Key Elements When Designing and Delivering Effective Indigenous Falls Prevention Programs


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Falls are now the second most common cause of injury for all Aboriginal and Torres Strait Islander people in Australia

Recovery post fall with serious injury (fractured neck of femur, head injury etc.) does require ongoing care and therapy to optimise functional outcome and quality of life. Rehabilitation and Allied Health services in the Australian general population have been reported to be too inflexible and difficult to access.

Indigenous people report often when trying to access mainstream healthcare of discrimination, judgment and communication problems.

When targeting aboriginal people for health promotion programs there are seven key elements which have been identified by indigenous communities as necessary if it will be accessed and be effective.

Indiginous Specific

A very consistent message is the need for the Health Programs to be indigenous specific. A lot of falls data is general populationrock-art-375225_640which has different demographics to ATSI population. Having the ability to modify the program to incorporate community specific variances that is important for that community.

Community owned

Kinship is a deep sense of family and community and is very strong amongst indigenous population. In communities everyone knows everyone and their family line. Self-determination is also strong in many communities. Preference is for an organisations/groups within the community to deliver any new program. Feeling safe to share their story and how they feel in a friendly environment is important for participants to interact.

No age limit

Along with Kinship is a need for the programs to have no age limit. That way children, carers and partners and family are welcome to attend. Family is not like family as in immediate family. Indigenous family is the community and a concept that whole of the local community is family.

Longer duration

Having a program that is of a longer duration so participants can drop out of and back in is required for any health promotion program. Things come up that prevents attending such as sickness, family reasons, and community responsibilities and the needs of country.

This six weeks or this eight weeks thing, it’s just no good for the Koori [Aboriginal] community because people get sick


You can’t offer Koori communities short term fixes because it doesn’t fix anything


 Group based

Telling a yarn and sharing stories is the foundation of how Aboriginals interact with each other, as a community and the broader Australian community. Kinship is strong. Group based programs rather than one on one programs work best within this framework.

Low to no cost

Again the sharing of resources includes sharing of money. Health is high priority for the government and governmental agencies however for indigenous health is down low in their priorities. Indigenous communities are some of the poorest communities in Australia in terms of money. Preferably no cost programs are required to get people in and engaged.


Consideration for transport is also an important element which is also related to socio economic reasons. Even if people have a form of transport such as a car it may not be available due to sharing the car with family. Incorporating free transport into the program will remove a probable barrier and encourage greater participation.


Health programs specifically Falls Prevention require modification if wanting to deliver such programs within indigenous communities. Designing the program to be indigenous specific in a group setting factoring in cost and transport is important. Opening the program up to all ages and deliver over a longer period allowing for drop out and in will be more effective with aboriginal communities. Aboriginal communities are best to deliver such programs from already established groups within the community. Underlying all these key elements are the principles of kinship, country and family.

Primary Resource

  1. Lukaszyk C, Coombes J, Turner N J, Hillmann E, Keay L,  Tiedemann A, Sherrington C &  Ivers R (2018)  Yarning about fall prevention: community consultation to discuss falls and appropriate approaches to fall prevention with older Aboriginal and Torres Strait Islander people BMC Public Health 18:77 DOI 10.1186/s12889-017-4628-6

Secondary Resources

  1. Australian Government Department of Health (2013) National Aboriginal And Torres Strait Islander Health Plan 2013-2023 Retrieved from ISBN: 978-1-74241-979-4
  2. Government of Western Australia Department of Health (2010) Falls Prevention for Aboriginal People A tool for Aboriginal Health workers and Aboriginal communities Retrieved from

“Only A Nurse Could Laugh at This…”


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515v91wPEiL._AC_AA218_Book Title: “Only A Nurse Could Laugh at This…” – Funny Stories and Quotes from Real Nurses for When You’re Having “One of Those Days”

Author: Allie Wilson & Marty Wilson

Year: 2014


Australian ER nurse and pharmacist husband compiled together this book  of short stories about the funny, the odd and the bizarre things that happened to real nurses.

Any nurse will relate to many of these stories as we have all done something similar or seen something similar. Did I laugh?? No although I did smile at a few of the stories as it brought back good memories.

This book is quite short and might have been a better read if the authers had set up each piece with the back story to tease  out the humour more.

I give this book three hearts.  heartheartheart

Oh Sh*t I Almost Killed You!


Book Title: Oh Shit I Almost Killed You! A Little Book of Big Things Nursing School Forgot to Teach You 

Author: Sonja M Schwartzbach BSN RN CCRN

Publication Date: 1st April 2017

The author, an American nurse five years out of nursing school, shares humorously and at times irreverently her thoughts and opinions intermingled with stories of her professional journey. Exposing the reader to nursing in its truest stripped down form at the coal face and the bedside is somewhat distressing, disappointing, enlightening and encouraging all at the same time.

Nurse Schwartzbach light-heartedly provides heartfelt clarity to newbie nurses through hints, guidance and reflections on what real nursing is and points out that there are times when we all question our decision to take up nursing as our career pathway whatever stage of the journey we are on. Despite the book title there is very little use of profanity by the author and should not discourage those of us who are more easily offended from reading this nurses work.

This book is a GEM!!!!! It’s just as valuable to the student or newly graduated as it is to the battle-weary nurse that we become through long-term exposure to the system. It is apparent that the experiences nurses face are the same across the globe whether the USA, Australia or New Zealand.

I give this book five hearts.  heartheartheartheartheart






Understanding Conversion Disorder to better inform your patient sensitively


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Conversion Disorder has had a name recently with the update of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – Functional Neurological Symptom Disorder (FNSD).

The prevalence of FNSD is estimated to have a 1-3% occurrence rate in general population. In neurological outpatient clinics, the incident is thought to be as high as 25-30%.

“medically unexplained, neurological symptoms that are believed to develop
unintentionally in reaction to psychological and environmental factors
such as trauma or daily stressors.”

In previous years FNSD aetiology was believed to be anxiety/stress related. Sigmund Freud a 19th Century Austrian neurologist and founder of psychoanalysis theorised that anxiety is “converted” into physical symptoms.

More recent work in this area now suggests it has many interrelated and complex variables with or without an anxiolytic or stressful preceding event which makes treatment less than simple or a “one size fits all” scenario.

Diagnosing FNSD

Diagnosis of FNSD is considered clinically when all diagnostic testing is not compatible with presenting signs and symptoms. Misdiagnosis does occur although is less likely today due to significant advancements in diagnostics and research.

The DSM-5 diagnostic criteria for FNSD (conversion disorder) are as follows:

• One or more symptoms of altered voluntary motor or sensory function.
• Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.
• The symptom or deficit is not better explained by another medical or mental disorder.
• The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

PNSD is more prevalent in women than men, rarely found in children or the elderly and has an increased rate in people aged the mid to late 30s. Patient populations considered more at risk are those with a personality disorder or dissociative identity disorder.

Hoover’s sign is a test available to clinicians when assessing limb weakness which with a positive result “simply suggests that the majority of the weakness you are observing is not due to disease”.

  Breaking the news

”The doctor just told me my stroke is all in my head”.
”I can’t move my bloody arm”.
“I’m not making it up”.
“I’m not crazy”.

A diagnosis of FNSD can elicit strong emotional reactions from the patient and family if not handled sensitively. Mental health illness still has a stigma very much attached. Commonly families and staff don’t know what to say or how to care for the patient which can isolate the patient more with feelings of stigmatisation.

Use of a standardised non-judgmental script and having confidence in responding to emotive and challenging questions “you don’t believe me?” is necessary for the diagnosis disclosure.

The information provided is just as important as the delivery in explaining the diagnosis to your patient. While the initial conversation is not necessarily a nurses role, the ongoing reinforcement and provision of information related to the diagnosis certainly are.

Communicating that PNSD is a significant health condition requiring a whole of team effort for the condition to improve and symptoms resolve and as per below:
• the emphasis that symptoms are genuine and potentially reversible;
• explanation of the positive nature of the diagnosis (i.e., not a diagnosis of exclusion);
• simple advice about distraction techniques, self-help techniques and sources of information;
• referral on to appropriate physiotherapy and psychological services; and
• offering an outpatient review

Treatment options available

  • The treatment plan found to be most effective is one with a motor learning program and a behavioural approach which is individualised within a multidisciplinary team environment.
  • Person-centred goal setting with the patient/family is recommended.
  • Behavior-oriented treatment strategies include unlearning maladaptive responses to eliminate example for the patients’ belief the limb is paralysed by informing them 1. that all tests indicate the muscles and nerves are functioning normally 2. the brain is communicating with the nerves and muscles, and 3. this apparently lost ability is recoverable.
  • Pharmacological treatment includes prescribing of antidepressants and anxiolytics if indicated.

Clinical Take Home Message

• FNSD is a significant health condition requiring a multidisciplinary treatment plan based on a motor learning and behavioural approach.
• FNSD has many interrelated and complex variables with or without an anxiolytic or stressful preceding event.
• Motor learning program with a behavioural approach which is individualised within a multidisciplinary team environment is most effective.
• Sensitivity is required when disclosing diagnosis and with ongoing communication due to stigma and spoken or unspoken sense of not being believed.
• Treatment options available include individualised motor learning and behavioural approach programs, anti-depressants, anxiolytics, education, and suggestive therapy.

Carson A, Lehn A, Ludwig L, Stone J, 2016 Explaining functional disorders
in the neurology clinic: a photo story Pract Neurol;16:56–61. practneurol-2015-001241

Boeckle M, Liegl F, Jank R, Pieh C 2016 Neural correlates of conversion 
disorder: overview and meta-analysis of neuroimaging studies on motor
conversion disorder BMC Psychiatry,16:195 DOI 10.1186/s12888-016-0890-x

Septic Acute Kidney Injury – More than just Hypo Perfusion


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imageSeptic acute kidney injury (SAKI) has long been thought to be characterised by hypo perfusion (decreased blood flow to the kidney) and haemodynamic instability.

Prevention and treatment has been focused on ensuring patients were hemodynamically optimised and stable.

Recent studies have identified that not all patients with SAKI have evidence of hypo perfusion. A complex pathophysiological cascade of events and changes are now beginning to be researched further to gain better understanding of the underlying mechanisms at play


Sepsis (bacteraemia) occurs in response to an infection. Chemicals are released in the body to fight the infection. This triggers a cascade of inflammatory changes which can lead to multi organ damage and failure. Sepsis is potentially life threatening.

Acute Kidney Injury (AKI)

AKI is a syndrome and not a disease – a sudden occurrence of damage to the kidney or kidney failure. The ability of the kidney to filtrate out waste products from the circulatory system is effected causing a build-up of these waste products.

Patients who experience AKI have an increased risk for other health problems ie kidney disease, stroke, heart disease and of further episodes of AKI. Each additional episode of AKI increases the chances of developing Kidney Failure and Kidney Disease.

Until recently it was believed that a major characteristic of SAKI was kidney hypo perfusion.

Studies are now finding that AKI does occur in septic patients without kidney hypo perfusion or haemodynamic deterioration suggesting other mechanisms are at work.

Pathophysiological mechanisms underlying the development and progression of SAKI are quite complex and still not completely understood. Recent studies suggest

“key pathophysiological processes include renal macro circulatory and micro circulatory disturbance, glycocalyx disruption, surge of inflammatory markers and oxidative stress, coagulation cascade activation, imbalanced energy metabolism with release of ATP from damaged cells, bioenergetics adaptive response with controlled cell-cycle arrest, renalvenous congestion, and maladaptive TGF mechanism”


Damage to kidney tissue activates a repair process following the common ischemic reperfusion pathway.

Possibly due to a maladaptive response during this repair process AKI survivors are at a higher risk of Chronic Kidney Disease (CKD) and cardiovascular morbidities and mortality. Each subsequent episode of AKI further increases these risks.

Current treatments for SAKI are supportive therapies by nature

  • Fluid Therapy – use of isotonic crystalloids as initial management for expansion of intravascular volume.
  • Haemodynamic Optimisation – use of fluids and vasopressors help minimise further extension of kidney injury and facilitates renal recovery.
  • Diuretics – with AKI there is an increased risk for fluid overload and therefore use of diuretics is necessary to help rid the body of excess fluid and salt through urine.
  • Renal Replacement Therapy (RRT) – haemodialysis is this use of a dialyser which aides in removing waste from blood, restores electrolyte balance and removes extra fluid from the body.

There are now new and proposed treatments available which target the underlying complex pathophysiological changes of SAKI which are just starting to be used with some confidence.

  • Alkaline Phosphatase (AP) – an endogenous enzyme which has detoxification capacity
  • a-Melanocyte-Stimulating Hormone (a-MSH) – a strong anti-inflammatory cytokine which decreases inflammatory cytokines.
  • Toll-like Receptor 4 Inhibitor (TLR4) – Lipopolysaccharide binds to TLR4 on antigen-presenting cells to inhibit an inflammatory response
  • Heparin – suppresses the activation of inflammatory cells by binding and neutralising inflammatory mediators/enzymes released during the inflammatory phase.
  • Mesenchymal Stem Cells – have a renoprotective effect derived from the paracrine/endocrine secretion of bioactive factors and exosomes.


SAKI is on the rise in many counties possibly due to various factors associated with microorganism resistance to antibiotics, increased use of cytotoxic drugs leading to large numbers of individuals in communities who are immune compromised and an aging population.

Further research and better understanding of the pathophysiology underlying SAKI will provide an opportunity for a more robust and vigorous response by health clinicians to this scenario.

Managing Increased Fluid Loss from Stomas Post Operatively


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The incidence of stoma formation (colostomy, ileostomy, jejunostomy) in the western world for the adult population is 2-4 per 1000 population with colorectal cancer being the most common (65%) indicator for this procedure.

30 % patients with a new stoma experience high output (HOS) defined as more than 1500 ml output in 24 hours on two consecutive days. In the first couple of days post stoma formation output is expected to be somewhat high due to the bowel adapting to the new changes, however, this situation resolves rapidly. Output exceeding 3000 ml in 24 hrs is classed as excessive output stoma (EOS).

Causes of high output from a stoma are

  • Infection 43%stoma-nurseconvo
  • Prokinetic agents (drugs) 14%
  • Unknown 43%

HOS is classified even further as early onset (EHOS) and late onset (LHOS).

Early High Output Stoma

16% stoma patient experience early high output stoma (EHOS) on average occurring around Day 8 post-operatively. EHOS is defined clinically as more than 1500ml per 24 hours on at least two consecutive days within three weeks of stoma formation usually occurring before discharge from hospital.

Late High Output Stoma

The prevalence of late high output stoma (LHOS) is 14% occurring on average around Day 25. The development of HOS occurring more than three weeks post stoma formation is classed as LHOS.

Unfortunately, studies have found that as many as 28% of stoma patients are readmitted to hospital with significant weight loss (5-7 kgs).

23-43% of these readmissions are due to HOS with evidence of electrolyte imbalance and dehydration. Electrolyte imbalance is of significant concern. Magnesium, Potassium and Calcium are particularly affected in this clinical scenario.

Electrolyte Imbalances                                                                     

  • Hypomagnesaemia – low levels of Magnesium is common in stoma patients due to the decrblood-test-nurseconvoeased absorption surface area of the bowel. Magnesium is a key component of many chemical reactions inside the cells of the body which are required for muscle and nerve activity, maintenance of normal heart beat and a healthy immune system.
  • Hypokalaemia – low potassium levels are also common however treatment is less than effective until Magnesium levels are normalised first. Early signs of hypokalaemia are general weakness, muscle cramps and numbness and tingling usually experienced in the lower extremities first.
  • Hypocalcaemia – As per above, treatment for low calcium is less than effective until the Magnesium levels are within normal range.


The first line of treatment for stomas with high output is to diagnose and treat the underlying cause before commencing nutritional and pharmacological intervention.

Clostridium Difficile is seen in an increasing number of hospitalised patients experiencing diarrhoea and HOS patients should be screened to rule out this as a cause of their high stoma output.  Studies suggest this agent is associated with 3-10 per 1000 general hospitalisations.

Medications which have been found to increase the risk for high output are as per below, and consideration should be given to ceasing and or replace with alternative drugs.

  • Metformin
  • Prokinetic (maxalon, laxatives, erythromycin)
  • Cortico-steroid abrupt withdrawal

Bowel Obstruction is another quite serious possible cause for high outputs as is Short Gut Syndrome (intestines fail to absorb enough nutrition and or fluids in and occurs in normal length bowel or shorter bowel due to surgery).

Suggested protocol by Arenas Villafranca et al. describes a 3 stage approach to the treatment of stomas with high output.

Initial treatment includes

  • restricting oral fluid intake to 500-1000 ml per day avoiding hypotonic fluids i.e., tea, coffee, alcohol, fruit juices
  • administering IV replacement therapy
  • prescribing of Loperamide 2mgs before each meal and at night is recommended
  • daily weighs and strict fluid balance and
  • monitoring of blood analysis is necessary and treat imbalances as necessary.

If stoma output has resolved in 2-3 days then increase oral fluid intake, withdraw medication and start serum therapy (injection of serum containing antibodies to the disease specifically being treated)

If high output continues Stage II treatment recommendation is to

  • continue with restricting oral fluidshydration-therapy-nurseconvo
  • increase Loperamide and commence omeprazole
  • If fats, pus or undigested food/medications are present suggestive of malabsorption, steatorrhea or pruritic bilious output add cholestyramine to the medication regime

If the high output persists, a further 2-3 day’s – Stage III is initiated. Stage III includes

  • supplementation with hydro and lipid soluble oral vitamins
  • maintain loperamide
  • add codeine (only if >15ml/min creatinine clearance)
  • increase cholestyramine if malabsorption continues
  • after two weeks if HOS >2000mls add octreotide for 3-5 days if no improvement suspend this treatment.

A success rate of 100% was achieved in Arenas Villafranca et al. study with use of the early examination and treatment protocol as described above.

Given such results consideration for a standardised protocol for the treatment and management of high output stomas, should be formalised.


Primary Reference

Jose J Arenas Villafranca, Cristobal López-Rodríguez, Jimena Abilés, Robin Rivera, Norberto Gándara Adán and Pilar Utrilla Navarro 2015 Protocol for the detection and nutritional management of high-output stomas Nutrition Journal  14:45 DOI 10.1186/s12937-015-0034-z

Additional Reference

Kwiatt M,  Kawata M, 2013, Avoidance and Management of Stomal Complications, Clin Colon Rectal Surg 2013;26:112–121. DOI 10.1055/s-0033-1348050. ISSN 1531-0043.

Rostami K, Al Dulaimi D. 2015 Elemental diets role in treatment of High ileostomy output and other gastrointestinal disorders,  Gastroenterol Hepatol Bed Bench 2015;8(1):71-76).

Risk of phosphate neuropathy from phosphate based enema use


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Use of hypertonic sodium phosphate enemas (ie Fleet) in the elderly may cause severe phosphate neuropathy and  hyperphosphatemia.

Deposits of phosphate crystals form within the kidneys causing kidney dysfunction. Sodium phosphate is absorbed into the blood stream due to the significant absorption properties found in the bowel.

Cleansing enemas are used in hospitals for pre operative bowel preparation and when bowel activity has not occurred for many days and the risk of bowel obstruction is real. First line treatment should always be non pharmacological. In addition to strategies below patients should be provided with opportunities to sit on a toilet/commode regularly (at least daily particularly postprandially).

  • patient education                             image
  • hydration
  • diet
  • activity

Enemas distend the bowel stimulating colon contractibility causing stool expulsion. Phosphate enemas additionally stimulate the bowel muscles to contract facilitating stool expulsion. Adverse effects for all enemas irrespective of the active ingredient includes electrolyte imbalance (metabolic derangement) and bowel perforation.

Bowel perforation can generally be related to muscle weakness of the bowel wall, an obstruction or incorrect positioning of the patient during enema administration. Bowel perforation, hyperphosphatemia and phosphate neuropathy may occur, causing death in up to 4% of cases post enema administration.

Symptoms of acute phosphate nephropathy are:

  • lethagy
  • drowsiness
  • decreased urination
  • swelling of ankles, feet and legs.

Symptoms of hyperphosphatemia potentially are:

  • muscle cramps                                               image
  • joint pain
  • tingling and numbness

and in prolonged states:

  • itchy skin
  • pain
  • skin rashes

Patient groups at risk for phosphate neuropathy and hyperphosphatemia are:

  • aged > 65 years

and patients with

  • CKD
  • dehydrated
  • bowel obstruction, delayed bowel emptying or active colitis and
  • on medications (diuretics, angiotensin converting enzyme [ACE] inhibitors, angiotensin, receptor blockers [ARBs], non inflammatories ( NSAIDs) and analgesics (opiates)

Preventing constipation particularly post operatively is vitally important. Being aware of your patients usual bowel habits and routines provides a baseline for the development of their bowel management plan.

“A stitch in times saves nine”

Negating the need to consider the use of enemas is a primary role of the nurse. Asking your patient “have your bowels moved today” is not a rhetorical question. Enquiring about the bowel activities of your patients is only the first step in preventing constipation. Doing something about lack of bowel movements is necessary.

Caution in use of phosphate based enemas for bowel cleansing pre procedure or for treatment of constipation is highly recommended. If administration is prescribed then nurses must be aware of patients at risk for hyperphosphatemia and phosphate neuropathy. Initiating a conversation with the prescriber regards the risks and clinical reasoning for your particular patient is necessary for their safety and wellbeing.

Adults fluid consumption impacts on risk chronic disease


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image66% of adults exceed the World Health Organisation (WHO) free sugar recommendation solely from fluid consumption.


A WHO study of 16,276 participants across 13 countries published in 2015 found that 66% adults exceeded the free sugar recommendation (free sugars <10% of total energy intake) from beverages alone without taking into account their food consumption.

Exceeding WHO recommendations for free sugar is associated with higher risks of

  • Weight gain image
  • Obesity
  • Metabolic syndromes
  • Type 2 diabetes and
  • other health problems

WHO estimates that by the year 2030 diabetes will be the seventh leading cause of death worldwide. Diabetes is associated with complications affecting the kidneys, eyes, feet, and cardiovascular system.

In Australia it is estimated that over 13% people with diabetes have lower limb nerve damage and 15% experience retinopathy. Diabetes is now considered the leading cause of end-stage kidney disease.

In people with diabetes, cardiovascular disease (CVD) is the primary cause of death, with around 65% of all CVD deaths in Australia occurring in people with diabetes or pre-diabetes. Furthermore, 41% of people with diabetes also report poor psychological well-being with reports of anxiety, stress, depression and feeling ‘burned-out ‘ from coping with their diabetes. Moreover, diabetes is ranked in the top 10 leading causes of death in Australia.


National Diabetes Strategy Advisory Group Consultation Paper

Risk of chronic kidney disease has already been demonstrated to be linked to the types of beverages consumed. Kidney Health Australia has adopted the viewpoint that there is

  • lack of evidence to suggest that drinking water in excess of thirst is beneficial
  • water is the preferred option to satisfy thirst
  • recommended fluid intake is proportional to thirst and individual circumstances
  • from the kidney perspective all fluids consumed counts towards the daily fluid intake and
  • drinking fluids when first sensation of thirst registers (thirst is a sign of dehydration)

Daily fluid intake is influenced by many factors. Fluid intake requirements are increased if

  • living in hot or tropical environments
  • increased activity and exercise
  • medical conditions causing excess obligatory fluid loss ie diabetes insipidus or conditions requiring increased urine flow ie renal calculi.

Fluid intake requirements are decreased in patients with end stage kidney disease and also those patients with certain cardiac and respiratory conditions ie cardiac heart failure.

Dehydration signs and symptoms include some of the following

  • headachesimage
  • fatigue and lethargy
  • slow reaction times
  • dark coloured urine
  • dry cracked lips.

Unfortunately fruit juice is still perceived as a healthy option despite the low water, high sugar content. Public health education programs encouraging adults to increase water consumption in preference to sweetened fluids so as to decrease their risk of chronic disease (ie CKD, T2DM, obesity) is required.

Nurses continue to play a significant role in educating patients and reinforcing health information. To be successful in effecting health change the message must be consistent, evidence based and current.

References :

Guelinck I, Ferreira‐Pêgo C, Moreno L A, Kavouras S A, Gandy J, Martinez H, Bardosono S, Abdollahi M, Nasseri E, Jarosz A, Ma G, Carmuega E, Babio N, Salas‐Salvadó J 2015 Intake of water and different beverages in adults across 13 countries Eur J Nutr 54 Suppl (2):S45-S55 DOI:10.1007/soo394-015-0952-8


Missed care by nurses impact patient safety

The incidence of missed care (of one or more cares) is 79% in even the best of work environments with a 92% incident rate found in the lower work environment deciles according to a 2013 study by Ball, Murrells, Rafferty et al.

Missed nursing care is considered  an error of omission defined as any aspect of required patient care that is omitted (either in part or whole) or significantly delayed. It first became recognised conceptually in 2006 in work conducted by Beatrice J Kalisch in the United States.

The quality of nursing care significantly determines (in part) patient outcomes. The patient safety in healthcare movement focuses on eliminating errors of commission (i.e. medications to wrong patient). Errors of omission (i.e. not ambulating a patient) are less detectable, problematic, more prevalent and detrimental than errors of commission.


imageSituations occur within the practice environment  causing a negative impact on nurses time availability for all of the cares required. Nurses at the bedside are very much aware of the care that they provide and those cares they omit.

The nature of providing nursing care lends itself to significant fluctuations in care requirements at any given time due to individual patient care requirements and demands. Flexibility and multi tasking are a necessary nurse characteristic in order to respond to these demands effectively.

Alarmingly there are increasingly more incidences where care needs to be prioritised, rationed or missed all together. Sound clinical reasoning and decision-making is required to ensure appropriate and safe decisions are being made most of the time.
Nursing is seen in healthcare budgetary terms as a ‘cost’ rather than ‘revenue’.


Increased restrictions placed on healthcare around the world mainly due to the global financial crisis is to reduce costs. Nursing labour resources is a significant drain on global health budgets making nursing a target for continual cost costing measures.
A negative correlation has been found between missed care and hours per patient day (HPPD) as well as registered nurse hour per patient day (RN HPPD). The higher the HPPD and RN HPPD the lower the amount of missed care.


There is no evidence in the literature that substitution of nurses with nursing assistants increases the rate of ‘missed care’. Studies conducted in medical, surgical, rehabilitation and intensive care units identified significant amounts of care being missed:

  • ambulation (84%)
  • assessing effectiveness of medications (82%).      image
  • patient teaching (80%)
  • mouth care (82%)
  • turning (82%)
  • timeliness prn medication (80%)

Interventions less likely to be missed include:

  • patient assessment each shift (17%)
  • glucose monitoring (26%)
  • hand washing (30%)
  • formal reassessment (36%)

One study in 2004 of frequency hallway ambulation by hospitalised older adults on medical units found that 73% of adult patients did not ambulate at all. This is despite clinical guidelines recommending the ambulation of adult inpatients at least three times each day.

Theoretically if ‘missed care’ could be reduced and surveillance increased would result in improved patient safety and better patient outcomes.

Patient satisfaction is accepted generally as a vital
indication of the quality of care provided.

Nurses, the care they provide and the organisational environment (cleanliness, meals) are strongly connected to patient satisfaction.Studies have demonstrated an association between nursing and patient satisfaction identifying nursing care as the only hospital service having a direct and strong relationship with overall patient satisfaction.

Other studies have found that patient perceived nurse caring is a major prediction of patient satisfaction. A 2011 European study of surgical patients spanning six countries reported that caring behaviours enacted by nurses determined a consistent proportion of patient satisfaction.

imageThe research is certainly out there that levels of HPPD and RN HPPD impact on rates of ‘missed care’, patient safety and outcome. Viewing nursing purely as a cost does not reflect ‘the whole picture’ on what appropriate levels of nurse staffing can have on healthcare budgets.

It could be argued that investing in nursing at the bedside in real terms by providing adequate staffing and skill mix whilst ensuring nurses have adequate resources at point of care will impact positively on the healthcare budget. Reduced adverse clinical outcomes, decreased length of stay, increased patient and staff satisfaction reduced errors of commission and errors of omission play a significant positive role and impact on healthcare costs.

Five questions nurses should ask prior to crushing medication:Legal implications


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An estimated 55% of drugs are administered unsafely according to 2015 Australian study Downey et al “Don’t rush to crush:audit of modifications to oral medicines for patients with swallowing difficulties”.

In the UK and Australia most drugs are “authorised for marketing” (licenced). The drug must be given (form, dose,ranges) according to its licence. Medical officers and pharmacists have legal authority to prescribe and dispense medication outside the drug license. Nurses do NOT have such authority. 

Altering the form of a drug (ie crushing) for many drugs is operating outside its licence. There are five questions nurses need to ask before proceeding with crushing medication.

1. Is there a valid clinical reason for the need to crush medications?

Patients experiencing difficulty with swallowing medication is common especially in the elderly. A nurse’s role in medication management is to ensure the patient receives their drugs as per the medication regime prescribed by a medical officer.

Crushing medications can destroy the physical and chemical properties of the drug. This can impact on the drugs effectiveness and potentially increase toxicity causing harm to the patient.

Individual preference, family pressure and ‘taking too long to swallow I don’t have enough time to stand here and wait’ are some reasons nurses might crush medications. These are NOT valid clinical reasons to crush.

Difficulty with swallowing (dysphagia) is a valid clinical reason considered appropriate for crushing medication. Nasogastric and PEG tubes being in situ are other valid reasons. If a patient is experiencing dysphagia they should be referred to a speech language pathologist for a swallow review and assessment. 

2. Is the doctor prescribing the medication aware of the nurses intent   to crush the drug?

Nursing concerns regards a patients swallow or requests from patient/family for crushing medication should be escalated appropriately. Assuming the medical officer and pharmacist are aware is not an acceptable response if decision to crush is challenged legally or professionally.

Medication management is a team effort. Patient/family, medical officer, nurse,
pharmacist and speech language pathologist are involved. Assessing and providing treatment for swallowing difficulties is important. A patient with a nasogastric or PEG tube for feeding purposes requires a comprehensive review of their medication regime.

Once a drug is prescribed and supplied outside of its licence (ie crushing in most
instances) the pharmaceutical company is no longer liable for potential side effects or harm. Clinicians making the decision to crush the drug is now liable for potential side effects or harm.

3. Are there alternatives preparations of the drug or alternative drugs available negating the need to crush?

Many drugs are not suitable for crushing ie slow release, enteric coated etc. With
increased technology and manufacturing processes it has become more difficult to determine visually if a drug is suitable to be crushed or not.

In many instances there are alternative preparations of a drug which bypasses the
necessity for crushing. Within each class of drugs are options a prescriber has in treating a condition. This allows the prescriber to choose a drug which has an alternative preparation which may be more suitable.

A conversation between the nurse, prescriber and pharmacist in most instances will be able to problem solve the issues involved without needing to crush the drug concerned.

4. Is the drug suitable to be crushed?

Some drugs are able to be crushed. The prescribing medical officer must be made aware the intent is to administer it by crushing. This needs to be clearly documented by the medical officer preferably on the patient’s medication order.

A valuable resource in Australia is a document “Don’t Rush To Crush”. This was developed in 2011 (and recently revised) by Society of Hospital Pharmacists of Australia. Additionally this text has been added to MIMS Online providing quick and easy access to all clinicians involved in medication management.

“Don’t Rush To Crush” provides comprehensive information of all oral solid drugs
available in Australia including if they can be crushed, the risks associated and how they should be prepared for administration to the patient.

5. Has the patient/family been informed of the risks associated with crushing of medications and provided consent?

Providing treatment and care outside of what is considered “usual care” requires patient consent. Consent includes providing the patient with the rationale/reason for the variance of care, the risks associated and alternative options available. Cushing medications would be considered outside usual care given the legal implications and risk for potential harm. 

The discussion and provision of consent should be well documented in the patients medical notes. The prescribing medical officer is responsible for the gaining of consent. Once a drug is NOT prescribed or administered in the form according to the marketing licence the pharmaceutical company is no longer liable legally for drug reactions.

The prescribing medical officer prescribing a drug outside of the marketing licence is legally liable for drug reactions.

A pharmacist providing a drug in the full knowledge it has been prescribed and/or administered outside of the marketing licence is additionally held liable for any drug reactions.

Nursing staff who crush medications without the knowledge of the medical officer and pharmacist is liable solely for any drug reactions potentially causing patient harm.

Providing safe nursing practice and care to patients is a nurse’s top priority. By asking these five questions of themselves or their colleagues prior to crushing any medication safeguards and protects patients and nurses equally.