IRO

 Naas General Hospital: A recent meeting with management helped identify current acting positions and numbers of unfilled vacancies.There are expected to be 10 nurses on the graduate programme commencing next year.This is to replace current agency and overtime. The INMO will continue to pursue the filling of all current vacancies in conjunction with local nurse representatives. - Derek Reilly, IRO KDOC Vista Clinic Naas: The INMO has withdrawn from talks at the Labour Relations Commission following KDOC’s failure to provide accounts to this organisation for the current year. KDOC were seeking to reduce nurse’s premium pay while refusing to provide accounts or indicating if management grades or other health professionals were taking a pay cut. Derek Reilly, Industrial Relations Officer, stated that the INMO ‘.... would only re-enter talks when and if management provided us with detailed accounts and a current business plan.’ - Derek Reilly, IRO Tallaght Hospital: Fifty four pre-registration nurses due to finish their training have been offered positions pending registration with NMBI. Some 35 newly qualified nurses will be offered positions until January 7, 2014. These posts are being offered at the incorrect rate of pay. The matter has now been referred to the services of the Labour Relations Commission and a date for a hearing is expected shortly. - Derek Reilly, IRO Midland Regional Hospital: Following representations by the INMO, management has agreed to extend the contracts of nurses who graduated in 2012 in the Midland Regional Hospitals, by six months on the 2nd point of the staff nurse salary scale. Prior to securing this agreement, management had advised that the only way to remain in employment was to apply under the staff nurse graduate scheme on inferior pay or work through agency, at a higher cost to the HSE. - Lorraine Monaghan, IRO



MITTEEOFTHE3LIGO2EGIONAL Hospital Managing Attendance Committee, involved a rolling slide show highlighting the main points of the national policy. There were various information stands, including ones on occupational health, manual handling

The interim Emergency Department at Letterkenny General Hospital pictured at the time of its construction in July after the flood which destroyed 40% of the Hospital’s floor space. Refurbishment works are ongoing

In Brief

Kilcreene Orthopaedic Hospital: The INMO made representations to management on behalf of a number of members in Kilcreene Orthopaedic Hospital who had made individual applications to increase or decrease their contracted hours. Management had initially refused such requests on the basis that approval would result in either a loss or surplus of hours in the service, which could not be accommodated because of the moratorium. The INMO worked with these members collectively and subsequently submitted applications for the group whereby the overall hours balanced out meaning that there would be no impact on the service. Management agreed to approve the change in hours on this basis and they are in the process of revising contracts of employment. - Lorraine Monaghan, IRO

Successful Sligo Regional Hospital staff welfare event held A STAFF welfare event took PLACEAT3LIGO2EGIONAL(OSPItal in September to highlight the national managing attendance policy and inform staff of the support services available to them during their working life. The event, which was o rg a n i s e d by a s u b co m -

while the coronary care unit remains temporarily accommodated in medical 3. The temporary emergency depar tment continues to experience severe demands o n i t s l i m i te d, d e c re a s e d capacity. This is compounded by the loss of 19 beds due to the relocation of specialities as an interim solution. There is ongoing work to open 11 beds in the old gynaecology ward on a phased basis once refurbishment work is complete. In the meantime, the hospital is working on a revised escalation policy to cope with the early increase in attendances at ED, which has come unexpectedly before winter. Th e I N M O co n t i n u e s to engage with management


s) N D I V I D U A L S  D U T Y A N D attendance pattern will be maintained, ie. four-day working week etc s- ILEAGE WILL BE PAID AND travel time allocated to individuals who redeploy s,OCKERSANDCHANGINGFACILIties will be provided in OLOL s. O STAFF MEMBER WILL BE REQUIREDTOWORKONCALL s. O STAFF MEMBER WILL BE REQUESTEDTOWORKOUTSIDE their scope of practice s. O STAFF MEMBER WILL BE expected to work as a lone worker s3 TAFF MEMBERS WILL HAVE access to premium shifts, overtime and on-call if it is their individual wish to make themselves available for same. A review clause was also built into the agreement. This agreement will facilitate the opening of a closed theatre and a reduction in the waiting list in OLOL. - Tony Fitzpatrick, IRO

Refurbishment continues at Letterkenny


restoration of the payment with retrospection. Restoration of acting allowance The INMO had referred the case of a nurse in the north EASTTOTHE2IGHTS#OMMISsioner Service, who’s acting up allowance had been ceased back in 2009 following a brief sick leave absence. /N THE EVE OF THE 2IGHTS Commissioner hearing the HSE agreed to restore the payment of the acting allowance retrospective to 2009. Furthermore, it was agreed that the member would be regularised into the clinical nurse manager 2 position. Management has now reinstated the acting up allowance, paid the monies owed retrospective to 2009 and her appointment is being processed. Louth County Theatre redeployment agreement Management sought the r e d e p l oy m e n t o f t h e a t r e nurses from the Louth County hospital to Our Lady of Lourdes (OLOL) to accommodate the opening of the theatre that has been closed due to staffing shortages. This would be an interim arrangement pending the appointment of seven theatre nurses by November 2013. The INMO negotiated the following terms: s4HISISAVOLUNTARYREDEPLOYment arrangement


tions including the restoration of subsistence payments to the Dundalk midwives in September 2010 with retrospection to April 2009. However, management refused to restore the payment to the Monaghan midwives. In July 2013 the Labour cour t in recommendation NUMBER,#2ADDRESSED the issue of the termination of the interim agreement from 2001. It recommended that the subsistence arrears due for the period August 2008 to September 2011 be paid to the Monaghan midwives. It STATEDTHATTHEQUALIFICATION allowance, which has been PAID BE BOUGHT OUT AT  times the annual loss in comPLIANCEWITHTHE03!FORMULA The Cour t also recommended that the Monaghan staff retain the paid meal break pending a wider review of rosters/working arrangements in Monaghan. The full recommendation is available on the Labour court website. Restoration of subsistence payments to the Cavan/Monaghan palliative care team The INMO made representations to management when it was brought to our attention that management had unilaterally ceased the payment of subsistence to the Cavan/Monaghan palliative nursing team. As a result of these representations management confirmed the


F O L LO W I N G t h e d e c i s i o n of the former North Eastern Health Board to cease maternity services on an interim basis at Monaghan General Hospital and the Louth County Hospital in Dundalk, an interim agreement was reached between the INMO and management to accommodate the redeployment of midwives. This interim agreement included terms such as: s 0AYMENT OF MILEAGE AND subsistence s2 ETENTION OF QUALIFICATION and location allowances s2 E T E N T I O N O F P A I D M E A L breaks s0ROVISIONOFTRAVELTIME s2 E T E N T I O N O F P R E M I U M payments s, U M P S U M P A Y M E N T S O F )2a ANDa It was originally envisaged that the interim agreement would last for one year, however one of the terms of the agreement was that it would be reviewed when management made a final decision on the future of maternity services at Dundalk and Monaghan. Management sought to terminate the agreement and A NUMBER OF ,2# HEARINGS took place in 2011 and 2012. Management also unilaterally ceased the application of some of the terms of the agreement. Some of these issues were addressed in direct negotia-


November 2013 Vol 21 Iss 9




LRC resolves Wexford acting up dispute A DISPUTE between the INMO and the HSE-South over the nomination of a staff nurse to act up in a CNM 1 post without agreement has been resolved with the assistance of the Labour Relations Commission. In May this year, a CNM 1 post became vacant in St John’s Hospital, Enniscorthy, as the Acting CNM1 moved into an Acting CNM2 position. Hospital management sought expressions of interest from the staff nurse cohort in the Hospital to fill the acting CNM1 post, but without sanctioned payment of the acting-up allowance no interest in doing so was elicited. Management then proceeded to nominate a nurse to actup as CNM1 without their agreement. The INMO wrote to management to advise that they could not compel any INMO member to act-up into a promotional nursing post without his/her agreement to do so, and advised that a nurse could not be forced to act-up into a higher post for which they have not applied. Furthermore, the INMO advised that the more appropriate way to

have the post filled would be to ensure that the post was advertised and permanently filled by open competition. Management advised that, while they had applied for derogation from the moratorium to fill this post, this was not forthcoming from the HSE and therefore they would be nominating a nurse to act-up in the post until sanction to permanently fill the CNM1 post was received. The nurse nominated by management to act-up in the CNM1 post agreed to do so under protest for a threemonth period, contingent on the arrangement being reviewed in three months and contingent on the acting-up allowance being paid. A dispute on the matter was referred to the LRC by the INMO in June 2013 and a conciliation conference was held in late September 2013. Agreement on the matter was reached between INMO and HSE-South, as follows: s- ANAGEMENT UNDER TAKES that it will not nominate or require a nurse to act in a promotional nursing post without his/her agreement

Liz Curran, INMO industrial relations officer

and where there is no contractual agreement to act-up s" OTHSIDESEXPECTTHATTHE full implementation of the SSN/LTA (senior staff nurse/ long-term actors) aspect of the Haddington Road Agreement may address this issue in the future s- A N A G E M E N T A G R E E S T O review the current arrangement that is in place with the Acting CNM1 concerned s- ANAGEMENTWILLRESUBMIT the application to the HSE to fill the CNM1 post substantively and for payment to the acting CNM1 in the interim, retrospective to June 24, 2013. 3PEAKINGONTHEMATTER ,IZ Curran IRO said that it was important that this dispute

was resolved by way of the HSE accepting that it cannot force a nurse to act up into a higher nursing post without their agreement where the nurse had no contractual obligation to do so. “ This result has implications for nurses everywhere, given the increased number OF VACANCIES ARISING IN KEY nurse management posts in recent years due to the moratorium, and given that senior HSE management refuse to fill such posts on a permanent basis. “ The INMO fully agrees that all promotional nursing posts need to be filled as soon as they become vacant, in order to maintain the clinical governance and nursing leadership required in all wards / areas to ensure optimal care is delivered to patients. However, it was the manner in which this was achieved in this instance that the INMO TOOKISSUEWITH4HE).-/WILL continue to monitor progress in this case, particularly with respect to the permanent filling of this important CNM post in the Hospital,� said Ms Curran.

In Brief V

 St Vincent’s Private Hospital: A new collective agreement has been accepted by INMO members following a local ballot. This AGREEMENTMIRRORSTHEPROVISIONSOFTHE(2!ANDPROTECTSTHELINKWITHPUBLICSECTORPAY!PARALLELPROCESSISCONTINUINGAIMED at restoring the time plus one-sixth unsocial hours premium. - Philip McAnenly, IRO




Sunbeam House Services:4HISEMPLOYERWHOHASNOTPAIDINCREMENTDUETO3TAFFSINCEHASCAUSEDADISPUTEBYSEEKING to introduce the provisions of the HRA, except for those relating to increments. The unions and management have jointly sought the assistance of a Joint Review Group and are awaiting the appointment of same. - Philip McAnenly, IRO


St Catherine’s ID Services, Wicklow: The INMO is currently in discussions at the LRC regarding attempts by management to introduce cost cutting proposals due to severe budgetary problems. As a result of INMO pressure, management has agreed to reverse plans to introduce redundancies. Funding set aside for redundancies will now BE USED TO PAY  OF THE OUTSTANDING INCREMENTS FOR  ON A PHASED BASIS TO CONCLUDE BEFORE -ARCH  - Philip McAnenly, IRO



November 2013 Vol 21 Iss 9

Employment tribunal win for practice nurse THE INMO successfully represented a practice nurse at the Employment Appeals Tribunal under the Redundancy Payments Acts. The practice nurse had been working in a general practice in the Midlands from 2001 up to 2010 when the general practitioner she was employed by retired. The nurse continued working in the practice, initially through agency, and was subsequently taken on by a newly appointed GP. The INMO argued that a genuine redundancy situation existed when the practice nurse’s employer retired in 2010 and therefore she was entitled to a redundancy pay-

ment. The respondent argued that there was no redundancy as the practice nurse was not out of work at any time but rather there was a transfer of undertaking. They further argued that the new GP took over the same building and equipment (owned by the HSE); there was a transfer of patients/GMS list; and a transfer of the GP practice nurse. The Tribunal heard, during direct evidence and cross examination, that the practice nurse’s previous service was not recognised by her new employer and information was also provided to demonstrate that the GMS contract is unique, in that it is specific

Ennis General roster talks LOCAL engagement occurred

at Ennis General Hospital in Clare in relation to revised rosters in the local injuries and medical assessment units. Management had proposed the removal of ‘link nurse’ from the night shift. However, the INMO counter proposed the retention of this post until the end of December, when a review of the implementa-

tion of the Smaller Hospital Framework in the region can be assessed. This review should consider the impact of the Framework on regional bed capacity, and the ability of University Hospital Limerick and the ambulance service to accommodate all patients requiring transfer from Ennis for level-four hospital careMary Fogarty, IRO

HSE takes over Cregg House WISDOM Services ceased to

provide care to the intellectual disability population in the north west of the country on October 1. From that date, its services and employees were transferred to the HSE. To avoid client disruption, Cregg House campus and its associated community group homes will continue to be used by the HSE. Legally, each Wisdom Services employee became an employee of the HSE on the date of transfer. The INMO ensured that all its

members’ terms and conditions of employment were preserved. The INMO, in conjunction with IMPACT, secured the transfer of Wisdom Services employees to the HSE superannuation scheme with effect from October 1, for pension purposes. INMO IRO, Maura Hickey, commented: “This has been a long process, throughout which nurses felt very uncertain and insecure. It is now time for moving forward and new beginnings.�

to the appointed GP and once a GP leaves a practice then that contracts ends, ie. it is not transferable. The Employment Appeals Tribunal accepted the arguments put for ward by the INMO and stated in its decision that the new GMS contract issued by the HSE ‘was unconnected with and had no similarity to the previous contract’. They further stated that ‘no liabilities under the former contract carried over to the new contract’ and therefore a transfer of undertaking did not occur in this case. The Employment Appeals Tribunal found that the cir-

Lorraine Monaghan, INMO industrial relations officer

cumstances of this case met with the definition of redundanc y under the Ac t and instructed the respondent to pay the GP practice nurse nine years’ redundancy payment. Lorraine Monaghan, IRO

Allowance dispute ongoing at St John’s Hospital I M P L E M E N T A T I O N of the Smaller Hospital Framework in the emergency department of St John’s Hospital, Limerick commenced in late September. However, management did not consult with any of the health service unions in relation to this, despite the consultation process requiring the participation of all stakeholders. M anagement wrote to the INMO giving one day’s notice of its intention to remove the payment of the location/specialist qualification allowances in the clinical observation unit. This allowance was recently reinstated for a small group of members following a Labour Court recommendation. Management of the Limerick hospital stated that these allowances must now be removed as the acute medicine plan is fully implemented


Mary Fogarty, INMO industrial relations officer

at the hospital. The INMO rejected this on the basis that the unit remains open despite the fact that hospital management assured the Court that it would be closed when the acute medicine programme was fully implemented. The Labour Court has since confirmed that these allowances are to remain in place while the clinical observation unit is open. - Mary Fogarty, IRO

November 2013 Vol 21 Iss 9



Section News

INMO refers Wexford ID dispute to LRC THE INMO has sought the assistance of the Labour Relations Commission (LRC) to resolve a dispute with the HSE about the implementation of the additional hours provision of the Haddington Road Agreement in Wexford Residential Intellectual Disability Services (WRIDS) in Wexford. A number of INMO members in this service applied to t h e i r d i re c to r o f n u r sing in early July 2013 to be

allowed to maintain their existing working hours, with the associated pay reduction, as provided for under the Haddington Road Agreement. All of the appropriate paperwork was submitted to management in good time, and the director of nursing forwarded the applications of our members to the HSE for sign-off. However, these applications were returned to the director

communicating with staff in St James’s regarding these changes over the next couple of months and there will be a full consultation process agreed with the trade unions on the implementation of this proposal. S t J a m e s’s a l s o announced that the Hospital intends to establish a quality and safety management programme. It w a s a l s o s t a te d a t t h i s time that it is intended to establish a separate facilities management directorate. - Albert Murphy, IRO

WIN November 2013 Vol 21

Iss 9

 Mount Carmel Hospital: A new collective agreement has been accepted on a 2:1 basis by INMO Members following a local ballot. This agreement mirrors the provisions of the HRA and protects the link with public sector pay. This is important in the context of the proposed sale by NAMA of the hospital and the consequent ‘transfer of undertaking’ protection of members’ pay and conditions of employment. This agreement also provides for the phased payment of outstanding monies and compensation due following a number of Labour Court Recommendations. The agreement also makes a definite commitment to restore the time plus one-sixth unsocial hours premium in specific circumstances that the INMO believes are attainable. - Philip McAnenly, IRO M ount Carmel theatre staff: Members in the theatre department have voted to accept a Labour Relations Commission proposal. This proposal compensates nurses after management removed the time in lieu arrangements for being on-call from Saturday evening to Monday morning. The proposal will result in each nurse getting 19 (15 plus 4) days leave. - Philip McAnenly, IRO



Alber t Murphy, INMO industrial relations officer

In Brief


ST JAMES’S Hospital in Dublin has confirmed to the Irish Nurses and Midwives Organisation that it intends to restructure t h e d i re c to ra te s i n t h e Hospital. Currently there are 10 directorates in St James’s Hospital which have been in operation for nearly 20 years. During this time there have been significant changes within the struc ture of the health system, clinical services, patient population and treatment regimes. This has occurred in tandem with an increase in performance-led demands within the system. These revised structures will be the subject of consultation with staff and representative organisations over the next number of months. It is not expected that these organisational changes will result in changes for staff nurses and members on a day-to-day basis. The Hospital will be

which clearly states: “Management will allow persons to opt to remain on their current hours with appropriate pay adjustments.” A Conciliation Conference of the LRC is scheduled for November 21, 2013, which the INMO will attend along with representatives from PNA and SIPTU (Nursing) who are equally affected by this dispute. - Liz Curran, IRO


St James’s announces directorates restructuring

of nursing and marked ’not approved’ by a more senior manager. Further discussions with the INMO, PNA and SIPTU (Nursing), aimed at resolving the issue with the HSE-South were unsuccessful, and so the INMO referred a dispute to the LRC on the matter in September 2013, citing the HSE as being in breach of the Section 1.5 of the Haddington Road Agreement (on page 39)

Dalkey HSE Community Unit: Members with INMO representation have resisted efforts by management to introduce rigid and inflexible rosters for core staff within HRA provisions. This Unit is being staffed by a high proportion of agency nurses. Management sought to roster core HSE Staff in a way that would result in them being on duty at all times across 24/7. This would have resulted in custom and practice changing with consequent loss of salary and childcare complications for our Members. CNMs were being required to change their own rosters at short notice to ensure CNM cover across all Monday to Friday shifts with loss of Sunday premium. Management has now accepted that these changes can only occur with the agreement of staff. - Philip McAnenly, IRO

High calibre speakers at annual triage event FIFTY-FIVE nurses travelled to Limerick in October to enjoy the Telephone Triage Section’s ninth annual conference. Members of the Section reported that the conference was, without doubt, one of the best to date. While the numbers attending were lower that on previous occasions, the calibre of speakers was “second to none”. INMO president Claire Mahon delivered the opening address at the conference, and in her speech spoke about the importance of section conferences. She also talked about the compulsory continuous professional development points system that is being introduced by the Nursing and Midwifery Board of Ireland (NMBI). It is interesting to note that this particular day carried six continuing education units from the NMBI.

Pictured at the Telephone Triage Section conference were (l-r): Bernadette Queally, screening co-ordinator of the National Screening Programme; Margaret O’Connor, clinical nurse specialist; Claire McMahon and Carmel Murphy, joint national secretaries of the Telephone Triage Section; and Breege Clarke, national vice chair of the Telephone Triage section

Delegates received an update on anaphylaxis, urticaria, population-based screening, immunisations and pain management in endof-life care. An exceptionally

poignant talk on suicide was also heard at the conference. The feedback received from everyone who attended the event was very positive. The conference organisers

Retired section get away to the Marble City THE Kilkenny River Court Hotel

was the venue for the Retired Section’s autumn break in October. Fourteen members of the Section stayed at the hotel, which is situated on the banks of the River Nore, overlooking Kilkenny’s majestic 12th century castle. Walking through the city’s winding streets, the retired nurses and midwives explored various famous sites, including Shee Alms House, Kytelers Inn, St Canice’s Cathederal, Rothe House, Court House, St

Members of the INMO Retired Section enjoying their recent autumn getaway to Kilkenny

Mary’s Cathedral and the Black Abbey. A highlight of the trip was dinner in the Campagne res-

taurant, which was recently awarded a Michelin star. Everyone on the trip was captivated by the city of craft and beauty.

obtained sponsorship from a number of local companies, which provided raffle draw prizes and contributed greatly to the running costs of the day.

Win a hotel stay MEMBERS who attended the annual theatre nurses’ conference in April at the Crowne Plaza Hotel in Dublin may recall that the hotel was experiencing some heating issues on the day of the event. As a goodwill gesture, the management of the Crowne Plaza has kindly donated a gift voucher for an overnight stay for two at their Santry hotel. To be in with a chance of winning, simply email jean@ with ‘Count me in’ as the subject line.

You are not alone Counselling, legal advice, domestic assistance and bodily injury cover Free helplines provided by DAS, 365 days a year, 24/7



Tel: 1850 670 407 for counselling or 1850 670 707 for other services See for further details November 2013 Vol 21 Iss 9 WIN November 2013 Vol 21 Iss 9


Quality & Safety

A column by Maureen Flynn

Bulletin Board

A PRACTICAL GUIDE TO CLINICAL AUDIT THIS month we focus on the ‘Practical

Guide to Clinical Audit’. The HSE Quality and Patient Safety Directorate developed the guide to equip healthcare professionals with the necessary knowledge to plan, design and conduct a clinical audit. It provides a reference guide for healthcare professionals already involved in clinical audit and a learning resource for those who are new to the process. What is clinical audit? Clinical audit is the systematic review and evaluation of current practice against research-based standards with a view to improving clinical care for service users. It is about evaluating practice against a defined ‘best practice standard’ and making changes if current practice is not in line with best practice. A clinical audit aims to ensure quality – that we are doing the things that we should be. Measuring practice against known standards is not a new idea. During the Crimean War in the 19th century, Florence Nightingale measured, monitored and used her influence to improve hygiene standards in the field hospitals thus leading to an improvement in mortality rates. Why clinical audit? Clinical audit facilitates a reliable way of: s Proactively measuring the effectiveness and performance of healthcare against agreed standards s Improving the quality of patient care provided by identifying actions to bring practice in line with these standards s Providing assurances of service quality to patients, clinicians and the health system. Involvement in clinical audit can expose us to new knowledge and provide evidence of our reflection and commitment to continuing professional development. Clinical audit involving the multidiscipli-

Sustaining improvements

Planning for audit

Standard/ criteria selection

Making improvements

Measuring performance

nary team can also assist in improved communications among multidisciplinary team members. Stages of clinical audit Clinical audit is a process that is often described as a continuous ‘cycle’ with stages that must be undertaken to ensure that the audit is systematic and successful. The image used throughout the document aims to illustrate this ‘cycling’ through the five stages - see figure above. These stages are planning for audit; standard/criteria selection; measuring performance; making improvements and sustaining improvements. Each stage is broken down into steps providing a practical guide to the methodology of clinical audit. The clinical audit guide and resource The practical guide provides direction on carrying out clinical audit for both individuals and clinical teams. It lists current drivers in the Irish health service and describes the five stages approach to clinical audit. The document discusses the resources required to support clinical audit and the

With INMO director of industrial relations Phil Ní Sheaghdha

need to consider ethical and data protection issues. Further resources in the form of sample templates, checklists and summaries are contained in the appendices. The guide also provides links to more detailed information resources. Opportunity to get involved Clinical audit is intended to help you measure the extent to which your day-to-day practice is consistent with best practice. This improves practice if required, with the objective of improving the quality of care and treatment provided. Why don’t you reflect on your area of practice and identify possible audit topics? Clinical audit is most effective when it is carried out as a team activity. Initiate a discussion with colleagues; start small. The guide can be accessed at www. or about/Who/qualityandpatientsafety/ Clinical_Audit/ We welcome feedback on your experience of the clinical audit resources, and about how they might be improved.

Query from member Are there any guidelines regarding the use of social media for nurses and midwives?

These guidelines advise that the privacy and confidentiality and professionalism of nursing and midwifery values have to be protected at all times and the legal rights of privacy and confidentiality of patients and colleagues have to be respected at all times. A simple recommendation of the guidelines is that you stay professional at all times. You do not post messages or information about something you wouldn’t want your colleagues and managers to see and if you are about to publish something that you wouldn’t say in a room full of people, then don’t do it. You are always at risk of your employer taking offence at matters relating to your work or indeed they may also have concerns in respect of matters relating to patients or how nurses/midwives do their job, conduct their business, etc. if posted on a public forum. The INMO will represent you if you require this service however it is important that you familiarise yourselves with these guidance notes and adhere to them. The best way to protect this aspect of your social media presence is to keep it separate from your professional life and free of any mention of patients, clients or colleagues. Please see pages 10-11 for full details on the social media guidance document.

Maureen Flynn is the director of nursing (national lead for quality and safety governance development) at the Office of the Nursing and Midwifery Services Director, Quality and Patient Safety Directorate, HSE

Query from member Will there be a facility to purchase or transfer service under the new public service pension?

Acknowledgements With thanks to Dr Ian Callanan, clinical audit coordinator at St Vincent’s Healthcare Group (chair); Joan Malone, clinical midwife manager 3 (project manager) and members of the HSE Clinical Audit Advisory Group, who prepared the guide and resources. The INMO and the HSE are signatories to Patient Safety First - the initiative through which healthcare organisations declare their commitment to patient safety. Through participation in this initiative, those involved aspire to play their part in improving the safety and quality of healthcare services. This commitment is intended to create momentum for positive change towards increased patient safety. For further information see

Query from member My mother passed away recently on a Tuesday. I was not rostered to work on that day, however I was rostered to work the Wednesday and Thursday. The funeral took place on the Friday which was also my day off. What compassionate leave am I entitled to?

About the HSE Quality and Safety Directorate: The Quality and Patient Safety (QPS) Directorate of the Health Service Executive (HSE) was established in January 2011, on the appointment of the National Director, Dr Philip Crowley. The role of the QPS Directorate is to provide leadership and be a driving force by supporting the statutory and voluntary services of the HSE in providing high quality and safe services to patients their families and members of the public.

November 2013 Vol 21 Iss 9


Reply Under the new pension scheme (single scheme for the public service operational January 2013), there will be a facility to purchase temporary service and to allow private pension transfer.

The Department of Finance has to develop what is termed ‘purchase tables’ that will set out the value in the single scheme of other service being purchased or private pension. We are advised that the Department of Finance is in the process of completing these tables but they are not finalised as yet. When they are completed, they will consult with the public services committee of the Irish Congress of Trade Unions prior to issuing them. We will update members of any progress in relation to this matter.

Due to a production error, the HSE’s clinical governance document on the ‘safety pause’ was not published alongside last month’s column. It is now available on the page opposite.



A great deal of correspondence has been received by the INMO in respect of this matter. We had input into a guidance document in June 2013, which we have agreed, in conjunction with the regulation body, NMBI. This guidance document clearly sets out the boundaries between your personal life and professional life and discussions of same in public forums such as Facebook, Twitter, etc.



November 2013 Vol 21 Iss 9

Reply The granting of compassionate leave is at the discretion of the employer. However, standard guidelines exist in the public health service for the granting of compassionate leave with pay to employees on the death of a relative. In the case of the death of a mother a maximum of three working days may be granted. Compassionate leave may only be granted provided staff are rostered for duty. As you were only rostered for duty on the Wednesday and Thursday you should apply for compassionate leave for these days.


Keeping the private sector informed

Minister’s commitment to better environment

in INMO HQ for Harvey Group of Nursing Home nurses and others. I have also received requests from other directors of nursing who are interested in the INMO providing these and other education and training days for their nursing staff. The feedback I have received so far, from nurses working in private and voluntary nursing homes, is that you want to see the organisation in your workplace, educating and sharing information. So I hope to develop more LINK nurses so the INMO will reach all nursing home nurses. Let’s link together – contact me by email at: or Tel: 01 6640643.

THE Minister for Health James Reilly is committed to creating a better environment to support midwives in meeting the demands put upon them and the services in which they work. This was according to Dr Siobhán O’Halloran, chief nursing officer of the Department, who was speak ing at the INMO/RCM Northern Ireland All-Ireland Midwifery Conference in Dublin last month on behalf of the Minister. The conference is a collaborative initiative by the INMO and the Royal College of Midwives (RCM) Northern Ireland. Its theme this year was ‘Maternity Care – Everyone’s Affair. Practices, Partnerships, Policies and Possibilities’. Dr O’Halloran told those attending the conference that Minister Reilly is aware that the demands on midwives in Ireland have increased both in complexity and volume over the past few years. She said: “There have been demographic changes which h a v e i n c r e a s e d d e m a n d. Ireland’s fertility rate is the highest in the EU and contrary to earlier predictions, the number of births has increased. “There have been increases in the proportion of first time mothers, an increase in the mean age of mothers and rising levels of maternal obesity, all of which combine to make an already pressurised environment even more so.” Savita Halappanavar Dr O’Halloran spoke about HIQA’s report into the care and treatment provided to the late Savita Halappanavar at UHG in October last year. She described it as a “compelling and sobering reminder of the importance of placing patient safety at the centre of our attitudes and actions at all times and in all circumstances”.



Private sector organiser Sheila Dickson updates members on the latest developments in the sector I HAVE been the private sector organiser at the INMO for almost a year now. I would like to thank all nurses, directors of nursing and owners in the private and voluntary nursing homes that I have had the pleasure of visiting, for facilitating me to meet with nurses working in this sector. I wrote to all nurses working in the private and voluntary sectors some months ago, in order to update details of work locations, education and training needs etc. It would be great to get more responses from members, so please fill in the short survey and return it to me or email/ring me. Nurses and Midwives Act I am delivering free 30-40 minute presentations on the Nurses and Midwives Act 2011 to inform nurses about future requirements to demonstrate evidence of continuing professional development as developed by the Nursing and Midwifery Board of Ireland (NMBI). I have been concentrating initially on the Dublin, Kildare and Wicklow areas so let me know if you would like me to visit your nursing home/area. Any nurse who has worked in the UK or the Philippines would be used to this criteria, and since October, the UK Regulatory body is also requiring evidence of Professional Indemnity Insurance from nurses and midwives for registration purposes. This relates to the EU Directive on Cross Border Health which was signed into law in 2011 and member states were given 30 months to transpose. As you are aware, professional indemnity insurance is included in your INMO membership fee along with other major benefits. New discount groupscheme This scheme has already been covered in WIN and I continue to issue passwords and sign up nurses to the scheme when requested. I am happy to meet small groups of nurses to show you the benefits

of the INMO Groupscheme and help to get you saving money! Tools for safe practice sessions Some of you will have attended the safe practice sessions, provided by the Professional Development Centre, advising nurses on key areas of practice such as clinical risk, documentation, report and statement writing. To date, three very successful safe practice sessions specifically aimed at private nursing home members have been rolled out in: s Tara Winthrop Private Clinic, Swords s Our Lady’s Manor, Dalkey s Marymount Care Centre, Lucan A further session took place in October

Focus F Fo o Special report from the All Ireland Midwifery conference

November 2013 Vol 21 Iss 9



Pictured at the All-Ireland Midwifery Conference were (l-r): Geraldine Talty, INMO first vice president; Mary Higgins, international officer of the INMO Midwives Section; Mervi Jokinen, RCM, London; Breedagh Hughes, RCM, Northern Ireland; Dr Siobhan O’Halloran, chief nursing officer; Claire Mahon, INMO president; and Allison O’Connell, INMO Executive Council member

“I want to ensure that the findings and recommendations from HIQA’s report will mean that we change the way we think and do business in the provision of healthcare,” she said. “I want to ensure all involved in the provision of these services have the information and support they need to fulfil requirement, and I want to ensure the monitoring of performance in our health service must incorporate a visible emphasis on patient safety,” she added. Dr O’Halloran identified five key actions to be taken: s4HEPRIORITISATIONOFAPATIENT safety culture in the HSE’s Annual Service Plan through specific measures focused on quality and patient safety including healthcare associated infections, medication safety and implementation of the Early Warning Scores s4HEDEVELOPMENTOFACODE of conduct that clearly sets out employers’ responsibilities in relation to achieving optimal safety culture, governance and performance s- ONITORINGPROGRESSONTHE implementation of the HIQA report recommendations, as part of HIQA’s monitoring programme against the National Standards for Safer Better Healthcare s$EVELOPMENTBYTHE$EPART-

November 2013 Vol 21 Iss 9

ment of Health of a national Strategic Plan for Maternity Services in collaboration with the HSE. This initiative will take account of the development of midwifery-led services and midwives will be consulted on its formulation s4 HECOMMISSIONINGBYTHE National Clinical Effectiveness Committee (NCEC) of four national clinical guidelines in line with the recommendations of HIQA’s report. New clinical guidelines According to the chief nursing officer, Minister Reilly has requested that the four national clinical guidelines be immediately commissioned as part of this process and as a matter of urgency. They are: s! NATIONALMATERNITYEARLY warning score guideline s! NATIONALPAEDIATRICEARLY warning score guideline s! NATIONALSEPSISMANAGEment guideline s!NATIONALCLINICALHANDOVER guideline. These guidelines are expected to make recommendations for staff education and training in order to assure the competence of doctors, nurses and midwives to handle critical life-saving clinical issues. Their implementation will be monitored and published on an ongoing basis through an agreed accountability frame-

work between the HSE and Department of Health. Early Warning Score Dr O’Halloran reported that all 41 target HSE hospitals have commenced implementation of the National Early Wa r n i n g S co re, w i t h 5 6 % reaching completion. She said that nurses and midwives have contributed hugely to the development of the HSE’s new national clinical programmes. “The establishment of hospital groups is a key building block in reform in our health services. It is intended that they will, in time, qualify as independent competing hospital trusts as we progress towards universal health insurance,” she said. She added that maternity services policy will guide the development of a national strategic plan for maternity services, which will be developed by the Department in collaboration with the HSE and its national clinical programme in obstetrics and gynaecology. New maternity hospital The chief nursing officer also spoke about the new national maternity hospital, which is to be built on the campus of St Vincent’s Hospital. She told the conference that there are already “significant synergies” between the two hospitals.

Maintaining Safe Practice Managing the Challenges for Clinical Nurse/Midwife Managers

for midwives heard at annual conference Dr O’Halloran said that the project will result in midwives operating in a vastly improved facility, enabling them to provide a better level of care. Patient Safety Agency The conference heard that the Department of Health is working closely with the HSE to ensure that there is visible and distinct leadership responsibility for patient safety and quality at a national level. Dr O’Halloran said: “One of my priorities is the establishment of a Patient Safety Agency and I have been doing detailed ground work with my officials on the basis and structure of same. I am considering proposals at the moment and expect to make a decision on the framework for the agency in the near future.” She said that the agency will be modelled on international examples such as the Canadian Patient Safety Institute, which aims to improve patient safety through shared learning and supporting implementation of interventions known to reduce avoidable harm. Haddington Road Dr O’Halloran acknowledged the role that the INMO played in negotiating the Haddington Road Agreement. “The sacrifices that public servants have made and continue to make, while at the same time maintaining and improving the health services, are playing a major part in the restoration of Ireland’s economic sovereignty.” President’s address Claire Mahon, president of the INMO, also addressed the midwifery conference. Speaking at the event, she said: “In this era of decreased resources, the pressure is always on to find more effective and efficient ways to provide quality assured care. It remains my

Attending the All-Ireland Midwifery Conference were (l-r): Deirdre Daly, Mary Higgins, Margaret Carroll and Colm O’Boyle from the INMO Midwives Section

firm belief that midwives, if only the policy makers would allow, could lead out quickly on new models of care. Ms Mahon said that this should begin with the establishment of new midwifery-led units for low-risk mothers, without delay. “All of the evidence emanating from such units in the areas of Louth and Cavan, only confirms that this type of service is preferred by mothers. It most certainly delivers high quality care on a more cost effective basis.” E l i z a b e t h Ad a m s, I N M O director of professional development, is now working with the senior midwife managers of four major maternity hospitals to examine the issues of staffing needs and the requirements for safe care. The Rotunda, the National Maternity Hospital, the Coombe and Cork University Maternity Hospital have already done a significant amount of preliminary work in this area. It is the INMO’s view that this work must influence the national review of maternity services, which is resulting from the recent reports from HIQA and other bodies. Midwifery officer Ms Mahon welcomed the appointment of Dr O’Halloran as the new chief nursing officer of the Department of Health. For the first time, this post is at assistant secretary

(senior management) level. The INMO is already seeking the appointment of a midwifery officer at the earliest possible date and is confident of early progress on this issue. “This senior appointment, which will see the post holder sitting at the management team level in the Department of Health is a significant development. It will help both the nursing and midwifery professions to achieve their full potential by ensuring a nursing and midwifery perspective is brought to bear in all policy analysis, consideration and formulation.” Pink Power She also spoke about the INMO’s Pink Power initiative, which was launched in autumn 2012 in response to the increasingly high levels of nurses and midwives making claims on their income protection scheme (available via their INMO membership) for breast cancer. Almost 3,100 members in 19 locations attended Pink Power breast check. Some 452 required follow-up appointments, including 113 mammograms and 46 biopsies. Three members were diagnosed with early stage breast cancer and are currently receiving treatment. Due to the success of the campaign, the INMO will be campaigning for the extension of the national Breastcheck


service to include all women over 40. The service is currently only available to women over 50. Maternity services Commenting on the Savita Halappanavar tragedy and the subsequent HIQA report, Ms Mahon said: “We welcome the National Review of Maternity Services and will actively participate in this important project.” She said that the INMO is conscious of the many issues raised by the HIQA report, and the coroner’s and HSE’s enquiries, which, she said had focused a “very sharp light” on staffing levels and standards of care in all maternity services in the Republic”. The INMO is actively supporting members who were working in UHG at the time of Ms Halappanavar’s death, and has committed to devoting all resources necessary to ensure that only positive things emerge from the tragedy. Ms Mahon said:“This must involve adequate staffing levels, appropriate skill mix and absolute clarity that midwife managers have the authority and autonomy to ensure adequate resources are always available to guarantee safe practice leading to safe care.” Poster competition The winning entry in the conference’s poster competition was entitled ‘What women want’. It was presented by a group from UCD, including lecturer, Denise O’Brien, and stage 4 midwifery students, Jean Doherty, Deirdre Kane and Kim Ryan. Health Minister Health Minister, Dr James Reilly, arrived too late to address the conference due to Dáil commitments. However, he met with a group of more than 20 midwives from both jurisdictions after the event for a full and frank debate on midwifery matters, which was much appreciated by all attending.

November 2013 Vol 21 Iss 9


Evening Education Sessions for Clinical Nurse/Midwife Managers – GRADES I, II, III have been organised in the following venues:

FREE For INMO members; €75.00 for Non Members Book by Credit/Laser Card TEL: 01 664 0618 All Sessions will run from 6.00pm – 8.30pm

Monday, Tuesday, 11th November 12th November

Thursday, Monday, 21st November 25th November

LIMERICK Castletroy Park Hotel, Dublin Road, Limerick.

GALWAY Clayton Hotel, Ballybrit, Co Galway.

DUBLIN INMO Office The Whitworth Building, North Brunswick Street, Dublin 7.

CORK The Western Room, River Lee Hotel, Western Road, Cork.

These sessions will be facilitated by:

t t

Dr Olwyn McWeeney, MG BCh BAO LLB, Lecturer in Health, Barrister at Law Michelle Russell, Nurse Consultant Please email or tel: 01 664 0618 of your intention to attend, including your „INMO Membership Number „ Mobile Telephone Number and „please state which Venue you will be attending.

Feature F Fe eat a ur ue

European midwives:

A day in the life

Tackling the challenges ahead

Mary Reilly: Clinical midwife manager Midwifery-led care in birthing units is proven as safe as consultantled care and requires fewer interventions. Ann Keating reports GIVING birth is the most powerful event

MIDWIVES came from 25 European countries to discuss matters relating to their education, research and practice at the general meeting of the European Midwives Association (EMA) hosted by the Croatian Chamber of Midwives recently in Zagreb. Time was also spent considering possible solutions to the challenges currently facing the profession. It is the first time that Croatia has hosted an EMA meeting; a fitting event in the year that it joined the EU. In his opening address, Marijan Cesarik, Deputy Minister of Health, noted the wellestablished co-operation between the Ministry and the Croatian Chamber of Midwives. Following the meeting, Mr Cesarik and his department expect to receive further information and recommendations on the application of best midwifery practice to the Croatian situation. In her address at the event, Barbara Finderle, president of the Croatian Chamber of Midwives, remarked that the absence of a midwifery school in the University of Zagreb adversely affects the possibility of higher education for midwifery graduates throughout Croatia. “The consequence for our healthcare system is the departure of midwives to other related professions and a consequent decrease in the number of practicing midwives.” Mervi Jokinen, EMA president, underlined the importance of open dialogue and the exchange of experiences between delegates. She praised the Croatian Chamber of Midwives for the active role it plays in EMA.

About the European Midwives Association The European Midwives Association (EMA) is a non-profit and non-government organisation of midwives (over 100,000 members) representing midwifery organisations and associations from the member states of the EU, members of the Council of Europe, the European economic area and EU applicant countries. The EMA provides a forum for European midwives to meet and discuss issues concerning midwifery and women’s health. It promotes minimum standards of midwifery education and practice within the EU and maintains a presence and contribution at venues affecting health policy and midwifery within the EU. About the Croatian Chamber of Midwives The Croatian Chamber of Midwives was established in 2009 with the vision of accomplishing independent midwifery in Croatia and developing the profession in general. The Chamber protects the rights and interests of midwives, promotes the identity and the dignity of the profession, and progresses midwifery through the improvement of education and legislation. Its strategic goals are: informing, educating, empowering and connecting midwives; strengthening the Chamber as a relevant body through promoting its work and the rights and interests of midwives; encouraging the harmonisation and improvement of the legislative environment in midwifery with other Croatian and EU legislation; encouraging the development of a corresponding midwifery education system and strengthening the institutional and financial capacities of the Chamber. About the Croatian Association for Promotion of Midwifery The Croatian Association for Promotion of Midwifery was established with the purpose of protecting and promoting midwifery and parenting. Its main goals are: advocating for the dignity of women and newborns; the promotion of the right of choice in pregnancy, child birth and breast feeding; promoting, supporting and protecting breastfeeding; educating pregnant women, breastfeeding mothers and all parents; and commitment to the possibility of choice in maternity care.

Among the topics discussed at the meeting were the inadequate utilisation of midwifery personnel, the low level of continuity of midwifery care for women, limited choice for childbearing women and restricted opportunities for midwives to work independently. Midwives throughout Croatia and their European colleagues are actively

seeking solutions to these problems and it is worthwhile noting that the implementation of the EU Directive relating to personal indemnity insurance will be a further challenge for European midwives. Mary Higgins is the International Officer for the Midwives Section at the INMO and ICM board member for the Central European Region


November 2013 Vol 21 Iss 9


in a woman’s life according to Mary Reilly, clinical midwife manager and practice development facilitator in the midwiferyled unit (MLU) at Cavan General Hospital (CGH). CGH and Our Lady of Lourdes Hospital, Drogheda, are the only hospitals in Ireland with an MLU. These units were established in response to the Kinder Report 2001, which showed that midwifery-led care as practiced in these units is as safe as consultant-led care and uses fewer interventions. The 2009 MidU (Midwifery Unit) study compared consultant-led care with the new model of care provided by midwives in the two hospitals. In this context, midwifery-led units (MLUs) are seen as an important and necessary development in the future organisation of maternity care – the benefits for women are immeasurable. Originally from Cavan, Mary trained as a general nurse in St James’s Hospital, Dublin. She did her midwifery training in The Coombe, where she worked for nine months before returning to Cavan in 1995. She later did a midwifery degree in Trinity College, Dublin and is also now a trainer in perineal suturing. In order to complete the picture she did the ‘Midwifery Examination of the Newborn’ course in Queen’s University, Belfast, in 2009. This means she can do the baby discharge examination. The MLU in Cavan has two suites, where a women’s partner and other children can be present for the birth. There is a sofa bed, TV, bathroom and a large bath where the mother can labour. The midwife works as an autonomous



November 2013 Vol 21 Iss 9

and holistic practitioner in the MLU. She facilitates the birth and will be in the room at all times, but is as unobtrusive as possible. The midwife acts as the gatekeeper of normality. Her role is to be vigilant and if the normal labour changes, the mother is transferred to the appropriate caregiver, ie. an obstetrician located three minutes away. The MLU caters for low-risk pregnancies and there is very strict criteria for eligibility, which has been drawn up in a three-page list. Factors such as age (over 40 or under 16) and a BMI over 30 would be considered high risk and therefore ineligible. As practitioners, some very difficult decisions have to be made and it is difficult to turn someone away if, for example, they have had babies there already and are over 40 for their next pregnancy, they are ineligible. In the nine months of preparation for the birth, a team of six midwives will get to know the mother. During the preparation period, the mother is educated with all the information she needs to use the MLU. Women must be convinced that they can do it for themselves. Mary commented: “You need the nine months antenatal time with the mothers in order to talk to them about keeping fit, healthy, eating well, sleeping well and preparing mentally for the baby. It is a mental as well as physical journey. If fear takes over during the birth process it can make it more difficult.” She added: “A midwife should be able to empower a mother so that she feels she is the most important person in the room.” The role of the midwife at a birth in the MLU is to observe and ensure wellness.

Mary Reilly, clinical midwife manager and practice development facilitator in the midwifery-led unit (MLU) at Cavan General Hospital (CGH)

Coaching of the birth is not led or driven by the midwife. Once the baby is six-hours-old it can be discharged. However, first-time mums may need a little more feeding support. There is follow-up care by the midwives from the unit for five days (down from seven due to cutbacks). After this time, they are discharged to the public health nurse. There were 134 births last year in the MLU. Some 48% of women attending the unit were transferred to an obstetrician for various reasons. The midwife’s expertise is normality, so if mothers deviate from that (eg. bleeding etc) during their pregnancy, the midwife must seek obstetric care. To highlight the service of the MLU in CGH, a new Facebook page was set up and the HSE website is also being updated. Mary – who is mother to three daughters – has also visited GPs in Cavan, Monaghan, Navan, Kells and Leitrim to advise them of the MLU service, so that their patients can make an informed choice. The unit takes GP referrals and direct referrals from women, as long as they meet the eligibility criteria.


Care following stillbirth


Midwives should support the parents of a stillborn infant with compassionate care and effective communication

Sheraton House, Hartlands Avenue, Glasheen, Co Cork

All programmes have Category 1 approval from Bord Altranais agus Cnáimhseachais na hÉireann

Best Practice in Medication Management

November 18, 2013

End of Life Care for Older People

November 25, 2013

Assertion Training – The Eight Step Approach to Healthy Self-Assertion

February 12, 2014

Introduction to Palliative Care

February 28, 2014

Medication Management in Diabetes

March 11, 2014

Introduction to Clinical Audit

March 28, 2014

Fee: €80 INMO members; €140 non-members. Book by credit/laser card by calling 01 664 0641/2 Please note that there is very limited onsite car parking

For further information contact

INMO Professional Development Centre Tel: 01 664 0641/2 or Email:

BREAKING bad news is something all midwives should consider. Adhering to evidence-based guidelines on disclosing bad news to families makes a difficult situation as bearable as possible for those receiving the news. The National Best Practice Guidelines on Informing Families can be used when communicating with parents who have given birth to a stillborn infant. 1 The guidelines were initially developed by the Federation of Voluntary Bodies in consultation with parents on the best way to inform families of their child’s disability. Importance of privacy and respect It is important to maintain confidentiality when discussing personal and sensitive issues with the family. Privacy for parents is important when enduring the loss of their infant and the midwife should facilitate this privacy when possible. This involves the midwife and healthcare team allowing parents time alone and limiting, or not allowing visitors, depending on what the parents want. The midwife should ensure parents have a private room to spend ample time with their baby. Hospitals should have a symbol to indicate the sensitivity of the parents’ case (eg. a sticker on the mother’s notes or on the door of the room). The bereaved parents The midwife should approach any conversation with the parents of a stillborn baby in a sensitive, dignified way. This involves maintaining privacy, and talking to parents in an empathetic manner. Actively listening to the parents will help the midwife to foster communication and a trusting relationship with them. The midwife should always show respect for the stillborn infant. This includes asking the parents what they

have named their baby, referring to the infant by this name and facilitating their willingness to speak about their baby. Research has shown that enabling choice at this time is very important to parents. The midwife may suggest that the couple create memories with their infant should they wish to (eg. the parents may wish to hold their infant after birth; provide skin to skin contact; bathe and dress the infant; involve other family members; and take photographs of their baby). It is also important to consider that not all parents will want to see their baby immediately after the birth. These individual decisions should be acknowledged and facilitated through effective communication between the midwife and the parents. If a trusting relationship has been established with the midwife, the parents may be empowered in their decisionmaking and benefit from this. This communication will also allow the midwife to inform parents of the wider supports available to them including pastoral care, counselling and voluntary support groups. These support services may help parents with their loss and future emotional wellbeing. The healthcare team The midwife should ensure effective communication with the multidisciplinary team to avoid any unnecessary distress. Everybody deals with loss differently, so it is essential that the midwife informs other healthcare workers of the individual needs of the grieving parents. Information should be shared between all multidisciplinary team members to ensure continuity of care. Communication between the acute and community-based services is paramount. GPs and public health nurses should be informed of the

Utilising the national best practice guidelines on disclosing a stillbirth to parents makes the situation as bearable as possible for those receiving the news

baby’s death in order to provide appropriate support to the parents. These issues can be facilitated by the use of a checklist in the mothers’ notes to ensure non-duplication of tasks and the provision of necessary services. When deciding who is involved in the care of the parents and their stillborn infant while in hospital, the midwife should ascertain if staff members have spent time with the mother and father previously. Parents have said that continuity of care was valuable for them and their experience of pregnancy and childbirth as it creates a trusting relationship between them and the midwife. Fostering a trusting relationship is particularly important for grieving parents. A key role of the midwife when caring for the parents of a stillborn infant is to support them with compassion and effective communication. It is impossible to undo tragic events but adhering to the guidelines allows the midwife to support the grieving family appropriately. Kiera Fisher is a midwifery student and Margaret Murphy is midwifery lecturer at the School of Nursing and Midwifery, UCC References 1. National Federation of Voluntary Bodies. National Best Practice Guidelines for Informing Families of their Child’s Disability, 2004. Available at:


November 2013 Vol 21 Iss 9


Check out our new courses for 2014! For more information log onto


Book now!

Your career development is important to the INMO. The Professional Development Centre is committed to providing high quality, relevant and up-to-date programmes for Irish nurses and midwives. For further information contact: INMO Professional Development Centre, Whitworth Building, North Brunswick Street, Dublin 7. Tel: 01 664 0641/2. Email: Information on all courses is also available on our website All courses listed are held in the Professional Development Centre, INMO, North Brunswick Street, Dublin 7. Courses are limited to 15 participants and under (except in exceptional circumstances).

Check out our New Courses at the Professional Development Centre! For more information log onto Assessment and Management of the Patient with Respiratory Conditions

Nursing the Cardiac Patient This one-day workshop is aimed at enhancing general nurses' knowledge of management of the cardiac patient. Topics covered in this one-day workshop include cardiac anatomy and physiology, cardiovascular assessment, cardiac tests, medications, chest pain and heart failure. Registration: 9.00am. Time: 9.30am-4.00pm Date: Dec 5, 2013. Fee: €80 members; €140 non-members

ECG Interpretation This one-day workshop is aimed at enhancing general nurses' knowledge of cardiac electrophysiology. It will provide participants with knowledge of cardiac rhythms, rhythm analysis and ECG interpretation (It is advisable to do the workshop on Dec 5, 2013, Nursing The Cardiac Patient also). Date: Dec 6, 2013. Time: 9.00am-3.00pm Fee: €80 members; €140 non-members

Assessment and Care Planning for Older People in Residential Care This workshop is aimed at providing nurses working in this sector with the most up-to-date information regarding policy and standards in older person care and will focus on the need for comprehensive assessment, including risk assessment and care planning for older people in residential care settings. Date: Feb 11, 2014. Fee: e80 members; e140 non-members

The study day is designed to provide nurses from the acute hospital setting with the knowledge to manage patients with respiratory conditions. Nursing services are now delivered in an environment involving greater complexity and increasing levels of technology. Nurses may have to intervene promptly in response to sudden changes in a patient’s respiratory status. This study day will provide an opportunity for nurses to update their knowledge, skills and understanding of respiratory assessment, problems and interventions to provide quality nursing care to patients. Date: Nov 7, 2013. Fee: e80 members; e140 non-members

Assessment and Management of the Patient with Sepsis Sepsis can occur at any age and in any clinical situation. It is considered a medical emergency and continues to have a high mortality despite advances in treatment. Nurses may need to take the lead in its assessment and management. This study day is designed to broaden the nurse’s knowledge and understanding of the: Body’s defence systems; Pathophysiology underpinning sepsis; Classification/stages of sepsis; Signs and symptoms; Importance of early recognition of sepsis and the initiation of appropriate interventions; Nurse’s role in caring for patients with sepsis; Discussion and rationale for Sepsis Six Regimen. Date: Nov 21, 2013 Fee: e80 member; e140 non-member

Best Practice in Medication Management This study day provides participants with an overview of the main issues associated with medication errors and near misses and explores evidence-based approaches to promote and implement safe medication practice. It helps participants to understand the 'risk management' approach to safe medication management practice in an organisation. It is underpinned by legislation and by An Bord Altranais guidelines. Date: Jan 27, 2014. Fee: e80 members; e140 non-members

are the Official Sponsors of the Professional Development Centre

Falls: Prevention, Management and Review The purpose of this programme is to promote a consistent approach in falls reduction for older people through assessment, individualised care planning and post falls review. This education programme promotes excellence amongst nurses who provide care to the patients at risk of falls, informed by current best evidence, lifelong and practice based learning. The main aim is to assist nurses to identify those patients or residents who are at risk of falls and to reduce that risk by providing knowledge on falls reduction techniques and ultimately improving patient safety and minimising injuries in the older population. Date: Nov 12, 2013. Fee: e80 members; e140 non-members

Healthcare Provider CPR & AED Course – The New 2010 Guidelines This one-day course is the newly released 2010 American Heart Association’s (AHA) guidelines for CPR and ECC for healthcare providers. The changes from the A-B-C Sequence to the C-A-B Sequence, and the rationale behind it, are explained in detail while providing the maximum time for each participant to gain the skills of resuscitation. The content of this course includes: adult, child and infant CPR; bag and mask ventilation; foreign body airway obstruction; use of the AED for adult and child. Before the course you will receive the new 2010 BLS for Healthcare Providers textbook. Limited to six participants per instructor. A fee of e50 will be charged if you wish to cancel your booking 10 days before the course begins. Date: Nov 15; Dec 6, 2013. Registration: 9.00am. Time: 9.15am-4.00pm. Fee: e125 members; e195 non-members (including cost of book and light lunch)

Infection Control This course gives a basic understanding of microbiology and shows clearly how infections spread directly and indirectly. Topics include: UV Light Box to highlight importance of hand hygiene followed by individual demonstrations; use of personal protective equipment; health and safety and risk management issues in infection control; a overview of common infectious diseases and blood borne viruses; management of difficult situations in infection control such as MRSA, C Diff, ESBLS, TB, HIV, hepatitis; and other current challenges. Date: Feb 20, 2014. Fee: Ð80 members; Ð140 non-members

Interview Skills This one-day new training course focuses on increasing the confidence and effectiveness of participants in a selection interview situation. The aim of this course is to develop the awareness, knowledge, skills and confidence of the delegates concerned in the very important process of recruitment and selection interviewing. Date: Nov 26, 2013. Fee: e80 members; e140 non-members

Introduction to Clinical Audit The aim of this one-day workshop is to introduce participants to the theory and practical application of clinical audit in Irish

healthcare. It is designed to provide participants with the necessary skills to implement clinical audit in their practice and be able to deliver evidence of improved performance for safer and better care for patients. It also gives participants the tools to demonstrate a baseline of performance and how to monitor quality improvement over time and introduce quality control in the current and future regulatory environment. Date: Dec 4, 2013. Fee: Ð80 members; Ð140 non-members

Introduction to Dementia Care This one-day programme is designed to enhance the healthcare practitioner's knowledge, strategies and skills that will improve quality of life for clients with dementia in their care. This interactive day, inclusive of case studies, DVD analysis and group work, aims to enhance participants’ knowledge while providing practical strategies in promoting a person-centred approach to caring for a person with dementia. Topics include: introduction to dementia; recognising the impact of environment on a person with dementia; identifying and responding to changes in behaviour creatively within your setting. The impact and progression of dementia relating to the person, their families and healthcare workers will be outlined in tandem with strategies to enhance quality of life for the team in your setting. Date: Nov 28, 2013. Fee: e80 members; e140 non-members

Introduction to Palliative Care This course will give an overview of the philosophy of end of life care, casting a wider net to include palliative care for conditions other than cancer. It will also cover the management of pain and of other distressing symptoms, spiritual pain and comfort measures in the last days of life, grief and loss. Date: Jan 28, 2014. Fee: Ð80 members; Ð140 non-members

Introduction to Stroke care This one day course is designed to facilitate an understanding of caring for a person with a stroke. The course provides an outline of the importance of a health promotion educational role and recognition of signs and symptoms of a stroke. The communication challenges and strategies in this key area of care, and psychological and psychosocial changes in tandem with family adjustment, are discussed. The course examines the development of a care pathway and links with educational material provision and self care of the staff within the care team. Date: Dec 11, 2013. Fee: e80 members; e140 non-members

Leg Ulcer Study Day This workshop will enable practitioners to explore and analyse current theories and practice in relation to patients with leg ulcers. Aims include to: Distinguish between the different causes of ulceration and associated pathophysiology and relate to epidemiology, risk factors and assessment; Review the nurse’s role in assessment of patients with leg ulcers; Review the role of Doppler in the assessment of the lower limb; Appraise the evidence for compression therapy and relate this to current practice; Explore the impact of psychosocial issues relevant to managing patients with leg ulcers and suggest strategies to

are the Official Sponsors of the Professional Development Centre

New Courses 2014

Professional Development Centre

Recognising Pregnancy Complications

INMO Safe Practice Campaign The Professional Development Centre is providing a nationwide series of workshops in workplaces and venues across the country. The aim of these workshops is to advise INMO members on key areas of practice such as clinical risk, report writing and statement writing, documentation and professional misconduct complaints to An Bord Altranais. Dates: Nov 7 – Kerry Community Hospital, Dingle; Nov 11 – West County Hotel Ennis (this is a change of venue); Nov 13 – St Patrick’s Hospital, Waterford; Nov 14 – Wexford Residential ID Services; Nov 20 – Radisson Blu Hotel, Letterkenny; Dec 9 – Mater Misericordiae, Dublin More dates and venues are available on our website To book a place please email or call 01 664 0616 Fee: INMO members Free; e75 non-members.




incorporate these within clinical practice; Explore the importance of the multidisciplinary team and the role of specialist clinics in the assessment and management of patients with leg ulcers. Date: Feb 25, 2014. Fee: e80 members; e140 non-members

physical crisis situation while maintaining the care, welfare, safety and security of clients and staff. Date: Feb 29, 2014. Registration: 9.15am Time: 9.30am-5.00pm. Fee: Ð100 members; Ð160 non-members

Management of Patient with Tracheostomy

Pain Management

This one-day workshop will provide the participants with the necessary knowledge, skills and confidence to evaluate and manage the nursing care of a patient with a tracheostomy. Date: Feb 25, 2014. Fee: Ð80 members; Ð140 non-members

This programme provides a comprehensive approach to assessment and management of pain in elderly care settings. It focuses on pharmacological and non-pharmacological methods and includes an overview of the ASK and LISTEN Approach. It discusses pain types, effective approaches and pain assessment tools. It provides an overview of the psychological consequences of unresolved pain and looks at use of the WHO three-step pain ladder. The concept of ‘total pain’ is explored. Spiritual or ‘soul pain’ is part of the discussion around advanced cancer pain. Date: Feb 19, 2014. Fee: e80 members; e140 non-members

Management Skills for Clinical Nurses Managers and Staff Nurses This course is aimed at equipping clinical nurse managers and staff nurses with management skills. Key topics include: management principles; decision making; team building; motivation of staff; and managing different skill mixes. Date: Feb 24, 2014. Fee: Ð80 members; Ð140 non-members

Medication Management in Diabetes This study day centres on two workshops, one focused on medication management in type 2 diabetes and the other on type 1 diabetes. Both workshops will look at the principles of safe and effective medicines management within clinical practice, as well as building on participants' previous knowledge and understanding of pharmacology. Other issues include the evidence base for medication management in diabetes, legal and professional frameworks, accountability, patient centred care, self management. Date: Jan 15, 2014. Fee: Ð80; Ð140 non member

Non-Violent Crisis Intervention This one day programme is to assist staff to provide the best care, welfare, safety and security for staff working in healthcare environments. The programme identifies behaviour levels that contribute to the development of a crisis and outlines appropriate staff intervention for each response. It also identifies verbal and non-verbal techniques to de-escalate behaviour. In addition the course outlines break away techniques that can adopted in a

Pregnancy-related complications can range from mild to moderate to life-threatening. The midwife’s role has always been paramount in recognising early signs which can easily be missed in busy antenatal clinics and wards. This one-day workshop will prepare midwives to listen to women’s concerns with a special focus on recognising those warning signs. The workshop is of extra benefit to new entrants to the midwifery profession. Date: Dec 12, 2013. Fee: Ð80 members; Ð140 non-members

Understanding Obesity and Weight Management This one-day workshop aims to provide a comprehensive understanding of the causes of obesity and the physiological principles involved in the onset of obesity and associated illnesses. Lifestyle treatment options such as dietary, exercise and behavioural interventions will be covered in depth, as well as non-pharmacological, pharmacological and surgical interventions. Participants will be equipped with the skills in the identification

and measurement of obesity and weight issues with practical approaches to management. They will be able to implement the most effective ways of working to prevent and manage obesity in their current practice. Date: Feb 17, 2014. Fee: Ð80 members; Ð140 non-members

Wound Care Management This one-day workshop will cover all aspects of wound management including the physiology, assessment, cleansing and management of wounds. Date: Nov 26, 2013; Feb 18, 2014. Fee: e80 members; e140 non-members

INMO Courses – Cork Office See page 28 for information on the courses that will be run at the new INMO Cork Offices

All programmes have Category 1 approval from Bord Altranais agus Cnáimhseachais na hÉireann

Application Form for PDC Courses

Early bookings are advisable


Practical Skills in the Management of People with Diabetes This one day course aims to provide nurses with the knowledge and confidence to deliver care to individuals with diabetes. It offers nurses a practical approach to diabetes, whether based in a community or hospital setting. It covers many theoretical aspects to diabetes, such as an explanation of the different types of diabetes, national and international guidelines, best practice, how to offer lifestyle advice to patients, as well as interactive workshops focused on blood glucose monitoring and injection technique. Other topics to be covered include treatment options in diabetes, understanding blood results, and dealing with the complications of diabetes. Date: Dec 5, 2013; Feb 26, 2014. Fee: e80 members; e140 non-members



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Pressure Ulcer Prevention and Management

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* Supply of a personal contact number is essential, in case of the unlikely event of late cancellation of a course

The aim of this workshop is to enable the practitioner to analyse

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their current practice and identify knowledge, strategies and skills that will improve outcome and quality of care in relation to patients with, or at risk of, pressure ulceration. Date: Mar 11, 2014. Fee: e80 members; e140 non-members

Please return form to: Professional Development Centre, INMO, Whitworth Building, North Brunswick Street, Dublin 7 Venue and times of workshops: Unless otherwise stated, courses listed are held at the Professional Development Centre. In order to better facilitate people attending workshops in the PDC, registration for most full-day workshops will take place at 9.45am and the courses will commence at 10.00am. Cancellation policy: In the event of unforeseen circumstances, a facilitator/trainer may be replaced by another suitably qualified person. Cancellation of any course must be given in writing at least seven days before the course begins. Fee will be refunded minus an administration charge. If a person cancels in less than seven days, no refund will be given. Receipts will be issued a week prior to course start date.


Professional Development Centre The Whitworth Building, North Brunswick Street, Dublin 7

Onsite Training Let us come to you! The Professional Development Centre of the INMO is proud to announce an extended portfolio of courses available to be run onsite in your own facilities. We currently have over 40 courses which can be brought directly to you. Onsite courses allow for more cost-effective training of staff. Courses are provided without the disruption and cost of travel. For a standard fee per course, any number of staff, up to a maximum class size of 25, can be fully accommodated in your own premises. All course packs and materials are provided and the courses are run by our highly skilled facilitators, who are experts in their fields. Every course we offer is Bord Altranais agus Cnáimhseachais na hÉireann Category 1 Approved. Successful completion of a course is awarded with a certificate that designates CPD points to the attendee for their annual quota. Your requirements will be discussed in advance to ensure that your choice of programme is customised to your specific needs.

For further information on our courses please contact:

Marian Godley, Course Co-ordinator Tel: 01 664 0642 or by Email:

Mastering the art of maternity care National Maternity Hospital Master Rhona Mahony spoke to Niall Hunter on her role and the issues facing the hospital DR RHONA Mahony took over as the first female Master of a Dublin maternity hospital in January of last year, attaining the mastership of the National Maternity Hospital against some tough competition from other obstetricians. Recently, the future of the 119-year-old hospital was put on a more solid footing when its long sought after move to the St Vincent’s site in south Dublin was sanctioned by Health Minister James Reilly. While it could be at least five years before this project becomes a reality, Dr Mahony believes this is a crucial development for the State’s health service and for women generally. She said her main hope for the remaining five years or so of her Mastership is that the new home for Holles Street will come to fruition at St Vincent’s. “We expect it to be at least a five-year project. The aim is to be not too much beyond the five-year mark. Essentially, we are building a new hospital within the existing hospital grounds at St Vincent’s.” Some €150 million has been earmarked for the project, but this is highly unlikely to cover the full costs of what will be a substantial building project. “It is an indicative figure. I think the first thing is to work out what is required,” Dr Mahony said. “This is a project of really critical State importance and we would completely acknowledge the very difficult environment that the government is working in and also the additional difficulty posed by the IMF in terms of balancing the books, and this is not easy.” Committed workforce The announcement of the planned move to a new home comes at a time when the Holles Street site is finding it increasingly difficult to cope with infrastructural and funding pressures. “We have had a large increase in our activity levels over the past six years. We



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Dr Rhona Mahony

have a moratorium on staff recruitment. We have had diminishing resources in terms of our budget and we have, to some extent, increasing patient expectations. Also we have increased expectations from our regulatory bodies such as HIQA, HSE, etc, so when you put that all together that is quite a challenge. “Looking back at recent years and where we are now, I think we have performed really well, considering all of these challenges, and the reason for this has been in us having a highly skilled and committed workforce.” Dr Mahony believes this survival against the odds has been a ‘good news’ story. “While the effects of the recession have been really painful across all sectors of society, not just health, there are positives here too, and the fact that staff have stepped up to the plate so successfully gives me great hope and inspiration.” Dr Mahony points out that Holles Street does not have the ‘luxury’ of running up waiting lists or placing patients on trolleys. “We have an ‘open door’ system. We

work at peak all the time and we also have ‘super-peaks’ which are unpredictable. On April 5 this year, for example, we had almost 50 deliveries in the hospital, whereas normally we would have 25-30 per day. We don’t have the option of a waiting list or having a ‘trolley’ system.” The number of births per year at Holles Street is currently around 9,000. “Our perinatal mortality rate is low – we are just under four per 1,000 for 2012 corrected for congenital anomalies, which is a phenomenal result.” When asked if continual cutbacks could have an affect on maternal mortality and morbidity, Dr Mahony said this was likely. “If you keep on cutting, and there isn’t adequate staff to deal with cases then it will. One problem we have at the moment is the complexity of our cases. Our typical patient is changing. Women having babies tend to be older than before, there are increased rates of obesity, increased diabetes, increased multiple pregnancy, an increased number of women who have underlying disorders who are now getting pregnant because of better healthcare. So that is giving us a much more complex groups of patients and I think that is going to impact on morbidity and on mortality. “So we need to invest in our future if we are going to be able to manage these women appropriately. We need now to lay down the infrastructure and the resources that can deal with these very complex cases.” Medical malpractice syndrome Speaking on the level of litigation against maternity services, Dr Mahony has some criticisms of the current situation. “I think the current system (of seeking redress in cases of alleged negligence/ adverse events) is not working very well. The courts are overwhelmed and the medical services are struggling to keep up


with the volume of work. The current legal system is one of tort, that relies on finding fault in order to compensate. “So if you like, the ‘pillars’ of medical negligence, are blame, litigation and punishment. Most doctors and midwives set out to do a good job, to care for their patients to the best of their ability. Not all adverse outcomes are the result of a person being negligent or careless, so it is very difficult for staff to be faced with the accusations and the personal questions raised about them when they go through a litigation case. “It is extremely difficult for staff when they find themselves in a courtroom setting. We are not trained for that. Doctors and midwives by their nature are inherently self-critical, that is the way we are trained and so it can be very damaging for staff to go through this. ”We actually now have a medical disorder called ‘medical malpractice syndrome’ suffered by clinical staff. The symptoms include anxiety, loss of appetite, depression etc.” Dr Mahony says there is certainly quite a high rate of depression among doctors and midwives who go through the legal system. “What we see in some cases, what I have seen directly and this hospital has experienced, is people changing their practice following a major case. They may either stop practising or avoid high-risk situations, or take early retirement. “That, of course, is not to say that where harm is done people should not be compensated. There are very clear-cut cases where an error has been made and it is imperative that patients are cared for and looked after - there is no issue with that.” Governance structures Holles Street’s governance structures are facing change with the rearranging of hospitals into groups and a drive to modernise voluntary hospital governance. “We are still not quite sure how that will pan out. We are now part of the Ireland East hospital group. We are looking at how we can care for our patients in a network of hospitals and make things better in terms of services, but the detail is a little bit unclear at the moment.” Does Dr Mahony agree with the Holles Street Governors Chairman, the Catholic Archbishop of Dublin, that the Holles Street governance structure is anachronistic, certainly in terms of having the Archbishop as chair of the board? “I don’t think he meant this particularly

as a critical comment. I think he was being relatively positive in terms of just allowing the hospital create a modern environment. We have a very robust governance structure at board level and internally. And we have been updating and upgrading our governance structures,” she said. In the modern sense, Dr Mahony says the National Maternity Hospital is not a Catholic hospital. “The Archbishop is very much a titular head. I have never met him. He has not in any way sought to interfere with hospital policy. We have a range of religions and ethnicities attending our hospital. And our staff are the same, so we do not see ourselves as a Catholic institution.” Abortion debate Dr Mahony played a prominent role in the debate leading up to the passing of the Protection of Life During Pregnancy Act. She says the guidelines to be drawn up in line with the legislation will be very helpful in terms of the day to day operation of the legislation and will be very necessary. “I think that is the step we are waiting for now and they will give clarity as to how this will play out. But again, very little changes practically with the legislation, despite the intense debate. This legislation does not change practice particularly, it very much copperfastens what existed already in terms of the Supreme Court’s interpretation of the Constitution. And it really just addresses the criminality that existed under the 1861 Offences Against the Person Act.” As to whether further liberalisation of the law on abortion is likely in the longer term, Dr Mahony says that would be much more a question for society than obstetricians. “Obviously, the recently passed legislation was very medical. We were dealing with risk to life and therefore we had a role in that conversation, but in terms of liberalising and providing choice, that is a matter for society.” Maternal mortality Maternal mortality rates have been highlighted lately in the wake of the tragic death of Savita Halappanavar. Dr Mahony stresses Ireland’s rate is low by international standards. “Our rate is somewhere around 8 per 100,000, in America it is about 24, in the UK it is about 12.5. I think we perform really well in terms of maternal mortality. What should be borne in mind is that we have much fewer resources than many other countries yet we are performing extremely

well. We should never be complacent; the whole issue of maternal mortality is very much a global conversation and there is no sensible obstetrician practising in the world who isn’t very concerned about it. Most maternal deaths are related to issues like haemorrhage, high blood pressure, sepsis, clots in the leg or the lung. “There’s nothing new about an early warning system; we have always looked at blood pressure, pulse, routine respiratory rate, temperature, etc. These observations have been recorded for many years. “I think with the new system we will standardise care throughout the State and that is a very good thing. I think where we have adverse outcomes, the main consideration must be to learn and to put systems in place to prevent such a thing happening again. This is not always possible; obstetrics is very unpredictable, very challenging, but we must never waste any learning opportunity we get.” Birth options “We work hard to provide a range of birth options for mothers. We are the only maternity hospital in Dublin running a home birth service. Then we have the Domino service. We have midwifery-led clinics, we have doctor- led clinics, we have high-risk clinics. We have private options for patients if that it what they choose. We really do try to give women a range of choices they are comfortable with so that they can choose a package of care that suits their needs,” said Dr Mahony. As for her views on home birth, she says Holles Street has had a very good experience with its home-birth scheme. “But it is very carefully regulated so we have very strict criteria as to eligibility for home birth and a very clear understanding that if a situation arises where we feel there is risk then there is a seamless transfer to hospital care.” “For first-time mothers, there is a very high transfer rate to hospital with home birth, up to 50%, and that merits consideration, but for women who may be having a second or third baby who are very uncomplicated it can work well. But obstetrics is unpredictable and things can sometimes go wrong very suddenly.” Regarding the view in some quarters that the HSE places too many restrictions on women seeking to have home births, Dr Mahony says this all comes down to a safety issue, which – as in all maternity matters – has to be paramount.


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A pilot for change The productive ward initiative, piloted in the Rotunda Hospital, is a driver for innovative change and improvement, writes Ajita Raman THE productive ward series is an initiative,

developed by the NHS Institute for Innovation and Improvement, and launched in the UK in 2007. It aims to motivate and cultivate healthcare teams to redesign and streamline the way in which activities are undertaken in the workplace. The goal for change is to increase the amount of time spent providing direct patient care and improving efficiency in the clinical areas. This initiative was introduced in Ireland in 2010 by the Health Service Executive (HSE).


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In 2012, the Rotunda Hospital was invited by the HSE to be one of the pilot sites. The Rotunda is a tertiary referral centre, that serves a mixed population from Dublin city and the surrounding areas. The primary focus of the adoption of this pilot was to increase direct patient care in order to add quality to patient experience and increase staff job satisfaction. The Lillie Suite (postnatal ward) was selected by the hospital executive management team to participate in the pilot programme. The ward has a capacity

for 29 beds, providing postnatal care for mothers attending the public, semiprivate and private obstetric service. The vision of the ward is aligned with that of the organisational strategic plan: to continually improve and enhance patient experience and to provide a safe and supportive environment for all patients during their transition to parenthood. The productive ward ethos is based on the ‘lean’ principles used in manufacturing industries. Lean is described as a reference-sustainable method to improve


Operating Department Nurses Section Conference the quality, cost-effectiveness and delivery of goods and services. The programme draws on the ‘Lean Thinking’ principle of reducing activities that do not add value. Many organisations are adopting these principles as a vehicle for continuous improvement. This methodology is also associated with ‘High Quality Care for All’1, which sets out a new foundation for a health service that empowers staff and gives patients more choice. Commencement of pilot The productive ward programme is based on a number of foundation modules and a toolkit is available through the HSE. Training, based on ‘Lean’, was provided for the frontline staff on the ward including the clinical manager, midwives, catering and household staff, and ward clerk. The aim of the training programme was to empower the team to identify areas on the ward for improvement by giving staff the information and skills they needed to make the necessary changes for success. Team meetings were organised and a plan of action developed on how change could be initiated. The team leader submitted a proposal and ward vision to the hospital executive management team, who were very receptive and supportive; this provided the encouragement needed to commence the journey. Communication was a key factor for success and to ensure the relevant information was made available for all staff. An information stand was set up specifically for the project so that all staff were involved. Each step was outlined to ensure the information was understood and could be acted on. During the initial training, the staff were advised that their first project should be simple, realistic, of short duration and achievable, with ease for a quick win. This worked to motivate the team to take on other modules. WOW module The Well-Organised Ward (WOW) module involves a series of actions that help create an ideal workplace by organising, cleaning and reducing waste, known as the five ‘S’s: s Sort: remove what is not needed s Set: right thing in the right place s Shine: keep things clean and ready to go s Standardise: an agreed, consistent process s Sustain: continually audit and improve.

The five ‘S’s are not about just having a good tidy up, but having a ward where equipment and stores are immediately made ready for the next person. The process for doing this is agreed and understood by everyone on the ward and changes are maintained once they have been implemented until they become second nature to the staff. There is also the option to go back and make further changes when things still are not quite right. In this way, staff begin to understand why things are done the way they are done. By completing the five ‘S’s it was possible to see changes to the workplace environment, which gave ownership to the staff. In addition, staff were made aware of the cost of all stock items in the ward, excess stock was recycled and an agreed stock level set. This resulted in a clutter-free store room, less waste and more time spent with patients. An additional bonus was cost savings to the ward. Information on the module ‘Knowing how we are doing’ was obtained by undertaking patient and staff satisfaction surveys. The findings of these surveys gave direction for ongoing improvements. In order to be able to measure improvements, a number of tools were devised to collect relevant data to sustain ongoing change. By using the tools, it became apparent if, and what, corrective action was required. In addition, it gave staff a reason to celebrate as goals were achieved. Nonetheless, the introducing the pilot does not come without its challenges: the main barriers are staffing levels, high patient activity, staff buy-in and time. The team leader needs to be able to generate enthusiasm on an on-going basis. To overcome the challenges, regular updates on the productive ward’s progress should be communicated to the team, which in turn helps to attract more buy-in and team commitment. The results of the pilot phase were: s Direct patient care increased by 15% s Staff job satisfaction increased by 7% s Cost savings in general stores and pharmacy achieved s Catering service revamped for patients, leading to improved quality of food and healthier menu options s Better organised ward and equipment easily located, making a more userfriendly environment for staff

s Time tak en for handover repor ts reduced by 10 minutes daily s Up to 60% reduction in interruptions after introduction of patient information board and improved signage. Embracing change and sustainability Like any change, the productive ward is a constant process that needs to be embraced as part of daily activity. As health service care providers the struggle is ongoing to bring about innovative changes and improvements in the current healthcare setting. Productive ward is often challenging as we try to embed new habits and working practices within minimum resources and it is an uphill battle for sustainability. However, it is important not to get frustrated and lose sight of the goals set. We have found that when a deadline is not met, it is possible to move the time limit, provided there is still some flow of activity. It is a matter of adjusting expectations; there are times when a pause is required before introducing a new module. The productive ward programme is a useful driver for improvement, which can be adapted for use in multiple healthcare settings. To work well a champion is required; this can be the ward manager or an interested staff member who can continuously motivate other staff. To make it work, it is important to set realistic goals and time scales and to know that activities can be linked to everyday work. Support from senior management is essential for a successful outcome. The initial findings of our pilot, has shown that Productive Ward is a programme you cannot afford to overlook if you are serious about embedding improvement capability into everyday work in the clinical areas. It is also key to the provision of quality care in recessionary times. Ajita Raman is the clinical manager of the postnatal ward in the Rotunda Hospital, Dublin References: 1. Department of Health, High Quality Care for All: NHS Next Stage Review Final Report. London: DH, 2008 2. Miller, D. Going Lean in Health Care. Cambridge, MA: Institute for Healthcare Improvement, 2005 3. NHS Institute for Innovation and Improvement. Releasing Time to Care: The Productive Ward. The Prototype development phase. Participant Information. Coventry: NHSI, 2007 4. The Productive ward series. Available at: http://www. 5. Stella W, Wilfred Mc Sherry. A systematic literature review of Releasing Time to care: The Productive Ward. Journal of Clinical Nursing, 2013; doi: 10.1111,1-11 6. Releasing Time to Care: The Productive Ward Module boxed set NHSSIPW book set. Institute of innovation and improvement, 2008


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Friday-Saturday, March 28-29, 2014. Limerick Strand Hotel

Poster Competition Perioperative Poster Competition Prize Fund - €1000 Closing date for entries – February 28, 2014

For further details on the conference and poster competition, please contact: Helen O’Connell, Email:, Tel: 01 664 0616

Clinical Focus Continuing education and moving points in medicine

The write method

In this section: Brain disease (below), child health page 45

Continuing Education Module 20: Brain disease

Bipolar affective disorder: overcoming treatment adherence issues

Aileen Rohan from the INMO library team provides a practical guide to academic writing

Sinéad Boland discusses the issues affecting adherence and how to address them

ALMOST all academic courses require some form of written assignment as part of a student’s assessment. Depending on the module, this could range from a 1,000-word assignment to be submitted online, to a 3,500-word literature review. When writing at degree level, nurses and midwives need to demonstrate an understanding of evidence by summarising key elements and comparing and contrasting authors’ views. Critical analysis is an important nursing skill in writing and in practice, and the approach to assignments is more or less always the same. Often, the hardest part of the assignment is deciphering what is being asked. It is imperative that all criteria are addressed in order to avoid losing vital marks. Ensure that you have checked the question, and know the required date and format of submission (electronic and hard copy are often required).You should then look at the topic and commence formulating your response. Work out the themes and keywords needed for research purposes. It is advisable to begin your assignments as soon as possible – even if this is just doing a quick search to start the process. Gather, read and critique literature Searching for information can be time consuming, however, the INMO library can assist in this area. It is crucial that you don’t spend all of your time just searching and reading. As you are reading, document your thoughts. You need to read, interpret and structure the data that you have gathered. Writing the essay All assignments should consist of:

MEDICATION is the cornerstone of treatment for bipolar affective disorder (BPAD), however, over the course of a year, more than half of patients with prescribed medication will stop treatment completely. Additionally, seven of every 10 patients will stop taking their medications at some time in their lives and nine out of 10 will think very seriously of abandoning it. The risks of interrupting treatment,with mood stabilisers in particular, is associated with a worsening of the course of the disorder and increased hospitalisations; more than half of those who stop treatment will experience a relapse within five months, and nine out of 10 will have a relapse within a year. The risk of suicide increases significantly and there is an added risk that the medication may not work as effectively as before when recommenced. The enhancement of treatment adherence is therefore a common therapeutic target, and is considered a priority because of potential neurodegeneration in BPAD and the neuroprotective effects of mood stabilisers and some atypical antipsychotics. Treatment adherence Treatment adherence can be defined as the extent to which an individual changes their health behaviour to coincide with medical advice. The term adherence has superseded ‘compliance’ and its patriarchal connotations, and emphasises the patient’s role in deciding to adhere to doctor’s recommendations, removing a sense of blame if the patient chooses not to follow recommendations.1 It also emphasises the need for agreement between patient and prescriber. Historically, research to identify key predictive factors for noncompliance in BPAD reflected this approach to treatment. These enquiries perceived patients as passive recipients of care which failed to sufficiently acknowledge that avoidance of sometimes complex, costly and unpleasant regimes may be entirely rational. They overlooked the influence of communication between patients and healthcare professionals.2 A more collaborative approach to treatment has now been proposed that underscores the importance of the therapeutic relationship and treatment concordance. Factors that influence adherence Research into treatment concordance has revealed that many factors can influence a patient’s degree of adherence to treatment, these include age, gender, culture, symptom severity, socioeconomic status and opinion of mental illness. Patients’ understanding of their condition is positively related to adherence. Attitudes towards BPAD and the patients’ health beliefs play

An introduction This gives your reader an overview of what you will discuss in your essay. It should be written in the future tense. The body This makes up the bulk of the assignment. Here, you discuss each point in turn and use appropriate references. Research studies should be presented in a logical order (eg. chronologically, thematically etc), while previous studies should be summarised and critically evaluated. This section is written in the present tense. Every part of the main body of the essay must also be structured. Each paragraph has a structure: one main point only; explain the point; and finally show evidence or examples. The conclusion This restates all the key points in your essay and should be written in the past tense. S o m e s t u d e n t s f i n d i t h e l p f u l to approach the organisation of an assignment through the word count. Unless given instructions otherwise, aim to use 10% of the word count for the introduction and 10% for the conclusion. It is important to double check all gram-

Tackling an assignment UÊÊ,i>`]Ê`iVˆ«…iÀÊ>˜`Ê՘`iÀÃÌ>˜`Ê̅iÊ >ÃÈ}˜“i˜ÌʵÕiÃ̈œ˜ UÊÊ>̅iÀ]ÊÀi>`Ê>˜`ÊVÀˆÌˆµÕiÊ̅iʏˆÌiÀ>ÌÕÀiÊ vœÕ˜` UÊÊ*>˜Ê>˜`ÊÜÀˆÌiÊ̅iÊ>ÃÈ}˜“i˜Ì UÊÊ,iviÀi˜ViÃÊ UÊÊ,i>`Ê̅iÊ>ÃÈ}˜“i˜Ìʈ˜vœÀ“>̈œ˜

mar and spelling prior to submission. Ask a colleague or friend to read through the assignment to ensure it is legible, flowing coherently, and that there are no spelling or grammar errors. References Keep a list of all articles used and make sure to note the reference details of any photocopied articles or book excerpts, including the volume, issue and page numbers. The Harvard referencing system is the usual method required by Irish universities and colleges. Further information on this is available from the INMO Library. Plagiarism is a serious offence, so reference all assignments accurately. Literature searching service: The INMO library staff can undertake a literature search for you. The staff will take details on what you are looking for and search the relevant databases. The resulting list will be sent to you, including 20-50 citations, which will give you an overview of the literature available on the topic. This service costs €6. One2One information retrieval training One2One training is on offer to assist members in searching the internet and electronic databases to find information. This is a skill that is extremely useful for professional development and career advancement. To avail of individual or group training, or for more information on any library service, contact the library team directly between 9am and 4.45pm, Monday to Friday. Alternatively, Tel: 01 6640614/06 or email:

a significant role in the emergence of poor adherence. Factors associated with non adherence Medication non adherence can include taking more or less of the medication than prescribed and can be intentional or unintentional. Non adherence can be viewed within the context of four interactive domains: patient, illness, clinician, and drug treatment. Patient factors Lack of insight into the nature of the disorder and the need for long-term treatment is strongly associated with non adherence in BPAD. Some patients are unwilling to accept that they have the disorder and hence believe that they do not require treatment. While others may perceive symptom-free periods as a sign of being ‘cured’ and a signal to discontinue further treatment.3 Non adherent patients are reported as prone to perceive taking medications as akin to ‘slavery’, fearing dependence, being ashamed because of taking psychiatric medications, considering medications as unhealthy or unnatural. Some patients view taking medications as a sign of personal weakness and as a reminder of their lack of control.4 Some patients may remember past hypo/ manic episodes positively and unconsciously want to repeat them. Research suggests that patients’ motivation to begin and continue treatment is influenced by their beliefs about treatment and how they judge their personal need for it. Patient adherence is more likely if they perceive that the advice to take medication makes ‘common sense’.5 Patients who have a strong belief in their personal control over the illness had lower engagement with treatment. Level of knowledge about medication is directly correlated to treatment adherence and patients’ attitudes, lower adherence, general opposition to prophylaxis, fear of side effects, denial of therapeutic effectiveness and illness severity.6 A study of 65 BPAD patients that evaluated insight into medication found that difficulty with adherence at the initial interview predicted future non adherence at one-year follow-up.7 Patients are primarily concerned by how well the treatment works to enable them to lead their daily lives. Patients’ expectations may vary from specific symptom relief to hopes for a complete cure, and their fears may be influenced by media and advertisements. If a medication is perceived as not decreasing debilitating symptoms, a patient is unlikely to continue taking it.8 Patients with BPAD feel more affected by depressive symptoms than by manic symptoms, and have indicated that they are more likely to

This healthcare professional education is sponsored by Lundbeck Ireland Ltd. WIN

November 2013 Vol 21 Iss 9


Lundbeck Ireland Ltd has had no editorial oversight of the final content

Clinical Focus

adhere to and view as successful treatments that reduce depressive symptoms. They are concerned with how safe and tolerable the treatment is. Patient concerns about possible side effects may contribute more to non adherence, than actually experiencing side effects. Concerns about long-term metabolic side effects from atypical antipsychotics also may limit adherence. Sociodemographic factors are not strongly associated with non adherence however several studies have identified a possible association with both ends of the life span – younger and older age, however the findings are contradictory. Adherence decreased in patients up to 41 years of age and increased thereafter. Illness factors Manic episodes carry the highest risk for non adherence. Evidence suggests that non adherence becomes a significant problem within the prodromal phase of an acute episode, occurring in 60-80% of patients who relapse in the month prior to hospitalisation. Cognitive impairment associated with frequent episodes has been proposed as a possible explanation. The presence of residual depressive symptoms is significantly associated with non adherence. Clinician factors Therapeutic alliance and access to care: Studies have highlighted the role of the therapeutic relationship and accessibility of services in non adherence. Clinicians communication style during follow-up and client satisfaction were both predictive of better medication adherence. The quality of the relationship between patient and clinician is associated with greater acceptance of BPAD and improved adherence and clinical outcomes.9 A collaborative communication style by the clinician enhanced client knowledge of the medication, improved satisfaction with medication and improved reliability of medication use. Bhugra and Flick reported that only about 50% of patients receive appropriate treatment for BPAD because of systemic barriers to gaining access to appropriate care.10 They assert that the current treatment environment relies heavily on a crisis response rather than an ongoing, long-term illness management approach. Drug factors Until recently research emphasised efficacy of medications as the most commonly cited reasons for stopping treatment. However adverse affects are now recognised as primary drivers of non adherence with weight gain as having the most affect. In an internet-based survey, 469 patients with BPAD indicated that medication-related weight gain and cognitive impairment were the most significant factors that affected adherence.11 Gianfrancesco and colleagues 2006 reported that antipsychotic treatment adherence in individuals with BPAD varied according to the type of antipsychotic medication, reflecting differences in both efficacy and adverse effects.12 The number of different medications prescribed and the complexity of the regime are described as risk factors because of the inherent difficulty for the patient to manage. The duration of treatment has been found to increase the likelihood of discontinuation when the patient feels well and does not understand the need to take medications to keep them well as opposed to getting them well.3 Other factors that may contribute to medication non adherence in BPAD patients include comorbid substance abuse or personality disorders, both of which are associated with more frequent relapse,13,14,15 single status, low education level,



November 2013 Vol 21 Iss 9

Clinical Focus

duration of being prescribed a mood stabiliser, family dysfunction and having a parental history of psychiatric hospitalisation.10 Improving adherence Medication strategies One of the most important factors influencing non adherence is the tolerability of the adverse effects. Hence the importance of choosing a medication with good tolerability. Medications that approach an optimum balance between efficacy and adverse effects may be associated with higher rates of adherence, better health outcomes and lower levels of health resource use. Johnson et al suggest that patients can contribute to clinical decision making regarding the management of their BPAD and stress the importance of involving patients in decision making and discussing tolerability versus efficacy when prescribing and planning future treatments.11 To manage emergent adverse effects during long-term treatment the following is recommended: use of sustained-release preparations to minimise peak levels and, hence, adverse effects; lowering of the dosage with more frequent follow-up visits; close monitoring of adverse effects; and using lower doses of a poorly tolerated drug in combination with another drug. Switching to another medication is an option, in the event of failure of the above mentioned strategies. Treatment alliance and access to care Key elements of collaborative care include the use of evidence-based treatment guidelines,patient psycho-education, collaborative decision making and a system to facilitate planned follow up and monitor outcomes.16 Research to address the gaps in healthcare services suggest the need to reorganise the current model of primary care, which is geared towards acute care. Instead, a planned approach to chronic care using evidencebased guidelines and protocols to support patient participation and self management was recommended.17 Education A clinician’s ability to help patients build insight is invaluable for their current and future treatment. The primary goal is to increase knowledge about the properties of medications and awareness of the patients role in managing medications. Information about the chemical changes in the brain that contribute to mood destabilisation or mood stability may help patients understand how symptoms are triggered and how medications work to protect mood stability. Patients knowledge about medication and the illness is proven to be a direct influence on adherence to lithium. The fact that the patients are informed about the illness, the treatment and risks of not taking it, positively influences adherence because it facilitates their acceptance of the illness and maintenance therapy. The higher the knowledge level the higher the adherence and the lower the toxicity risks. Simple strategies to improve concordance2 Basic communication: Establish a therapeutic relationship and trust. Identify the patients concerns. Take into account the patients preferences. Explain benefits and hazards of treatment options. Strategy-specific interventions: Adjusting medication timing and dosage for least intrusion. Minimise adverse effects. Maximise effectiveness. Provide support, encouragement and follow up. Reminders: Consider adherence aids such as medication boxes and alarms. Consider reminders via email or telephone or text. Home visits, family support, counselling. Evaluating adherence: Ask about problems with medication. Ask about missed doses. Ask about thoughts of discontinuation. With

the patient’s consent, consider direct methods: pill counting, measuring serum or urine drug levels. Liaise with GPs and pharmacists regarding prescriptions. Psychosocial interventions The factors associated treatment non adherence can be addressed through targeted evidence based psychosocial interventions as adjuncts to medication treatment, a number of which have been developed for BPAD. Important elements include a strong working alliance, psycho-education, structured sessions, goal setting, problem-solving, inclusion of family members in treatment, improving important relationships, and an emphasis on skills training: interpersonal communication, emotional regulation, responding to dysfunctional cognitions, and identification of prodromal symptoms with an action plan to address these symptoms. Although each has a different emphasis they all focus on medication management and fit with current models of patient centre care, on which the principles of concordance are based .Cognitive behavioural therapy (CBT ), interpersonal therapy (IP), familyfocused therapy (FFT) and group psycho-education (PE), may be used alone or in combination. CBT focuses on changing negative thought processes and maintaining behaviours. Numerous studies have found PE to impact positively on treatment adherence as well as improving outcomes.18 In addition to improving the understanding about treatment, PE can promote better management of the disorder, adherence to treatment, better insight, early recognition of symptoms, a healthy lifestyle, stress management and responsible use of drugs and alcohol.19 Group PE combines support and self management strategies and is the most common type of group facilitated by nurses. Group PE has been described as ‘the mood stabiliser stabiliser’ by enhancing the levels of and stability of serum lithium levels. PE may start on an individual basis in the acute setting, depending on the patients cognitive and behavioural state and can continue during the post acute maintenance phase in the form of individual or group sessions where it has most potential Role of the nurse Nursing processes for BPAD should aim to improve health and social functioning and decrease the burden of illness for families and patients. This is achieved through the use of action plans, teaching self-management techniques and the establishment of and maintenance of a therapeutic alliance alongside family and patient education. Mental health nurses are described as being trained in a broad spectrum of medical, psychological and social problems. Additionally, it’s reported that patients may be more open to nurses than to other medical professionals and they have closer contact with the patient. Nurses themselves assert that they are on a more equal level than their medical colleagues whose focus they argue is often predominantly biological.20 As nurses manage, and increasingly treat, patients with bipolar disorder in both inpatient and community settings, it means they are the continuous factor in the extended treatment pathway of the patient. Nurses are therefore integral to clinical care and best placed to incorporate psychosocial interventions into their scope of practice. Nursing interventions for BPAD promoting self-management education have been reported to assist people to develop realistic/helpful illness perceptions, which enhance treatment adherence.21

Results from studies exploring self management of BPAD conclude that nurses can support patients by preparing them for potential barriers to effectively self manage and help them to realistically appraise the process involved in self management. They suggest that in order to achieve this, nurses need to learn from patients which techniques they perceive as valuable in self management. The psycho-educational process allows the individual and the nurse to proactively discuss potential issues regarding treatment adherence. A study in 201021 aimed to explore how the delivery of mental health nursing care could be improved, examined which psychosocial interventions were effective and how they could be delivered by nurses. They concluded that group PE could most easily be implemented by mental health nurses. This manualised approach has very good evidence of sustained improvements over five years. This is a recovery-based approach that encourages self-management and focuses on medication adherence enhancement, identification of subtle early warning signs, lifestyle regularity and illness awareness. Sinéad Boland is a clinical nurse specialist in affective disorders and co-ordinates the bipolar education programme at St Patrick’s Mental Health services in Dublin References: 1. Crowe M, Wilson L, Inder M. Patients reports of the factors influencing medication adherence in bipolar disorder – An integrative review of the literature. International Journal of Nursing Studies 2011; 48: 849-903 2. Mitchell AJ, Selmes T. Why don’t patients take their medicine? Reasons and solutions in psychiatry. Advances in Psychiatric Treatment 2007; 13: 336-346 3 .Colom F, Vieta E, Tacchi MJ et al. Identifying and improving non adherence in bipolar disorders. Bipolar Disord 2005; 7 (Suppl 5): 24-31 4. Clatworthy J, Bowskill R, Rank T, Parham R, Horne R. Adherence to medication in bipolar disorder: a qualitative study exploring the role of patients’ beliefs about the condition and its treatment. Bipolar Disord 2007, 9: 656-664 5. Leventhal H, Diefenbach M, Leventhal EA. Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cognitive Therapy & Research 16: 143-163 6. Rosa AR, Marco M, Fachel JM et al. Correlation between drug treatment adherence and lithium treatment attitudes and knowledge in bipolar patients. Progress in Neuro-Psychopharmacology & Biological Psychiatry 2007; 31: 217-224 7. Yen CF, Chen CS, Ko CH et al. Relationships between insight and medication adherence in outpatients with schizophrenia and bipolar disorder: prospective study. Psychiatry Clin Neuroscience 2005; 59(4): 403-409 8. Foster A, Sheehan L, Johns L. Promoting Treatment Adherence in Patients with Bipolar Disorder. Current Psychiatry 2011; 10(7): 45-52 9. Sajatovic M, Biswas K, Kilbourne A, Fenn H et al. Factors associated with prospective longterm treatment adherence among individuals with bipolar disorder. Psychiatric Services 2008; 59 : 753-759 10. Bhugra D, Flick GR. Pathways to care for patients with bipolar disorder. Bipolar Disorders 2005; 7(3): 236-245 11. Johnson FR, Ozdemir S, Manjunath R et al. Factors that affect adherence to bipolar disorder treatments: a stated-preference approach. Med Care 2007; 45(6): 545-552 12. Gianfrancesco FD, Rajagopalan K, Sajatovic M, Wang RH. Treatment adherence among patients with bipolar or manic disorder taking atypical and typical antipsychotics. Journal of Clinical Psychiatry. 2006; 67(2):222-32 13. Berk L, Hallam KT, Colom F, et al. Enhancing medication adherence in patients with bipolar disorder. Hum Psychopharmacol. 2010;25(1):1-16 14. Sajatovic M, Jenkins JH, Cassidy KA, et al. Medication treatment perceptions, concerns and expectations among depressed individuals with type I bipolar disorder. J Affect Disord 2009; 115(3): 360-366 15. Sajatovic M, Valenstein M, Blow FC, Ganoczy D, Ignacio RV. Treatment adherence with antipsychotic medications in bipolar disorder. Bipolar Disord 2006 Jun; 8(3): 232-41 16. Susman JL. Improving outcomes in patients with Bipolar Disorder through establishing an effective treatment team. Primary Care companion J Clin Psychiatry 2010; 12(Suppl 1): 30-34 17. Von Korff M, Gruman J, Schaefer JK et al. Collaborative management of chronic illness. Ann Intern Med 1997; 127(12): 1097-1102 18. Grabski B, Maczka G, Dudek D. The role of psycho-education in the complex treatment of bipolar disorder. Archives of Psychiatry and Psychotherapy 2007; 3: 35-41 19. Sajatovic M, Davies MA, Ganocy SJ et al. A comparison of the life goals program and treatment as usual for individuals with bipolar disorder. Psychiatr Serv 2009; 60(9): 1182-1189 20. Goosens PJJ, Beentjes TAA, deLeeuw JAM. The Nursing of Outpatients with a Bipolar disorder: What Nurses Actually Do. Archives of Psychiatric Nursing 2008; 22, No.1 (February): 3-11 21. Crowe M, Whitehead L, Wilson L, Carlyle D et al. Disorder-specific psychosocial interventions for bipolar disorder-A systemic review of the evidence for mental health nursing practice. International Journal of Nursing Studies 2010; 47: 896-908


November 2013 Vol 21 Iss 9


Clinical Focus

Continuing Education Module 19: Child Health Table 1

Toddler nutrition: meeting nutritional needs and establishing good habits Good nutrition during the toddler years is essential to support this important period of physical, cognitive and social development, writes Jessica Schram BABIES grow at a lightning pace, tripling their birth weight and growing by an average of 25cm in length in the first year of life. From one to three years, this slows to just 8-12cm per year and an average weight gain of two to three kilos each year. While growth slows down somewhat during the toddler years, good nutrition remains essential to support this time of huge physical, cognitive and psychological development. Early childhood is the most intensive period of brain development during the lifespan. During the first three years of life, an infant’s brain has grown from 25% of its approximate adult size at birth to 80% of its final adult size. In order to support brain development, good nutrition is essential. Inadequate brain growth due to malnutrition can result in lasting behavioural and cognitive deficits, including slower language and fine motor development and later, lower IQ and poorer school performance. An adequate iron intake, in particular, is critical for maintaining sufficient oxygen-carrying red blood cells which are necessary to support brain growth. Iron deficiency, most often caused by poor nutrition in this age group, has been clearly linked to cognitive deficits in young children. Poor nutrition in toddlers can also lead to other nutritional deficiencies such as vitamin D deficiency which is detrimental to bone health, as well as other nutritional problems such as faltering growth, childhood obesity and constipation. Furthermore, research has shown that good nutrition during the early childhood years can have a lasting impact on lifelong physical health, reducing a child’s risk of developing obesity, coronary heart disease, hypertension, type 2 diabetes and cancer in adult life. Obesity Childhood obesity is a growing problem in Ireland, with one in four children considered overweight or obese. 1 Poor nutrition is one of the leading causes of obesity in childhood, a condition which is associated with a range of health risks including an increased risk of early onset type 2 diabetes, hypertension, asthma, musculoskeletal disorders, as well as psychological problems such as low self esteem and depression. As well as the increased risk of poor health in childhood, a major concern is that obese children will become obese adults. Childhood obesity results in almost one-third of adult obesity, and adults who were obese in childhood are more likely to be severely obese 2 which is associated with an increased risk of morbidity and premature mortality. It has been suggested that there are certain critical periods in childhood during which the development of obesity is associated with an increased risk of persistent obesity and its complications. Early infancy is one of these critical periods. BMI increases in the first year of life, decreases and then increases again at about five years of age. This is known as the period of adiposity rebound. Studies have found that children whose adiposity

rebound begins early, ie. in the toddler years, have a higher BMI in adolescence and adult life than other children. Iron deficiency Poor nutrition can also lead to iron deficiency.3 Young children have been identified as a group at high risk for developing iron deficiency because of their high iron requirements to support rapid growth. A healthy full-term baby is born with about 75mg iron/kg body weight endowed by the mother. A baby’s iron needs cannot be met by breast milk or formula alone and the endowed iron stores are used to meet requirements. Iron stores become depleted by four to six months of age, at which point the infant becomes fully dependent on external iron sources. Therefore, to avoid iron deficiency, iron rich foods should be included early in the weaning process and throughout early childhood. Iron in the diet is present as haem-iron in meat, fish and poultry, and as non-haem iron in vegetable foods; the latter requires vitamin C to enhance its absorption. Results from the recent National Preschool Nutrition Survey suggest that 23% of oneyear-olds, 10% of two-year-olds and 11% of three-year-olds have inadequate iron intakes. 4 Iron deficiency has been linked to impaired cognitive performance and motor development, and growth retardation which may not be fully reversible when the deficiency is corrected. Toddlers’ nutritional needs Toddlers aged between one and three years have high nutritional requirements relative to their size as they are still undergoing rapid growth and development, and are usually very active. Toddlers need between 1,000 and 1,400 calories a day depending on their age, size, and physical activity level. Their small stomach limits their capacity to eat large portions at mealtimes. Therefore, snacks are important and priority needs to be given to energy dense and non-bulky nutritious foods such as red meat, fish, poultry and dairy products. A toddler’s diet should consist of three small nutritious meals and two to three healthy snacks daily. For children under two years of age, high-fibre lowfat diets are generally not recommended as adequate fat and calories are needed for growth and development at this age. To achieve nutritional requirements toddlers should be given foods from each of the four main food groups every day: s Cereals, breads and potatoes s Fruit and vegetables s Milk and other dairy products s Meat, fish, eggs, beans, and pulses. The number of recommended servings from each group and the key nutrients they provide are shown in Table 1. The greater the variety of foods eaten within each food group, the better the

balance of nutrients provided. Commercial baby foods have lower nutrient content than homemade meals and should be discouraged. Remember that an average serving size for a toddler should be approximately one-quarter to one-third the size of an adult portion. Water and milk are the only suitable drinks for children, and toddlers should be consuming approximately one pint (1720oz) of regular cow’s milk daily (low fat milk is suitable over two years of age). Unsuitable foods for toddlers s Juices and high sugar foods such as chocolate, muffins, croissants, and sweets which provide ‘empty calories’, ie. calories but no nutrients, have no place in toddlers’ diets as they are filling and can displace a child’s appetite for nutritious foods. In addition, such foods can contribute to excess weight gain, tooth decay and promote a liking for sweet foods. This also applies to ‘no added sugar’ and ‘sugar-free’ juices s High salt foods such as crisps, commercial sauces and processed meats (sausages, ham, bacon), and the addition of extra salt to an infant’s diet should be avoided. A high salt intake in childhood may be linked with high blood pressure in later life s Whole or chopped nuts should not be given to children under the age of five years due to the risk of choking s Tea (any type) should not be given to toddlers as it contains caffeine and tannins which reduce the absorption of important micro nutrients such as iron. Start early An important goal of early childhood nutrition is to optimise children’s present and future health by fostering the development of healthy eating behaviours. Research has shown that eating habits learned in childhood continue throughout the lifespan. Therefore, if we can instil healthy eating habits from the beginning, we can help towards ensuring that healthy eating habits continue throughout childhood and into adult life. Babies are born with an innate preference for sweet foods and a liking for any other flavour needs to be learned. Exposing children to a wide range of different healthy foods during weaning and the early toddler years is essential to helping them accept a wide variety of different tastes. During the toddler years, the rate of growth slows down which may be reflected in a less reliable appetite. Parental concerns about distractibility at mealtimes, or the limited variety of foods accepted are not uncommon. Parents should be reassured that it is perfectly normal for healthy toddlers to eat well some days, and eat less on other days. Parents are responsible for providing a variety of nutritious foods, defining the structure and timing of meals, and creating a mealtime environment that facilitates eating and social exchange. Children are responsible for determining how much is eaten at each meal. Parents should trust in their child’s internal hunger and satiety mechanism and trust that their child will eat at the next meal time if hungry. Showing independence is also a normal part of toddler development and this often manifests in food refusal or fussy eating which is usually a passing phase but can potentially lead to an inadequate intake of certain nutrients if a prolonged issue. Strategies to manage fussy eating include: Repeated exposure Studies show that it can take up to 15 occasions of tasting a particular food for a child to start liking a food. Therefore even if a food is rejected on the first few tastings, patience, persistence and

Sponsored by an unrestricted grant from SMA Nutrition 46


November 2013 Vol 21 Iss 9

Recommended toddler nutrition Recommended servings per day

Food groups

Main nutrients provided

Bread, potatoes and other cereals

Carbohydrate B vitamins Fibre Some iron Calcium Zinc

Aim for four servings

Fruit and vegetables

Vitamin C Carotene Fibre Some iron

Two to four servings

Milk and dairy

Calcium Protein Vitamin B2 and B12

Three servings

Meat, fish and alternatives

Protein Iron B vitamins Zinc Omega 3 fatty acids

Two servings

Serve at each meal and some snacks

repeated exposure is likely to lead to eventual acceptance Parental role modelling Infants learn by watching others and mimicking their behaviour. Shared family mealtimes are an ideal opportunity for parents to model healthy eating behaviours. Positive parent-child feeding style Force feeding is never recommended. A stressful feeding experience will not produce a positive result. Toddlers should be encouraged to try new foods and praised when they eat well but negative behaviours should receive minimal attention. Stick to routine Throughout the “fussy eating” phase, continue to offer only healthy nutritious foods and regular meals and snacks. If family meals are refused avoid offering alternative drinks or foods which the child may prefer. If this approach is used consistently by all caregivers the toddler will soon learn to eat foods offered at mealtimes. Good nutrition during the toddler years is essential to support this important period of physical, cognitive, and social development. In addition, establishing healthy eating habits early in childhood can have a significant positive impact on health throughout a person’s life. Parents can foster healthy eating habits in toddlers by establishing a regular meal and snack routine, and by offering small portions of nutritious foods at meal and snack times. Jessica Schram is a senior paediatric dietitian at Tallaght Hospital in Dublin References 1. Growing Up in Ireland (2011) National Longitudinal Study of Children. Overweight and Obesity among 9-year-olds. Dublin: Government Publications Office 2. Dietz WH. (1994) Critical periods in childhood for the development of obesity. Am J Clin Nut; 59: 955-959 3. World Health Organisation. Worldwide Prevalence of Anaemia 1993-2005. Geneva: WHO Press, 2008 4. Irish Universities Nutrition Alliance. National Pre-School Nutrition Survey, Summary Report on: Food and Nutrient Intakes, Physical Measurements and barriers to healthy eating. 2012. Available at: Report_National_PreSchool_Nutrition_Survey_June_2012.pdf

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with with the the president president ICN Workforce Forum and EFN WE HAD the pleasure of hosting the International Council of Nurses (ICN) Workforce Forum in Dublin. Nine countries were repre-

sented at the event by a total of 25 delegates. Nursing leaders met at the event to deliberate on common trends affecting nurses’ capacity to deliver safe and effective patient care, including safe staffing levels. They also discussed the value of nurses to society. A common theme, which is now evident throughout the international workforce, is the impact that safe staffing levels have on patient care. As nurses and midwives it is imperative that we speak out and identify risks where they exist, maintaining our own high professional standards at all times. See page 8 for more on this meeting. The Forum was followed immediately by the European Federation of Nurses (EFN) meeting in Macedonia. I participate in the workforce committee at EFN and find that the same common strands are affecting nurses across the globe. A key worry in all healthcare settings at this time of austerity and cutbacks is safe staffing levels. I intend to work hard to campaign for safe staffing levels in Ireland. Using both Irish and international research, we have a wealth of information which proves that safe staffing levels lead to safer outcomes in patient care. I would like to congratulate Elizabeth Adams, INMO director of professional development, on her election to the executive committee of EFN. Congratulations also to Marianne Sipilä, from the Finnish Nurses Association, on her election as EFN president.

Ninth annual Telephone Triage conference I ATTENDED the ninth annual Tel-

ephone Triage Nurses’ Conference in Limerick in October. Many thanks to the committee for organising an excellent education day with great speakers, and also, to the companies who sponsored the day. Telephone triage nurses now play Pictured (l-r) were: Lorna Elmes, Telephone Triage Seca major role in Irish healthcare, a role tion chairperson; Carmel Murphy, Section joint secretary; that has evolved immensely in the Claire Mahon; Claire McMahon, Section joint secretary; and Breege Clarke, vice chairperson past decade. For many patients and their families, these nurses are the first point of contact. They evaluate, diagnose and educate patients by relying totally on verbal communication skills and decision-support software for assessment and documentation. The uses of telephone triage and e-health will become increasingly prevalent in our healthcare. This was demonstrated by the Department of Health announcing an E-health Strategy for Ireland recently. There was an excellent turnout on the day and I would encourage all members to keep an eye on the INMO website, and to connect with our sections and branches to avail of the excellent educational opportunities available. These are all now accredited by the Nursing and Midwifery Board of Ireland and will be accepted as part of your continuous professional development when the Nursing and Midwifery Bill is fully implemented.

New chief nursing officer ON BEHALF of the Organisation, I am delighted to welcome Dr Siobhan O’Halloran as the new Chief Nursing Officer. I look forward to liaising with her and meeting her when she settles into her new post.

Get in touch You can contact me at the INMO headquarters at Tel: 01 6640 600, through the president’s corner on or by email to:



November 2013 Vol 21 Iss 9

CNM/CMM meetings WE ARE currently organising a num-

ber of regional meetings for our CNM/ CMM Section. These two-hour sessions will contain an educational component to help our clinical nurse and midwife managers in their work and we hope to follow with a full day in the new year. I would strongly encourage you all to attend the sessions (see page 24).

RCN book launch I HAD the pleasure of attending a book launch hosted by RCN Northern Ireland in Derry. The book, entitled Nurses’ Voices from the Northern Ireland Troubles – Personal Accounts from the Front Line is by Margaret Graham and Jean Orr. It compiles nurses’ experiences of the Troubles in Northern Ireland. The stories, ranging from witty to tragic, are a great read and the book is available online from the publishers, RCN Publishing, at

Student and new graduate officer Dean Flanagan updates us on the pay issue facing pre-registration nurses and midwives I HAVE almost completed my visits to the colleges and universities around the country meeting first-year nursing and midwifery students. I would like to say a huge hello to everyone I have met so far and a big thank you to the busy lecturers and staff who facilitated our meetings. However, I know I haven’t got to meet everyone yet and if you or a friend missed the opportunity to talk to me, you can join the INMO online at I hope to meet second-, third- and fourth-year students in the next few months, and also the new graduates. In the meantime, please feel free to contact me any time by emailing: or Tel: 01 6610466. Please also keep a close eye out for the Youth Forum meetings, which will be starting very soon in Dublin, Cork and Galway. I plan to attend all of the meetings and I encourage all students to become active in the Student Section of the INMO as your local section meetings can offer you valuable support and guidance. Feel free to contact me for further details if you would like to attend these meetings. Minimum wage issue I would like to give a brief update to you all on the issue of the minimum wage and pre-registration nurses and midwives. The INMO is aware that the pre-registration rate of pay is being paid at 50% (the internship pay scale). This is, however, less than minimum wage. As these new graduates are no longer students and cannot be defined as staff

nurses until they receive their Nursing and Midwifery Board of Ireland (NMBI) pins, the INMO is seeking that the HSE pays them as per the first point of a healthcare assistants pay scale, until registration come through. The Organisation is preparing a case for the Labour Relations Commission and I will be looking for active members to support us on this important issue. Graduate scheme The Office of Nursing and Midwifery Services announced the first outline of the New Graduate Scheme in October. It confirmed that the School of Nursing and Midwifery Royal College of Surgeons Ireland (RCSI) will provide the programme, which will consist of three modules in total. Each module will incorporate two supported face-to-face days, with the remainder of the module accessed online and in conjunction with self-directed student work. On completion, programme participants will be awarded a professional certificate in nursing and midwifery (applied professional and clinical development NQF Level 9). The part-time programme will be delivered via a blended learning approach of online and face-to-face methods. The face-to-face component will be delivered at regional sites to facilitate ease of access. I will continue to update all members as more information becomes available. Social media I am delighted to welcome the new guidance to nurses and midwives on social media and social networking, which was published by the NMBI. The

INMO was involved in the research of the guidance document, and I would recommend all nursing and midwifery students to read it carefully. It includes guidelines for healthcare professionals using social media, advice on privacy settings, confidentiality and defamation issues, and some practical examples based on real cases involving social media. O verall, the document is a ver y s h o r t a n d i n fo r m a t i ve p i e c e a n d can be found on the NMBI website ( or the INMO website ( Emigration debate In September, I took part in a discussion on RTÉ’s Prime Time about young people leaving Ireland. The programme was organised in response to comments made by Minister for Transport, Tourism and Sport, Leo Varadkar, about Ireland’s ‘brain drain’. The programme is available on http:// Christmas panto time It’s that time of year again folks: “Oh no it isn’t, oh yes it is!” It’s Christmas pantomime time and the INMO has teamed up with the Tivoli Theatre in Dublin and the Cheerios panto, ‘Jack and the Beanstalk’, which stars TV3’s Alan Hughes. Tickets are available for the December 11 show at 18.30pm at a special discount rate of €16, which represents a saving of 45%. To avail of the offer, call the Tivoli box office on Tel: 01 4544472 and quote ‘INMO’. I hope I get to meet everyone there!


November 2013 Vol 21 Iss 9


Athlone Branch


RNID Education Session

INMO, The Whitworth Building, North Brunswick Street, Dublin 7 email: Tel: 01 6640600

DEMENTIA CARE for nurses working in residential centres for people with disabilities

Branch Officers


Professional Development Centre, INMO The Whitworth Building, North Brunswick Street, Dublin 7

Date: Time:

Wednesday, 4th December 2013


â‚Ź30.00 INMO members; â‚Ź70.00 non-members


Joan Scanlon Secretary

Latest news GREETINGS from the INMO Athlone Branch. We may be small with 158 members, but there is a high level of activism among our members, who attend local, regional, national and international meetings, including the recent International Council of Nurses (ICN) conference in Melbourne and European ID meetings. There is a busy hospice and activity units in the local St Hilda’s centre, which provides services for 125 adults and children with intellectual disabilities. Branch chairperson, Joan, is the day service manager in the older adult services and advocates for the empowerment of each individual within the service. The enactment of legislation that is presently before the Oireachtas, which advocates for the individual’s rights and choices, is eagerly awaited. The Branch provides members with support and updated information on issues such as pensions, sick pay, dignity at work and bullying. Branch IRO, Lorraine Monaghan, is always generous with her time, expertise and professionalism. Our branch members face the same challenges as every other and our motto is ‘Nurses and midwives working together’ and we welcome both current and new members to attend our meetings.

10.00am - 12.30pm (1.00pm - 2.00pm - Section Meeting)

This short session is organised by the RNID Section of the INMO to help nurses gain an understanding of the impact when caring for people with dementia in residential centres for people with disabilities. To book a place by credit/laser card please call:

01 664 0641/2 Industrial relations update

Kathleen Garvey Treasurer

Patricia Hayes Standing orders committee

sEarlier in the year, management attempted to reduce the nursing service in the MIDOC out of hours service by removing nursing cover after midnight over weekends and bank holidays. Following representations from the INMO, management pulled back on the implementation of this proposal, and to date, nursing cover after midnight continues to remain in place. t5IFIPTQJDFJO"UIMPOFSFDFOUMZDMPTFEVOFYQFDUFEMZGPSBUXPXFFLQFSJPE as all beds were empty. There was some redeployment of staff to St Vincent’s Hospital which is on the same grounds as the hospice, however, management were unable to provide all staff with their rostered, contracted hours. Following INMO intervention, management gave their commitment to honour the rosters of staff into the future and agreed to restore the hours of any staff members who were down hours as a result of the unplanned closure. They also accepted that staff were not obliged to take annual leave on management instruction and without notice. Management advised that they would work proactively to fill hospice beds on a continuous basis. t5IF*/.0SFQSFTFOUFEBOVNCFSPGQBMMJBUJWFDBSFOVSTFTJO8FTUNFBUIBU the Labour Relations Court in September in a long running dispute with the HSE regarding an overpayment that had occurred from 2006 to 2010. Management were seeking to recoup payments without any consideration of each individual’s financial circumstance. At the Court, management agreed to discount tax for years not within the four-year timeframe for a revenue refund, and offset annual leave accrued for call outs and subtract it from the overall amount owing. Management also agreed to arrange a repayment plan with each individual having regard to their financial circumstances when determining the amount and duration of the recoupment of monies owed.

Early bookings are advisable


Application Form for RNID Education Session Dementia Care 04.12.13 â‚Ź30 INMO members; â‚Ź70 non-members

Name: Address:

Working Together

Tel (home/mobile):*


Tel (work):

Call 01 664 0641/2

Email: Job title: Place of employment: Title of workshop:

RNID Dementia Day

04.12.13 Venue of workshop: INMO HQ Dublin Date of workshop:

INMO Member: T Membership No:

Fee enclosed: ÂŁ Have you attended an INMO workshop before?: Yes

T No T

(Cheques/postal orders payable to ‘INMO’. Receipts will be issued a week prior to course start date).

CODE: 5031

Non-member: T

* Supply of a personal contact number is essential, in case of the unlikely event of late cancellation of a course

Are you a registered Nurse T Midwife T

If you have any special dietary requirements please contact us at least ďŹ ve days in advance at Tel: 01 664 0642

Branch workplaces and areas covered Anne Harney 52



Please return form to: Professional Development Centre, INMO, Whitworth Building, North Brunswick Street, Dublin 7 Venue and times of workshops: Unless otherwise stated, courses listed are held at the Professional Development Centre. In order to better facilitate people attending workshops in the PDC, registration for most full-day workshops will take place at 9.45am and the courses will commence at 10.00am. Cancellation policy: In the event of unforeseen circumstances, a facilitator/trainer may be replaced by another suitably qualiďŹ ed person. Cancellation of any course must be given in writing at least seven days before the course begins. Fee will be refunded minus an administration charge. If a person cancels in less than seven days, no refund will be given. Receipts will be issued a week prior to course start date.


Áras Rónáin nursing unit complete 10k cancer fundraiser

Caring for a troubled nation SOCIALLY and politically, Dublin in the 1860s

was a wretched place. It was a city of poverty, disease and death. Stifled by economic stagnation and political dependence on its imperial master, about half the population of the ‘second city of the empire’ lived in poverty, the type of abject economic and social squalor that can only be imagined as we obsess over the relatively minor deprivations of the current recession. In the second half of the 19th century, epidemics of cholera, smallpox and typhoid were frequent in Ireland. The hospitals that had developed in Dublin up to then were far removed from the high-tech healthcare centres of today. They were places where the poor went to die, and frequently they didn’t want them, particularly if they had infectious diseases. The wealthier stayed away from hospitals, choosing instead to be treated at home by their personal physicians. Sr Eugene Nolan’s history of the Mater Misericordiae Hospital provides this sobering 19th century vignette: “… (Dublin) suffered from poor sanitation and regular outbreaks of disease. It had no formal water supply and sewage made it way among

the streets to the River Liffey, which often had corpses floating in it, because access to cemeteries was too expensive.” It was against this background that the original vision of Catherine McAuley was realised and the Mater opened its doors 152 years ago. The facilities, although primitive by today’s standards, were first

SEVEN staff and friends from the Áras Rónáin community nursing unit took part in Cancer Care West’s biggest annual event, the ‘Galway Bay 10’, in September. The event, which incorporates a half marathon and a 10k walk/run, raises funds for the charity and helps develop cancer support services in the west of Ireland. More than 2,200 people took part in this year’s walk/run, including many nurses and midwives. This year, the Áras Rónáin group – some of whom were participating in the event for the ninth year – raised a total of €3,000. This money will help Cancer Care West to continue to offer much needed services and support to cancer patients in the region. Funds raised from the ‘Galway Bay 10’ have supported the building and operating costs of the Inis Aoibhinn residential facility at Galway University

regarded by some as being too luxurious for the poor – for example the use of hair, instead of the traditional straw mattresses. Sr Eugene’s lavishly-illustrated history outlines how the Mater developed in tandem with the often troubled history of the Irish State and the rapid expansion in medical knowledge, technology and education over the past century and a half. The book looks at how the Mater dealt with World War One, the struggle for independence, the ‘troubles’, and the Stardust fire. It also outlines how the Mater pioneered treatment in areas such as heart surgery and examines the history of nursing and nurse education at the hospital. One theme throughout the book is the tension between the Mater’s desire to maintain its independence and ethos as a voluntary institution in the face of increasing State funding and regulation. Caring for the Nation is a fascinating read for anyone interested in Irish medical and nursing history. - Niall Hunter Caring for the Nation by Sr Eugene Nolan RSM, is published by Gill & Macmillan. ISBN 978-0-7171-57808 RRP €29.99









11 13






18 19 21



Name: Address:


20 22




Across 1. Resin. (3) 3. Broke-stoned again? Made an enemy so. (11) 8. Violet-blue colour. (6) 9. A camping mix-up for the military undertaking. (8) 10. Reassure, assuage. (5) 11. Telling fibs. (5) 13. Lid. (5) 15. 9\Yegj=n]kgja_afYd[dgl`af_& +$,! 16. Leave an article in front of a Cork town. (7) 20. Giant of Greek mythology, such as Atlas. (5) 21. Nimble. (5) 23. Stag movie – from Disney! (5) *,& Game not found in well-insulated homes? (8) 25. Wound or shock caused by a sudden injury. (6) 26. Congenital condition characterised by a fissure in the roof of the mouth. (5,6) 27. English river that is vexed at heart. (3)

Down 1. Congenital neural tube defect. (5,6) 2. Walking in shallow water. (8) 3. Irate. (5) ,&Alkmk]\YkYharrYlghhaf_7L`YlkY little fishy! (7) 5. Country where the plane crashed. (5) 6. Spectre. (6) 7. Noise. (3) 12. A finish with a flourish gets a thousand part of a fish with beer! (5,6) 13. Shoreline. (5) ),&Bird often seen with Batman. (5) 17. This sleepy creature might disturb a used room. (8) 18. Implement. (7) 19. Buccaneer. (6) 22. The number of pints in a gallon. (5) 23. The canal boat can smash a berg. (5) *,&Bespectacled Disney dwarf. (3)

Hospital, and also the opening and maintenance of Cancer Care West ’s Support Centre in Galway. All nurses and midwives are encouraged to participate in the event next year by running the 10k, or by simply walking the distance along the Salthill promenade.

Genetic link to alcoholism highlighted NEARLY two-thirds of people in Ireland

Sponsored by:


Pictured after participating in the ‘Galway Bay 10‘ were (l-r): Edel Hourigan, Rita McDonagh, Emer Concannon, Noreen Watts, Mairead Walsh, Nessa Joyce and Anne Conneally, from the Áras Rónáin community nursing unit

believe alcohol dependence has a genetic component that runs in families, according to a new study conducted as part of the ‘Reduce Your Alcohol Use’ campaign. The campaign, which is sponsored by Lundbeck Ireland, aims to help raise awareness of the genetic link associated with alcohol dependence. As part of the initiative more than 800 mature drinkers, aged 30 plus, were surveyed to see how alcoholism has impacted on Irish families’ alcohol consumption. Over 42% of participants had

a family history of alcohol problems, while 31% admitted drinking moderately or not at all as a result of how people in their family consumed alcohol. Some 43% claimed they drank two or more times a week, with 30% of males consuming seven or more drinks on a typical occasion, while half of the women claim they had four or more drinks. Past research revealed that if a parent has a drug or alcohol addiction, their child is eight times more likely to develop one; up to 60% of a person’s risk for alcoholism is genetic.

Solutions to October crossword: Across: 1. Sod 3. Baby bouncer 8. Always 9. Adhesive 10. Bilge 11. Dying 13. Field 15. Bedside manner 16. Scalpel 20. Drums *)&Klggd*+&:daeh*,&J]b][l]\ 26. Demonstrate 27. Sty Down: 1. Soap bubbles 2. Download +& :gqf]  ,& Q]Yjf]\  -& Mh]f\ 6. Clinic 7. Rue 12. Guilty party )+&>Y\]\),&<g[ck)/&HYla]flk 18. Builder 19. Logjam 22. Lucan *+&:jY[]*,&J]\

The winner of the October crossword is: Brigid Callaghan from Mountmellick, County Laois

L`]hjar]oadd_glgl`]^ajklYdd[gjj][l]fljqgh]f]\& Closing date: Monday, November 18, 2013 Hgklqgmj]fljqlg2 Crossword Competition, L`]Ogjd\g^Ajak`Fmjkaf_$E]\E]\aYHmZda[Ylagfk$*-9\]dYa\]Klj]]l$<mfDYg_`Yaj]$;g<mZdaf

Pictured at the launch of the digestive disorders clinic supported by Colpermin were (l-r): Clare Gardiner, brand activation assistant and Nikki Maguire, brand activation manager, Johnson & Johnson; with Geraldine Meagan and Leon Ellison, MedMedia, publishers of . The digestive disorders clinic is a patient resource and includes a wide range of information on prevention and treatment of problems with digestion, including cramps and spasms, irritable bowel syndrome and advice on travel. It provides an IBS symptom checker and a food diary

Cancer Care West enhances the care and treatment of cancer patients and supports patients and their families during and after treatment. For more information,visit www. or

Globetrotters urged to prioritise vaccinations ONE-IN-EIGHT people in Ireland (13%) know someone who has contracted an infectious disease overseas, according to new research. Despite this, only 23% of those who have travelled to at-risk countries in the past two years got vaccinated against these preventable diseases. T h e H e a l t h y Tr a v e l i n f o r m a t i o n campaign, on behalf of Sanofi Pasteur MSD, is urging travellers to look after their health. The campaign revealed that 15% of Irish adults recently travelled to an exotic country where vaccinations would be recommended, such as Asia, Af r i c a , S o u t h A m e r i c a a n d Ce n t ra l America. Yet, just 62% of travellers felt vaccinations are an important precaution when travelling. New research shows that in general, one-in-seven Irish adults think about vaccinations before travelling (16%), ranking them as the fourth most important part of travel preparation after booking travel insurance (59%), doing online research (35%) and getting a haircut (19%). The main diseases that travellers vaccinated against in the past two years included typhoid fever, diphtheria and tetanus, hepatitis A and hepatitis B. For more information on travel health, visit


November 2013 Vol 21 Iss 9




MON E Y MATTERS Your questions answered by Ivan Ahern

Save money on your car and stay safe this autumn AS WE settle into autumn, we’ve pulled together some tips and advice that will help to keep you safe on the roads, while also saving you money. Weekly basic car maintenance1 Taking 20 minutes each week to look over your car can help to avoid major car trouble in the long-term. This will help to save you money as well as keeping you and your family safe. It doesn’t cost you a great amount of time or money, but these regular checks will ensure that your car is geared up for the week ahead and any long haul trips you may have to take. s Check all lights s Check the oil in the engine, brake fluid, windscreen wash and the level of anti-freeze s Check the grip on your tyres and look out for uneven wear – a sign of suspension problems or wheels out of alignment. Save money on fuel2 Shop around for fuel! The price differences between petrol station fuel prices can be quite significant, often as much as five cent per litre. Avoiding rush hour traffic can help to reduce the amount of fuel your car uses while you are stuck in traffic. Plan an alternative route or if possible leave earlier to avoid traffic jams.



November 2013 Vol 21 Iss 9

How you drive can impact your fuel consumption – the harder you brake and accelerate, the more fuel your car consumes. Reducing your speed can help to cut down on costs. For example, cutting your speed from 110kph to around 80kph, will use about 25% less petrol. Travel light – remove heavy items such as golf clubs, roof racks and bike racks, which can weigh down your car and increase fuel consumption. Plan your journey Take the time to plan your journey before you set off and give yourself some extra time to allow for any unforeseen delays which you may encounter. This will reduce your risk of speeding and keep you and your passengers safe. When planning a long journey, factor in time to stop off for some light refreshments and a stretch break. What to do if you break down on a motorway1 s Pull onto the hard shoulder as far away from the inside lane as possible s Turn your front wheels towards the hard shoulder s Try to stop near an emergency phone s Switch on your hazard warning lights s Keep your sidelights on if it is dark or visibility is poor s Get out of your car on the passenger side s Keep passengers away from the motorway and keep children under control s Walk to an emergency phone on your side of the motorway. These phones are free and connect directly to the Gardaí who can work out where you are. As a result, it’s better to use them rather than a mobile s Face oncoming traffic while on the phone s After phoning, return to your car s If you’re travelling alone and feel at risk, you may want to wait in the front passenger seat with the doors locked. If someone approaches, wind down your window a little to talk to them. Only unlock the door once you’re sure that they are genuine s Before you rejoin the motorway after a breakdown, build up speed on the hard shoulder and watch for a safe gap in the traffic. Your car safety checklist1 It is advised that motorists carry a number of essentials in the boot of their car:


January 2014

Thursday 7 Retired Nurses and Midwives Section biennial conference, 9.45am, INMO HQ. Contact: or Tel: 01 6640648

Saturday 18 ODN Section meeting, 11.30am, Mater Hospital. Contact: jean@ or Tel: 01 6640648 Wednesday 22 Telephone Triage Section meeting, 11am, Portlaoise. Contact: or Tel: 01 6640648

Monday 18 Nurse Midwife Education Section, 11.30am, INMO HQ. Contact: or Tel: 01 6640648

s s s s s s

High visibility vest Spare fuel Hazard warning triangle Spare wheel Tow rope De-icing equipment (for glass and door locks) s Spare bulbs s First aid kit s Fire extinguisher s Working torch s Car blanket. Know your car insurance benefits Check your car insurance policy document and know your benefits. If you have 24-hour breakdown assist and windscreen cover keep the helpline numbers and details in your phone or in your glove compartment. In 2012, over 7,000 of our customers countrywide who encountered motor difficulties availed of our breakdown assist service.3 Many of these customers were members of the Nurses’ Car Insurance Scheme. INMO members can get preferential rates through this scheme. For further details and benefits please contact us. Tel: 01 4708042. Ivan Ahern is the director of Cornmarket Group Financial Services Ltd Sources: 1. 2. 3. mapfre asistencia This information is intended only as a general guide and has no legal standing. Members who have specific questions relating to their personal finances, Superannuation entitlements, etc. are advised to seek professional advice and can contact Cornmarket at (01) 408 4000. Cornmarket Group Financial Services Ltd. is regulated by the Central Bank of Ireland. A member of the Irish Life Group Ltd. RSA Insurance Ireland Ltd. is regulated by the Central Bank of Ireland. Telephone calls may be recorded for quality control and training purposes. MAPFRE ASISTENCIA Compania de Seguros y Reaseguros SA trading as MAPFRE ASSISTANCE Agency Ireland is regulated by the Direccion General de Seguros y Fondos de Pensiones del Ministerio de Economia y Hacienda, Spain, and is subject to the Central Bank of Ireland’s conduct of business rules. Administered by Cornmarket Group Financial Services Ltd, Christchurch Square, Dublin 8.

Saturday 23 GP Practice Nurse Section, 11am, INMO HQ. Contact: or Tel: 01 6640648 Friday 29 Beaumont Hospital Dialysis and Transplant conference, Hilton Dublin Airport Hotel. Contact: tunconference2013@beaumont. ie

December Tuesday 3 Assistant Directors Section meeting. 11am, INMO HQ. Contact: or Tel: 01 6640648 Wednesday 4 RNID Section Dementia Care education session. INMO HQ, 10am-12.30pm. Fee: €30 (INMO members)/€70 (non members). To book, contact: marian@inmo. ie or Tel: 01 6640641/2 RNID Section meeting, INMO HQ, 1-2pm. Contact: or Tel: 01 6640648

Saturday 7 Midwives Section meeting, 2pm, INMO HQ. Contact: or Tel: 01 6640648

February Monday 3 Nurse/Midwife Education Section meeting, 11.30am, INMO HQ. Contact: or Tel: 01 6640648

Attention clinical nurse and midwife managers Y Evening education sessions will be held in November on ‘Maintaining Safe Practice – Managing the Challenges’ at the following venues: sMonday 11 – Limerick Castletroy Park Hotel sTuesday 12 –INMO HQ sThursday 21 – Galway Clayton Hotel, Ballybrit sMonday 25 – Cork River Lee Hotel, Western Road Fee: Free for members, €75 for non members. Contact: or Tel: 01 6640648 See page 24 of this issue of WIN for more information

INMO Library Opening Hours November 2013 9am-4.45pm Monday-Friday:

For further information on the library and its services, please contact: Tel: 01-6640614 Fax: 01-661 5012, Email:

GP Practice Nurse Section Y The GP Practice Nurse Section will hold its next meeting at 11am on Saturday, November 23, in the head office of the INMO. Clare Treacy, INMO director of social policy regulation and recruitment, and Phil Ní Sheaghdha, INMO director of industrial relations, will discuss indemnity insurance at the meeting.

INMO Membership Fees 2013 A Registered nurse


(Including temporary nurses in prolonged employment)

B Short-time/Relief


This fee applies only to nurses who provide very short term relief duties (ie. holiday or sick duty relief)

C Private nursing homes


D Affiliate Members -


Working (employed in universities & IT institutes)

Practice nurse members are strongly encouraged to attend. For further details, please contact: or Tel: 01 6640648.

E Associate Members -


Not working

F Retired Associate Members €14 G Student nurse members No Fee

Condolences Y Condolences to the family of Celine O’Carroll, who died after a short illness in September. Celine was the assistant director of nursing in infection prevention and control in the Mater Hospital, Dublin. She will be sadly missed by her family, friends and colleagues in the Mater Hospital. RIP YCondolences from the Clonmel Branch to Michael Dowling, INMO Rep for Damien House Services in Clonmel, and his family, on the recent death of Michael’s mother Therese Dowling. RIP


World of Irish Nursing, Nov 2013  

World of Irish Nursing Magazine, Irish Nurses & Midwives Organisation, November 2013

World of Irish Nursing, Nov 2013  

World of Irish Nursing Magazine, Irish Nurses & Midwives Organisation, November 2013