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OCTOBER 08Vol. 4 Issue 4ISSN No. 1649-7643

FEATURECancer Related Fatigue and its impact onthe Surgical Patient

FEATUREHandwashing Practices:Implications for NursingStudents

www.iarna.ie

FEATUREClinical Practice:Rhythm Strip Series

ContentsChairperson’s LetterEditorial

FEATUREHandwashing Practices: Implications forNursing Students

Disclaimer: The Irish Journal of Anaesthetic & Recovery Nursing and the Irish Anaesthetic & Recovery Nurses Association can accept no responsibility forthe accuracy of contributed articles or papers appearing in this publication and any views or opinions expressed herein are the views of contributor(s) andnot necessarily the views of the Editor(s) Association. No responsibility for loss or distress occasioned to any person acting or refraining from acting as aresult of the material in this publication can be accepted by the authors, contributors, association or publisher. It is the policy of the Irish Anaesthetic &Recovery Nurses Association to correct any mistakes or errors in any edition that are brought to the attention of the Editor(s). This will be done in thefollowing edition. Please send details to Irish Journal of Anaesthetic & Recovery Nursing, P.O. Box 5, Togher, Cork, Republic of Ireland.

Editorial Team: Josephine Hegarty Ph.D. (Editor), Grainne McPolin (Managing Editor), Aileen Burton (Production Editor), Ella Walsh (Editorial Panel).

Editorial Committee: Professor George Shorten (Department of Anaesthesia, Cork University Hospital, Wilton, Cork & Hon. President IARNA), Allen Murphy(Graphic Designer), Fiona Gaethlich (Express Publishing, Athens), Deirdre Hennessy (Dept. of History, UCC), Melanie Oakley (Editor BJARN).

Irish Anaesthetic & Recovery Nurses Executive Committee: Fionuala O’Gorman (Chairperson), Sheila Murphy (Vice-Chairperson), Grainne McPolin (Asst Sec.),Ann Hogan (Hon. Secretary), Mary Walsh (Membership Secretary), Ann Hogan (Secretary), Josephine Hegarty, Eilish Daly (Treasurer), Mary Crowley.

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© Copyright all contents IARNA

Josephine Hegarty Editor

Grainne McPolin Managing Editor

CONFERENCE REPORT27th National Conference of the AmericanSociety of PeriAnaesthesia Nurses

Photo Gallery

About the Journal

Hospital profile: Limerick’s Mid-Western Regional Hospital Complex

FEATURECancer Related Fatigue and its impact onthe Surgical Patient.

Aileen Burton Production Editor

Breda Needham Committee Member

Breda Fitzpatrick Laffan Secretary

Ella Walsh Editorial Panel

Lorraine O’Rourke Membership Secretary

Lorraine Murphy Features Writer

Fionuala O’Gorman Chairperson of IARNA

Sheila Murphy Web Manager

Ann Hogan Committee Member

A Publication part-funded through the Department of Health & Children National Lottery Grant Assistance.Development assistance of IJARN is granted through kind support from our patron

Prof G Shorten, Dept of Anaesthesia, Cork University Hospital and the South of Ireland Anaesthetics Association.

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FEATUREClinical Practice: Rhythm Strip Series

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Chairperson’s Letter & Editorial

Chairperson’s Letter

Editorial

Dear Colleagues

I wish to welcome you allto the 7th annualconference here in theSouth Court Hotel. Thiswill be the first time theconference is being held inLimerick. I wish to thankthe Limerick membersBreada Needham, BreadaFitzlaffen for their

contribution. At last years conference weconducted a research project onhypothermia, the results of which will bepresented at the Limerick conference andthis project has also been accepted forpublication in The American OperatingRoom Nurses Journal (AORN).

Another issue that I feel is relevant to ustoday is the topic of advocacy for nurses.Therefore our closing address will bedirected towards advocating for ourpatients and ourselves as professionalnurses. I feel this is very relevant in ourcurrent health care climate.

I look forward to meeting you all and yourcontinued support as members of IARNA.

SincerelyFionuala O’ Gorman

Dear Colleagues,

I hope that you find this edition of thejournal enlightening. The focus in thisedition is on issues which are important inthe practice of all health care professionalsin the surgical field.

We are delighted to welcome on board BridO’Sullivan who is an experiencedcardiovascular nurse. Brid will regale uswith a series of publications on theinterpretation of ECGs and Rhythm Strips.In addition Dawn Farrell writes thatAnaesthetic and Recovery nurses acting aspreceptors are in an optimal position topositively influence student hand hygienepractices. Patricia O’Regan also discussesthe impact of cancer related fatigue on thepatient journey.

I would also like to take this opportunity towelcome on board Aileen Burton who willact as Journal editor for the next edition ofthe journal; I hope that you will supportAileen by writing about your nursingresearch or practice developmentexperiences for the journal.

Lastly, I anticipate that the conference inLimerick will be successful and will wetyour appetite for more sharing ofknowledge and ideas, which will befacilitated in Dublin in 2009.

Professor Josephine Hegarty,PhD MSc RNT BSc RGN

Fionuala O’Gorman

Chairperson

Vol. 4 Issue 4 October 2008 Irish Journal of Anaesthetic & Recovery Nursing

Handwashing Practices: Implications for Nursing Students

Dawn FarrellBSc, RGN

Research Assistant & Staff Nurse at 4B, CUHCatherine McAuley School of Nursing & Midwifery,Brookfield Health Sciences Complex,University College Cork,Cork.

T: +353 21 [email protected]

Eileen SavagePhD, Med, BNS, RSCN, RGNAssociate Professor

Catherine McAuley School of Nursing &Midwifery,Brookfield Health Sciences Complex,University College Cork,Cork.


Anna O’ LearyRGN, BSc, NDCC, MSc.Lecturer

Catherine McAuley School of Nursing & Midwifery,Brookfield Health Sciences Complex,University College Cork,Cork.


Correspondence to:Dawn Farrell

References

Barrett, R. and Randle, J. (2008). Handhygiene practices: nursing students’perceptions Journal of Clinical Nursing17, 1851-1857.

Bradbury-Jones, C., Sambrook, S. andIrvine, F. (2007). The meaning ofempowerment for nursing students: acritical incident study. Journal ofAdvance Nursing 59(4) 342-351.

Brennan, G. and McSherry, R. (2007).Exploring the transition and professionalsocialisation from health care assistantto student nurse Nurse Education inPractice 7, 206-214.

Burton, A. (2007). Examining HandDecontamination Practices in theRecovery Room Irish Journal ofAnaesthetics and Recovery Nursing 4(1)6-8.

Centres of Disease Control andPrevention (2002). Guideline for HandHygiene in Health-Care Settingshttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm (10th January 2007).

Creedon, S. (2005). Healthcare workers’hand decontamination practices:compliance with recommendedguidelines Journal of Advance Nursing51(3) 208-216.

5Vol. 4 Issue 4 October 2008 Irish Journal of Anaesthetic & Recovery Nursing

Handwashing Practices: Implications forNursing Students Editor’s perspective

Anaesthetic and recovery nurses acting aspreceptors are in an optimal position topositively influence student hand hygienepractices. In addition patient wellbeing iscontingent on nurse’s optimal compliancewith hand hygiene guidelines. Thereforethis article is vital reading for allpreceptors.

More than a century has elapsed since arelationship between handwashing andhospital acquired infections has beenidentified (Burton, 2007). Yet, health careworkers still fail to recognise thisrelationship in everyday practice. Thehands of health care workers are deemedthe primary mode of transmission ofinfection. Therefore the simple procedureof proper handwashing is fundamental tohand hygiene and is considered one of thesingle most important control measuresfor preventing the spread of hospitalacquired infections (also known asnosocomial infections). The importanceattached to handwashing and to theprevention and control of infection inhospital settings has become subject to aplethora of guidelines in the Irishhealthcare system including SARI (2004)guidelines for hand hygiene in the Irishhealth care setting, Health Informationand Quality Authority (2007) guidelinesand the Centres for Disease Control andPrevention (2002) guidelines. However,despite the heightened emphasis oninfection control, and exhaustive researchidentifying its merits in preventinghospital acquired infections, compliancewith handwashing still remainsunacceptably low. It is regrettable thatcompliance rates for handwashing havebeen found to be less than 40%(Hugonnet et al, 2002, Creedon, 2005).

All healthcare workers have a criticalresponsibility to comply with good hand

hygiene practices. In exercising thisresponsibility healthcare workers haveobligations to be knowledgeable in theprinciples of handwashing and infectioncontrol. Numerous studies have beenperformed on healthcare workers’knowledge, attitudes and behavioursconcerning handwashing and infectioncontrol to determine reasons for lowcompliance rates (Creedon, 2005,Creedon, 2006, Whitby et al., 2006a,Barrettand Randle, 2008). Qualifiednurses have been sampled in many ofthese studies. Nurses are key healthcareworkers in preventing the spread ofinfection due to their continuous contactwith patients, and also they comprise thelargest portion of the healthcareworkforce. Although nursing students aredirectly involved in patient care duringtheir undergraduate education, there hasbeen little explicit discussion in theliterature to date on the implications ofhandwashing practices for nursingstudents. This paper aims to provide anoverview of some previous research thatexamined knowledge, attitudes andbehaviours in relation to handwashingpractices among nurses with particularconsideration to implications for nursingstudents. First, an overview of theproblem of hospital acquired infection ispresented.

The Problem of HospitalAcquired InfectionHospital acquired infection (also known asnosocomial infection) is defined as “aninfection acquired at least 72 hours afteradmission to the hospital” (Weller, 2000p. 279). Nosocomial infections are widelyrecognised as common in hospital settingswith the incidence of hospital acquiredinfections ranging from 6% to 32%(Creedon, 2005). These infections pose a


6 Vol. 4 Issue 4 October 2008 Irish Journal of Anaesthetic & Recovery Nursing

serious threat to all patients and affectnearly 10% of inpatients (Henderson andVillanueva, 2004). Multi drugresistant/notifiable pathogens associatedwith hospital acquired infection havedetrimental effects for patients (Wills,2006a). Hospital acquired infections arenotorious for the manner in which theycomplicate the course of the primaryillness, prolong hospital stay and causesubstantial morbidity and mortality. Inaddition they result in economic burdenand distress on patients and their familiesand the health sector. It is estimated thatat least 20% of hospital acquired infectioncould be prevented (Harbarth et al., 2003)and handwashing is fundamental to thisprevention.

Influence of Knowledge ofHandwashing PracticesLack of knowledge is a factor that canhave a negative effect on handwashingpractices. Researchers that have examinedknowledge of healthcare workers prior toimplementing an intervention programmehave reported deficits concerning qualityof handwashing, hand cleansing and gloveuse indications, risks associated with non-compliance and existence of publishedguidelines (Huggonnet and Pittet, 2000,Creedon, 2006). Interventionsimplemented by these researchersincluded education and training classesemphasising compliance to publishedguidelines. In addition, interventionprogrammes included training in correcthandwashing techniques, poster displaysand feedback of hand hygiene rates andnosocomial infection rates. Higuera andRangel-Frausto (2004) found that policyeducation and performance feedback ledto improvements in healthcare workerscompliance to handwashing practices,with rates increasing from 35.8% to75.8%. However, these results aretransient. Rosenthal et al. (2005) arguedthat reinforcement through long-termfeedback intervention programmes areessential to sustain long-termimprovements in compliance rates withhandwashing. These findings concur withother intervention programmes and inaddition reductions in nosocomialinfections rates have been evident (Pittetet al., 2000).

A conclusion that can be drawn fromprevious studies therefore is thatknowledge acquisition requires ongoingreinforcement and so there is a need tointensify educational programmes aimed

at teaching handwashing practices toqualified nurses. A challenge in thisregard within the current health serviceclimate of nurse shortages is to addressthe problem of clinical nurses finding itincreasingly difficult to attend in serviceeducation sessions.

The implications for nursing students aresuch that knowledge acquisition ofhandwashing practices needs ongoingreinforcement throughout theirundergraduate curriculum. Wills (2006b)identified the benefit of intensifyingeducational programmes on handwashingand microbiology in the curriculum. Thus,intensifying education will increaseunderstanding and enhance motivation,ultimately bridging the theory-practicegap. Although there has been littleresearch to date specific to nursingstudents, the findings of a recent Belgianstudy by Vandijick et al. (2007) onundergraduate nursing students’knowledge and perception of infectioncontrol were favourable. Nursing studentswere found to possess adequate knowledgein relation to handwashing and anincrease in this knowledge was noted overtheir three year programme. However, theresearchers cautioned about assumptionsconcerning the impact of knowledge onpractice implying that adequate knowledgelevels may not necessarily translate intoproper handwashing procedures in clinicalpractices.

Beliefs and Attitudes towardsHandwashing PracticesBusy working conditions are recognised asa major problem in the health servicetoday. Pittet et al. (2004) found thatphysicians perceived handwashing as adifficult task. Lack of time was anothercontributory factor found to impact oncompliance, linking a higher demand forhand cleansing and heavy workloadconditions with a lapse in handwashingcompliance (Huggonett and Pittet, 2000).

In contrast, Creedon (2005) and Wongand Tam (2005) found that nurses had agenerally positive attitude towardshandwashing guidelines, with the beliefthat compliance with handwashingguidelines has a positive outcome and thattime was not a major issue. Similarly, in astudy by Snow et al. (2006), nursingstudents reported high personalcommitment and understanding of thenecessity of handwashing. Despite thiscommitment and understanding,

References

Creedon, S. (2006). Health CareWorkers’ Hand DecontaminationPractices Clinical Nursing Research15(1) 6-26.

Health Information and QualityAuthority (2007) Annual Report 2007http://www.hiqa.ie/media/pdfs/HIQA_Annual_Report_2007.pdf (6th August2008).

Henderson, S.O. and Villanueva, H.(2004). Handwashing in the emergencydepartment Annals of EmergencyMedicine 44 (Supplement 1) S75-S75.

Higuera, F. and Rangel-Frausto, M.S(2004). National multi-centre study toevaluate the effect of education andperformance feedback on handwashingin intensive care units of three Mexicanhospitals: differences between gender,healthcare worker and type of procedureAmerican Journal of Infection Control32(3) E58-58.

Harbarth, S., Sax, H., Gastmeier, P.(2003). The preventable proportion ofnosocomial infections: an overview ofpublished reports Journal of HospitalInfection 54, 258-266

Hugonnet, S. and Pittet, D. (2000).Hand Hygiene – beliefs or science?European Society of ClinicalMicrobiology and Infectious Diseases 6,348-354.

Hugonnet, S., Perneger, T.V., Pittet, D.(2002). Alcohol-Based handrubimproves compliance with hand hygienein intensive care units Arch Intern Med162, 1037-1043.

Hunt, D.C.E, Mohammudally, A., Stone,S.P. (2005). Hand hygiene behaviour:attitudes and beliefs in first yearmedical students. Journal of HospitalInfection 59(4) 371-373.

Jungbauer, F.H.W., Van Der Harst, J.J.,Groothoff, J.W., Coenraads, P.J. (2004).Skin protection in nursing work:promoting the use of gloves and handalcohol Contact Dermatitis 51, 135-140

Lankford, M. G., Zembower, T. R.,Tricks, W.E, Hacek, D.M., Noskin, G.A,Peterson, L.R. (2003). Influence of rolemodels and hospital design on handhygiene of healthcare workers EmergingInfectious Diseases 9(2) 217-223.

Lusardi, G. (2007). Hand hygieneNursing Management 14(6) 26-33.

Maury, E., Alzieu, M., Baudel, J.L,Haram, N., Barbut, F., Gidet, B.,Offenstadt, G. (2000). Availability of analcohol solution can improve handdisinfection compliance in an intensivecare unit American Journal ofRespiratory Critical Care Medicine 162,324-327.

Picheansathian, W. (2004). Asystematic review on theeffectiveness of alcohol-basedsolutions for hand hygieneInternational Journal of Nursing 10,3-9.

Pittet, D., Hugonnet, S., Mourouga,P., Sauvan, V., Toveneau, S.Perneger, T. (2000) Effectiveness ofa hospital-wide programme toimprove compliance with handhygiene Lancet 356, 1307-1312.

Pittet, D., Simon, A., Hugonnet, S.,Pessoa-Silva, C.L., Sauvan, V.,Perneger, T.V. (2004). Handhygiene among physicians:performance, beliefs, andperceptions Annuls of InternalMedicine 141, 1-8.

Rosenthal, V.D., Guzman, S.,Safdar, N. (2005). Reduction innosocomial infection with improvedhand hygiene in intensive care unitsof tertiary care hospital in ArgentinaAmerican Journal of InfectionControl 33, 392-397.

Snow, M. White, G.L., Alder, S.C,Stanford, J.B. (2006). Mentor’shand hygiene practices influencestudent’s hand hygiene ratesAmerican Journal of InfectionControl 34, 18-24.

Strategy for the Control ofAntimicrobial Resistance in Ireland(SARI) (2004). Guidelines for handhygiene in the Irish health caresetting http://www.ndsc.ie/hpsc/A-Z/Gastroenteric/Handwashing/Guidelines/File,1047,en.pdf (6th August2008)

Vandijck, D.M., Labeau, S.O, DeSomere, J., Claes, B., Blot, S.I(2007). Undergratuate nursingstudents’ knowledge and perceptionof infection prevention and controlThe Hospital Infection Society

Weller, B.F. (2000). Balliere’sencyclopaedic dictionary of nursingand healthcare London: BalliereTindall.

Whitby, M, McLaws, M-L., Ross,M.W. (2006a). Why healthcareworkers don’t wash their hands: Abehavioural Explanation InfectionControl and Epidemiology 27(5)484-492.

Whitby, M., Pessoa-Silva, C.L.McLaws, M-L, Allegranzi, B., Sax,H., Larson, E., Seto, W.H.,Donaldson, L., Pittet, D. (2006b).Behavioural considerations for handhygiene practices: the basicbuilding blocks Journal of HospitalInfection 1-8.

Wills, T. (2006a). Prevention ofhealthcare-associated infectionsincluding meticillin-resistantStaphyloccus aureus in Ireland –the way forward British Journal ofInfection Control 7(1) 13-15.

compliance rates to handwashing stillremain low. In addition, Lusardi, (2007)found that student nurses consciouslyacknowledged their personal responsibilityin preventing the spread of infection.However, it is possible that students’positive values often change as they donot challenge the actions of qualifiedstaff, this maybe due to a perceived lackof empowerment as a junior team member.This point was highlighted by Bradbury-Jones et al. (2007), in that nursingstudents reported a “lack ofunderstanding” and a “lack of voice” asindicative of disempowerment resulting indeskilling and silent submission due tofear of reprisal. Student nurses wished tointegrate into the multidisciplinary teamand not trigger conflict resulting indetrimental effects such as poor evaluationof clinical placement.

Another barrier to appropriate complianceto handwashing practices is nurses’negative attitudes towards handdecontamination products such as alcoholrubs or water and detergents. The area ofskin irritation and hand hygiene productshas generated a great deal of research(Jungbauer et al., 2004, Picheansathian,2004). It has been found that frequentwashing with hand decontaminationproducts can cause contact dermatitis,pruritus, mild skin lesions, dry and soreskin (Maury et al., 2000). Poor skincondition can, as a result, reducecompliance with handwashing guidelines(Creedon, 2005, Barrett and Randle,2008). Creedon (2005) concluded thatthe issue surrounding healthcare workers’skin irritation needs to be tackledimmediately.

Behaviours in relation tohandwashingLack of motivation among healthcareworkers to comply with handwashingguidelines suggests that handwashingbehaviour is a complex interaction of manyfactors with influences from biologicalcharacteristics, the environment,education and culture. Role modellinggreatly influences handwashing practicesin either positive or negative ways. Goodpractices demonstrated by role models canpositively influence other healthcareworkers’ handwashing behaviours. This hasimportant implications for nursingstudents who are typically allocated toqualified nurses as preceptors (sometimes

called mentors) who then act as rolemodels during the course of placementexperiences. Barrett and Randle (2008)found that nursing students reported otherhealthcare workers as positive role modelsfor their handwashing practices. A studyby Wong and Tam (2005) on a sample ofmedical students suggests that practicesof handwashing are influenced by peerbehaviour and clinical teachers who act asrole models. Nursing students are alsoexposed to the practices of otherprofessionals while on placement.According to the nursing behaviouralmodel by Whitby et al. (2006b) senioradministrators and doctors can have apositive influence on handwashingcompliance of nurses.

In contrast, a lack of compliance amongpractitioners can negatively influencebehaviours of junior colleagues. A study byLankford et al. (2003) found thathealthcare workers who work alongsidemore senior staff who did not comply withhandwashing guidelines were alsoconsiderably less likely to wash theirhands. Whitby et al. (2006a) also notedthat senior nurses did not always influencejunior nurses in positive ways. Similarnegative behaviours were found by Hunt etal. (2005) who reported low compliance offirst year clinical students, final yearstudents and qualified doctors. Manymedical students stated their reason fornon-compliance as being “nobody elsedoes it” (i.e. washes their hands)reflecting the negative influence ofconsultants and other role models. Thissuggests socialisation of students’ negativebehaviours in practice, which is a keyfactor in understanding infectionprevention behaviour. Cohen viewedprofessional socialisation “to involve theinternalisation of the values and norms ofthe group into the person’s own behaviourand self-conceptions” (Cohen, 1981, citedby Brennan and McSherry, 2007 p. 42).Barrett and Randle (2008) also identifiedthat student nurses need to fit into thenursing team and the fear ofunacceptance and negative relationshipswith staff as a factor in detracting fromhandwashing compliance. These findingsclearly suggest that handwashing practicesare influenced by the practices ofsuperiors.

Thus, nursing students may be exposed toboth positive and negative behaviours inclinical practices through role modelling





Wills, T. (2006b). The impact ofeducation on the handwashingbehaviours of student nurses IrishJournal of Anaesthetics and RecoveryNursing 3 (2)

Wong, T-W. and Tam, W. W-S. (2005).Handwashing practice and the use ofpersonal protective equipment amongmedical students after SARS epidemicin Hong Kong. American Journal ofInfection Control 33, 580-586.

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and socialisation. There is a need forheightened emphasis on positivehandwashing behaviours by preceptors inclinical practice and reinforcement of bestpractice principles to optimise students’compliance with recommended guidelines.The experiences gained by nursingstudents during their undergraduateeducation needs to be translated into theirprofessional practice as qualified nursesin ways that contribute to positive patientoutcomes in terms of infection control.

Fostering good handwashing behaviours innursing students are also vital since thesestudents will inevitably become preceptorsonce qualified and therefore act as rolemodels to nursing students. Longitudinalstudies are needed however to identifyhow nursing students’ handwashingexperiences and behaviours duringundergraduate education translate intotheir practices as qualified nurses.

ConclusionIn conclusion, poor compliance to goodhandwashing practices is a world widepublic health problem. Infrequent andpoorly performed handwashing practicesby nurses and healthcare staff that aremost frequently in continuous contactwith patients is an ongoing concern forpatient safety. In essence, failure ofhealthcare workers to comply withhandwashing reflects negative attitudes,beliefs and behaviours. More researchneeds to be performed on nursingstudents to establish what detracts themfrom good handwashing practices.Multilevel and multifactorial educationaland motivational programmes tailored tospecific groups are needed to enhanceleadership in order to empower nurses.Consideration to how nursing students canbe socialised into positive handwashingpractices in clinical practice is also animportant step in the right direction.

Hospital profile: Limerick’s Mid-Western Regional Hospital Complex


Hospital profile: Mid-Western RegionalHospital Complex, LimerickLimerick’s Mid-Western Regional HospitalComplex which includes the DooradoyleHospital site, St Nessan’s CroomOrthopaedic Hospital and St Munchin’sObstetric Hospital. The Mid-West HSEHospital network also includes St John’sHospital, Ennis General and NenaghGeneral Hospital. There are currently 15consultants and 16 trainees in theDepartment of Anaesthesia, Intensive Careand Pain Medicine in the Mid-WesternRegional Hospital complex. The network ofhospitals is currently undergoing areorganisation of services that offers bothchallenges and opportunities for the acutehospital service in the region.

A historical perspective: The Mid-WesternRegional Hospital, Limerick was built in1955 with an original bed complement of276. The site comprised of 28 acres inDooradoyle, on the road to Cork. Over thenext 40 years many developments tookplace. During the 1980's advances intechnology meant that several areas of theexisting hospital building were modifiedand converted to new uses and a numberof extensions added. In December 1995approval was granted for theredevelopment of the existing regionalhospital into a state-of-the-art modernfacility with the full range of treatment,diagnostic, medical, social and generalservices departments and the stafffacilities required to service the out-patient and in-patient needs of thecatchment areas population.

The hospital complex has been linked withUniversity College Cork Medical School forover forty years. In what was a greatdevelopment for the region, University ofLimerick Medical School was establishedin 2007. It will have an annual intake of132 Irish medical students in 2010. It isthe first “graduate entry” medical schoolin Ireland. In addition the Department of Nursing andMidwifery spearheads the education ofnurses in the region under the leadershipof Bernie Quillinan (Head of Department).The school has an annual intake ofapproximately 150 undergraduate studentnurses and midwives.

Professor Harmon is adjunct Professor ofAnaesthesia and Pain Medicine inUniversity of Limerick. He was appointedin 2006. His main clinical and researchinterests include Pain Medicine and theuse of Ultrasound in the perioperativeperiod.

A special thank you on behalf of IARNAto Professor Harmon for his assistancewith the organisation of the annual IARNAconference in Limerick.

Professor Dominic Harmon


Patricia O’ReganCollege Lecturer,

Catherine McAuley School ofNursing and Midwifery, Brookfield Health SciencesComplex,University College Cork.

021 4901491

References

Ahlberg, K., Ekman, T.,Gaston –Johannson, F. and Mock, V. (2003)Assessment and management of cancerrelated fatigue in adults. The Lancet,362, 640 – 650.

Aarons, H., Forester, A., Hall, G. andSalmon, P. (1996). Fatigue after majorjoint arthroplasty, relationship to preoperative fatigue and post operativeemotional state. J Psychosom Res 41,225 – 233.

Corner, J. and Bailey, C. (2001) CancerNursing, Care in Context. Oxford:Blackwell Publishing.

Curt, G., Breitbart, W., Cella, D.,Groopman, J.E., Horning, S.J., Itri, L.M.,Johnson, D.H., Miaskowski, C., Scherr,S.L., Portenoy, R.K. and Vogelzang,N.J.,(2000). Impact of fatigue on the lives ofcancer patients: findings from the fatiguecoalition. The Oncologist 5 ,353 – 360.

DeCherney, A.H., Bachmann, G.,Isaacson, K., Gall, S. (2002)Postoperative Fatigue Negatively Impactsthe Daily Lives of Patients RecoveringFrom Hysterectomy. Obstetrics andGynaecology 99, 51-57

Dillon, J. E. and Kelly, E. (2003) TheStatus of Cancer Fatigue on the Island ofIreland: AIFC Professional and InterimPatient Surveys. The Oncologist, 8, (1),22–26.

Donovan, H.S. and Ward, S. (2005)Representations of fatigue in womenreceiving chemotherapy forgynaecological cancers. Oncology NursingForum 32, (1), 113 – 116.

Given, B., Given, C.W., Mc Corkle, R., etal. (2002): Pain and fatiguemanagement: results of a nursingrandomized clinical trial. OncologyNursing Forum 29, (6), 949-56.

Glaus, A. (1993) Assessment of fatiguein cancer and non-cancer patients and inhealthy individuals. Supportive CareCancer 1, (6), 305-15.

Godino, C., Jodar, L., Duran, A.,Martinez, I. and Schiaffino, A. (2006)Nursing Intervention to decrease fatigueperception in oncology patients.European journal of Oncology Nursing,10, (2), 150 – 155

Hall, G. and Salmon, P. (2002)Physiological and PsychologicalInfluences on Postoperative Fatigue.Anesth Analg 95:1446-1450

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Cancer Related Fatigue and its impact to the surgical patient

Cancer Related Fatigue and its impact onthe Surgical PatientIntroductionCancer represents a significant burden tosociety and the healthcare system; inhuman terms for patients and theirfamilies, and in terms of the resourcesconsumed in the diagnosis, treatment andmanagement of the disease (Redaelli etal, 2003). Many people with cancerundergo surgery for diagnosis, treatmentor palliation. Fatigue is a commonsymptom that accompanies surgery,chemotherapy, radiation therapy, andbiologic response modifying therapy.Cancer related fatigue is the key sideeffect reported both in the Irish context(Dillon and Kelly, 2003) andinternationally (Maughan et al, 2002).Cancer patients have reported fatigue asthe symptom that has the most negativeimpact on their quality of life comparedwith nausea, depression and pain - thesymptoms ranked most highly byoncologists (O’Regan, 2008; Curt et al,2000). Cancer patients who areundergoing surgery will potentiallyexperience fatigue prior to their surgery asa result of their pre-existing disease, theirphysical or psychological conditions.Other factors specific to surgery that mayexacerbate fatigue could include patient’spreoperative conditions, the type and theextent of their surgery, the anaestheticsinvolved in the surgery, pain and the useof opioid analgesia to reduce their postoperative pain. Post operative fatigue isan important issue following majorsurgery as it significantly delays patientrecovery. According to Hall and Salmon(2002), postoperative fatigue occurs aslong as 90 days after major abdominalsurgery. Despite these harrowing statistics

it is something that receives minimumattention in clinical practice. Despite thefrequency that cancer patients undergosurgical procedures, surgery tends to bethe least explored treatment modality in relation to fatigue.

Incidence of FatigueFatigue is one of the most commonunmanaged symptoms of cancer,occurring in 70% to 90% of cancerpatients and in 80% to 100% of thosereceiving chemotherapy (Maughan et al.,2003). Ahlberg et al (2003) whoidentified fatigue being present in 70% -100% of patients having cancertreatments, state that fatigue is moredistressing and disruptive to dailyactivities than the pain associated withthe disease. According to Miaskowski(1999), fatigue exists in 78% - 96% ofpeople with cancer and of these 12% ofpatients reported that they wanted to diedue to the severity of the symptom, while80% of oncologists also believed it is asymptom that is overlooked and undertreated in clinical practice. According toOtto (2001) the majority of patients withcancer, recovering from surgeryconsistently report fatigue which persistsfor up to 6 months. DeCherney et al(2002) concur and state that 74% ofpatients experienced moderate-to-severefatigue within the first few weeks aftersurgery. Post surgery, fatigue has asubstantial adverse impact on patientwell-being and quality of life, as well asnegatively impacting on their recovery andsurgery satisfaction rates (DeCherney etal, 2002).


Kehlet ,H. and Dahl, J (2003)Anaesthesia, surgery, andchallenges in postoperative recovery. The Lancet , 362 ,(9399),1921 -1928.

Maughan, T.S., James, R.D., Kerr,D.J., Ledermann, J.A., McArdle, C.,Seymour, M.T., Cohen, D.,Hopwood, P,, Johnston, C.andStephens, R.,(2002) Comparison ofsurvival, palliation, and quality oflife with three chemotherapyregimens in metastatic colorectalcancer: a multicentre randomisedtrial. The Lancet .359(9317):1555-63.

Mc Guire, J., Ross, G., Mortensen,N., Evans, J. and Castell, L. (2003)Biochemical markers for post –operative fatigue after majorsurgery. Brain Research Bulletin,60; (1-2), 125 – 130.

Miaskowski, C. and Lee, K. (1999)Pain, fatigue and sleepdisturbances in oncology patientsreceiving radiation therapy for bonemetastases. Journal of Pain andSymptom Management , 17,(5),320 – 332.

Miller, M., Maguire, R. andKearney, N. (2006). Patterns offatigue during a course ofchemotherapy: Results from a multicentre study. European Journal ofOncology Nursing. 11 (2) 126 –132.

O’ Regan, P. (2008) Cancer andwound care. In : Advances inWound Care, vol 1 White R, ed.Wounds UK Ltd. Aberdeen.

Otto, S. E. (2001). OncologyNursing (4th ed) St Louis : Mosby

Pick, B., Molloy, A., Hinds, C.,Pearce, S., and Salmon, P. (1994).Post operative fatigue followingcoronary bypass surgery :relationship to emotionl state andto catecholamine response tosurgery. J Psychosom Res. 38, 599-607.

Pickard-Holley, S. (1991): Fatiguein cancer patients. A descriptivestudy. Cancer Nursing 14 (1): 13-9.

Piper, B. F., Lindsey, A.M., andDodd, M.J. (1987). Fatiguemechanism in cancer patients :Developing nursing theory. OncologyNursing Forum, 14 (6), 17 – 23.

Reid, J.H. (1998) Literature review:Preoperative information – giving:an essential element ofperioperative practice. BritishJournal of Theatre Nursing, 8, (6),27 -30.

Redaelli, A., Cranor, C.W., Okano,G.J. and Reese, P.R. (2003)Screening, prevention and socio-economic costs associated with thetreatment of colorectal cancer.Pharmoeconomics. 21 (17), 1213– 1238.


Causes of FatigueThe causes of cancer related fatigue arenot fully known or understood. However,fatigue in cancer patients may have avariety of potential causes which includepre existing conditions, direct effects ofcancer treatment and the psychologicaland social demands of dealing withcancer. It is not entirely clear how thesefactors interact to produce or exacerbatefatigue. A variety of factors are believedto contribute to fatigue, including thecancer treatment, the low level of redblood cells (haemoglobin), sleepdisruption, stress, poor nutrition,inactivity and medication (Richardson etal, 1998; Godino et al, 2006). Theliterature highlights an overlap betweenfatigue and problems of psychologicaldistress, reduced functional ability andpain (Curt et al, 2000). Additionally,cachexia - weight loss is present in halfthe patients at diagnosis and two thirds ofpatients with advanced cancer whichagain will precipitate fatigue (Otto,2001). Piper et al (1987) proposed afatigue framework that encompassesbiochemical, physiologic, and behaviouralfactors that cause manifestations offatigue. These factors are modified by theperception of fatigue. Thirteen patternsare outlined as having an influence onfatigue:

• Accumulation of metabolites,• Changes in energy and energy

substrate, • Activity and rest patterns, • Sleep and wake patterns, • Disease patterns, • Treatment patterns, • Symptom patterns, • Psychological issues, • Blood oxygenation patterns, • Changes in regulation • Transmission patterns, • Environmental factors• Life events, • Social factors • Unique circadian rhythm.

Potential causes of fatigue specificallydue to surgery include: increased cardiaceffort, use of anaesthetics, route ofadministration of analgesia, alteration innutrition, decreased physical activity anduse of a variety of treatment methods(Otto, 2001). Potential common factorsthat can contribute to fatigue post surgeryinclude anaemia, pain, anxiety/depression(DeCherney et al, 2002) should be

assessed, evaluated and treatedaccordingly.

Impact of Fatigue in the ClinicalSetting Surgery has several applications in cancermanagement and treatment and is oftenthe initial and preferred treatment ofchoice for many cancers (O’Regan,2008). Surgery is frequently utilised inthe diagnosis and staging of cancerdisease including its treatment,reconstruction, prevention of disease andinsertion of therapeutic / supportivemedical devices. Despite certainlimitations, surgery continues to be a veryimportant treatment modality for cancer.By combining surgery with othertreatments such as chemotherapy andradiotherapy, mortality rates and diseasefree interval rates have increasedsignificantly (Otto, 2001). However withthis increase in treatment interventionsthe incidence of fatigue has subsequentlyincreased. There is considerable evidencestating that the occurrence of fatigueafter surgery may be especiallycompounded when adjuvantchemotherapy and radiotherapy prior to orimmediately following surgery are used(Corner and Bailey, 2001). According toDe Cherney et al (2002) 74% of patientsexperienced moderate-to-severe fatiguewithin the first few weeks after surgery,occurring more frequently and persistingtwice as long as pain. Fatigue was alsoindicated as the symptom that mostinterfered with daily activities, leading todepression, inability in concentrating andfeelings of frustration in a considerablenumber of post operative patients.Overall, it should be considered thatfatigue has a significant negative impacton patients’ quality of life as they becometoo tired to fully participate in, and enjoythe roles and activities that make lifemeaningful (Donovan and Ward, 2005). Kehlet and Dahl (2003) outline thepathogenesis of early postoperativefatigue to include sleep disturbancesinduced by cytokines and opioids, whilefatigue that persists for up to severalweeks depends on loss of muscle tissueand function, cardiovascular response toexercise, as well as level of preoperativefatigue. Surgery may also immobilisepatients because they may becomegenerally unwell, experience pain, or maybe attached to drains or infusions. Thiscould potentially lead to a cycle ofinactivity and fatigue. In addition,

Richardson, A., Ream, E. andWilson-Barnett, J. (1998) Fatiguein patients receiving chemotherapy:patterns of change. Cancer Nursing21: 17-30.

Winningham, M.L. and Barton –Burke, M. (2000) Fatigue inCancer: a multidimensionalapproach. London : Jones andBartlett.

Winningham, M.L., Nail, L.M.,Burke, M.B., et al. (1994): Fatigueand the cancer experience: thestate of the knowledge. OncologyNursing Forum 21 (1), 23-36.

Wu, H.S. and Mc Sweeney, M.(2006) Cancer-related fatigue:” It’sso much more than just being tired"Journal of Pain and Symptommanagement. 32 (3), 255 -265.

Zargar – shostari, K., Padison, J.,Booth, R., and Hill, A. (2008) AProspective study on the influenceof a fast track programme onPostoperative Fatigue andFunctional Recovery after majorcolonic Surgery. Journal of SurgicalResearch . Articles in Press.


Vol. 4 Issue 4 October 2008 Irish Journal of Anaesthetic & Recovery Nursing12

according to Mc Guire et al (2003) andAarons et al (1996), those patients witha significantly higher level of preoperativefatigue prior to major surgery alsoappeared to be those who were morelikely to be in a subjectively worseemotional and physical state post surgery.Many patients may also becomemalnourished and anaemic whileexperiencing chronic fatigue postoperatively which again will impact onboth their fatigue levels and postoperative recovery. Fatigue in cancerpatients undergoing surgery can thus lastfor weeks or months, and may be furtherexacerbated by anxiety as patientsprepare for surgery. Pain after surgery,the effects of anaesthesia, sedatives, oranalgesics may also cause fatigue. Kehletand Dahl (2003) recommend a numberof strategies that can reducepostoperative fatigue; these include acombined anaesthetic and surgical effortto reduce inflammatory responses(minimally invasive surgery, steroids, andopioid-reduced anaesthesia andanalgesia) as well as techniques toreduce catabolism (regional anaesthetictechniques, dynamic pain relief, andearly oral nutrition and mobilisation).According to Winningham et al (1994),despite the high incidence ofpostoperative fatigue observed in clinicalpractice, little research exists thatexamines causes and correlates ofpostoperative fatigue in people withcancer. Post operative fatigue is oftenoverlooked as a factor of recovery despiteit being a major problem followingsurgery (Zargar – Shosstari et al, 2008).Fatigue should be considered a majorissue for all patients preoperatively androutinely assessed for. Mc Guire et al(2003) and Pick et al (1994) highlightthat at 30 days post operatively fatiguewas highest in those patients whosenoradrenalin levels were the greatest.However, what is apparent is that whilefatigue is a problem following surgery itimproves with time but is compoundedby fatigue experienced from other cancertreatments (Winningham and Barton–Burke, 2000).

Nursing ImplicationsFor many people diagnosed with cancerand undergoing surgery, fatigue maybecome a critical issue in their lives.Fatigue may influence patient’s sense ofwell-being, daily performance, activitiesof daily living, relationships with familyand friends, and compliance withtreatment (Pickard-Holley, 1991; Glaus,1993; Given et al, 2002).Fatigue is regarded as one of the mostdistressing symptom that people withcancer develop and has majorimplications for their lives (Wu and McSweeney, 2006), The experience ofsurgery for the treatment of cancer isdifferent for each individual. All patientsshould receive thorough information presurgery including the likelihood ofdeveloping fatigue. Reid (1998) whooutline the vulnerability of the surgicalpatient, state that it is crucial that peri-operative nurses acknowledge the deficitof patients knowledge and redress thisbalance by providing continuousinformation. Peri-operative nursinginformation giving promotes optimumwell being, preparation for and copingwith surgery by empowering patients withknowledge such as pain control and thelikelihood of experiencing potentialsymptoms such as fatigue. Effectivepatient education ensures that patientshave the necessary information toparticipate effectively in care, and toadjust to the reality of their illness andits treatment. When patients have thenecessary education and knowledge, it islikely they will be more able to takeappropriate actions to manage thesymptom successfully, and will feel lessdistressed by its occurrence. In order toeffectively support cancer patients whoare experiencing fatigue and planappropriate intervention strategies,assessment is vital. Paying attention tothe patients own descriptions can helphealth care providers better understandfatigue from the individuals ownperspective and communicate better.Understanding fatigue and consequentlythe most appropriate managementstrategies should be a clear priority forthose caring for patients with cancer(Miller et al, 2006).

Clinical Practice: Rhythm Strip Series


Brid O’SullivanCollege Lecturer

Catherine McAuley School of Nursing and Midwifery, University College Cork

021-4901487

Bibliography

Bowbrick S, (2008) ECG of the MonthBritish Journal of Cardiac Nursing 3(6);236Moule P, Albarran J W, (2005) PracticalResuscitation Recognition and Response,Blackwell Publishing, OxfordPaul S, D. Hebra J D, (1998) The Nurse'sGuide to Cardiac Rhythm Interpretation:Implications for Patient Care by Saunders,PhiladelphiaPopelka K, A. (2005) Assessment of theCardiac System in Black J M, HokansonHawks J (2005) Medical Surgical NursingClinical Management for Positiveoutcomes 7th edition Elsevier Saunders,Missouri Woods S L, Sivarajan Froelicher E,Underhill Motzer S, Bridges E J, (2005)Cardiac Nursing Fifth Edition LippincottWilliams & Wilkins, Philadelphia.


Case Presentation This rhythm strip was recorded from“Jeremiah” a 74 year old farmer, duringa routine left inguinal hernia repair undergeneral anaesthetic. This man’s bloodpressure at the time of this strip was128/74; temperature 36.5° pulse 70,respirations; 14 per minute, and pulseoximetry measurement 97%. He wasphysically well prior to admission with nospecific cardiac history.

What does this rhythm strip show?

1. What is the heart rate?Look at the ECG paper. Count out 30large boxes. Now note the number ofQRS complexes within the 30 boxes and multiply by 10 to get the rate perminute. This method is effective for bothregular and irregular rhythms

Why? Because on standard 25mm/secondECG paper, each tiny box is equal to0.04 of a second in time.

There are five tiny 0.04 boxes in onelarge square box, therefore 5 x 0.04 =0.20 seconds= 1x large box Thirty of these large boxes: 30 x 0.2 =6.0 seconds x 10= 60 seconds or 1minute.

Voltage? Represents the height oramplitude of the waves. Vertically, there are five tiny boxes in alarge square and each tiny box represents1mm height. 5 x 1mm squares = 5 mm or 0.5 mV

2. What is the rhythm?

Are P waves evident? Is there a P before every QRS and a QRSafter every P? Are the P-R intervals regular or irregular? Are the QRS complexes regular orirregular? Are the QRS complexes wide or narrow?

Figure 1: This figure represents a normal PQRST complex.

Many perioperative nurses monitor patients’ cardiac rhythms. Brid O’Sullivan presentsa rhythm strip for you to review and analyse, as the first part of our series on ECG andrhythm strips analysis.


Vol. 4 Issue 4 October 2008 Irish Journal of Anaesthetic & Recovery Nursing14

Answer: Normal sinus rhythm, rate 70 per minute

3. Review the ECG complexes, Intervals and Waves

Normal Measurements Waveform This ECG strip

P waves Represents atrial depolarisation. Should be upright. 2.5 mm or less in height. Less than 0.11 of a Amplitude = 1mmsecond duration 0.8mm duration

Q waves First downward deflection from baselineShould not be deeper than 25% of Present. the following R wave Normal.

R wave First upward deflection, after Q. Present. The Q wave may or may not be visible. Normal.

PR interval This checks the impulse speed from SA to AV node. It is measured from the start of the P, to the first downward deflection of the Q wave. PR interval = Normal range = 0.12 - 0.20 seconds 4 x 0.4 = 0.16

The QRScomplex Represents conduction through the

ventricles- which causes ventricular contraction. QRS =0.8 secondsNormal range = 0.04 - 0.10 seconds (3rd complex)

The QT interval Measures duration and recovery of ventricular activity Assessed from the start of the QRS to the end of the T wave Affected by heart rate. Normal range = 0.35 - 0.45 seconds QT = 9 x 0.04=0.36

The ST segment Evident at the end of the QRS to the

start of the T wave. Isoelectric. No ST Should be level with the isoelectric line. elevation/depression.

The T waves Should be upright, not taller than 5mm in limb leads, or 10mm in Upright and normalchest leads. in lead II

The U waves May be evident after the T wave and is estimated to be around 10% amplitude of the T wave, most evident in V2-V4, Not evident in lead II.

15



Figure 2: Rhythm Strip

Conference Report


‘Be the Voice: Advocacy Through Education, Practice, Research and LegislativeInvolvement’.

The 27th Conference of the American Society of PeriAnaesthesia Nurses was held inGrapevine, Texas, approximately 40 km by road from Dallas. The Lone Star State washost to a Conference that brought nurses from the other 49 States. Indeed, there wasgood representation from Ireland sometimes known colloquially as the 51st State.The overall aim of the conference was to underline the necessity of advocacy inpatient care; the objective of the conference was to place the nurse at the centrestage of education, practice, research and legislation. In her opening address,Suzanne Gordon, a journalist, lecturer and visiting professor told a two thousandstrong audience of the urgent need for nurses to make the difficult transition from‘silence to voice’. She described the implications of ‘nursing’s invisibility’ on publichealthcare explaining why the public needs to know about nursing. Whilst Gordon’skeynote address was hard-hitting in places, it was invigorating to the point that itbrought life back into the voice of nursing advocacy.

The ASPAN Conference took place over four days of concurrent sessions that covereda wide ranging programme of the many diverse elements of peri-operative practice;from Infection Control to asthma and airway disease, from compartment syndromes topost operative neurological complications, from family visitation in PACU to care ofthe peri-anaesthesia patient. The increasing problem of obesity in peri-operativepractice was addressed in its many forms in the conference that confirmed it as anational epidemic in the USA. We were welcomed very warmly by our American hoststo the ASPAN Conference, some of whom will be travelling to Ireland to speak at the7th National IARNA Conference in Limerick on Saturday October 18th. We look forward to extending a very warm welcome to our American colleagues toIreland

Abridged presentations from the 27th National ASPAN Conference can be accessedon the IARNA Website in the coming weeks: www.iarna.ie

Grainne McPolinClinical FacilitatorPerioperative NursingUniversity Hospital Galway 27th National

Conference of the American Society of PeriAnaesthesia Nurses (ASPAN)

Texas USA May 4-8th 2008.

About the Journal


JOURNAL DESCRIPTION

The Journal is published on a quarterlybasis and provides articles, reviews, lettersand discussion on key topics, which arepertinent to the perianaesthesia nurse.Topics include updates on clinical issues,perianaesthesia nursing care, research onperianaesthesia nursing care, legislationand the practice of the perianaesthesianurse. Other features include updates onpractical innovations, book reviews,conference reports and educationsupplements.

AUTHOR GUIDELINES

The Irish Journal of Anaesthetic & RecoveryNursing welcomes manuscripts pertainingto nursing practice in the areas ofAnaesthesia and Recovery. The Journalendeavours to publish information oncurrent trends in the provision of optimumhealth care. Manuscripts (which examine anarea of clinical practice, details the author’sresearch or discusses practical innovations),short-case studies, papers expressingprofessional opinions or letters are welcomefrom all members of the multidisciplinaryteam.

EDITORIAL AND PEER REVIEW POLICY

Manuscripts are evaluated by the Editor andtwo members of the IJARN Editorial Board.While the Editor may modify the style of acontribution, major changes will bereviewed by the author prior to publication.

MANUSCRIPT PREPARATION

Submit three copies of the manuscript (onpaper) and one copy on a disc (MicrosoftWord document). Discs and paper copies ofthe manuscript will not be returned to theauthor. The manuscript must be doublespaced, wide margin (3.17 cm left and rightmargins and 2.54 for top and bottom) andshould be typed on one side of the paperonly. The word count should be up to 2000words (consult Editor for specific advice).The top sheet should display: paper title,author’s names, professional and academicqualifications, positions and place of work

and address to which all correspondenceshould be sent. Figures, legends, tables,pictures (submitted on a separate page)should be referred to in the text and theirappropriate position referred to in themargin. The main text should be precededby a short summary (100-200 words).

In the case of research carried out by theauthors, it is assumed that the authors haveconformed to the normal ethical aspects ofthe investigation and appropriate copyrightlaws.

References in the text should cite theauthor’s names followed by the date ofpublication, in date order e.g. (Murphy1990, McCarthy 1998 and Lennox 1999).Where there are three or more authors, thefirst author’s name is followed by et al(O’Sullivan et al 1999), all author’s namesare included in the reference list. Text takendirectly from another article i.e. a directquote should be referenced with the pagenumber (Ryan 2001 p. 29). A detailed listof references should be included as aseparate page which include author’ssurnames and initials, year of publication,title of paper, name of journal, volumenumber (and issue number where relevant)and first and last page numbers.

For a book citation include the author’ssurnames and initials, year of publication,title of book, (edition of book if appropriate)followed by the publisher and towncountry/state of the publisher.

When referencing a chapter in a book,details of the author and editor are given aswell.

About the JournalIrish Journal of Anaesthetic & Recovery Nursing

For further details or tosubmit an article pleasecontact Aileen Burton byemail at [email protected]

References

Bechtel, GA. and Davidhizar, R.(2005). Moving up the careerladder: staff nurses writing forpublication Nurse AuthorEducation 15(1) 7-9.

Happel, B. (2005). Disseminatingnursing knowledge - a guide towriting for publicationInternational Journal of PsychiatricNursing Research 10(3) 1147-1155.

Hodges, B. (2007). Writing forpublication: a personal viewPaediatric Nursing 19(2) 35-36.

Ruth-Sahad, L. and King. (2006).A diamond in the rough, to apolished gemstone ring: writing forpublication in a nursing journalDimensions of Critical CareNursing 25(3) 113-130.

Photo Gallery


L to RPat Smedley,

Education Officer,BARNA, Pam Windle,

Past President ASPAN,Sheila Murphy, CNM2

Recovery Cork UniversityHospital/ Web Manager

IARNA at the ASPANConference in Texas

Committee members ofthe British Anaestheticand Recovery NursingAssociation (BARNA) withFionuala O’Gorman andGrainne McPolin IARNAattending the annualconference of BARNA inJune.

Jan Odom-Forren ASPAN at the Launch of her book: 'Peri-Anaesthesia Nursing:

A Critical Care Approach at the ASPAN Conference in Texas

The IARNA committee would like tocongratulate Josephine Hegarty on herappointment as Associate Professor of Nursingat the Catherine McAuley School of Nursingand Midwifery, University College Cork.

Jessica Inch, Editor BJARN, Pat Smedley,Education Officer, BARNA, Sheila Murphy,CNM2,CUH, Manda Dunne, Chairperson,BARNA, Grainne McPolin, AnaestheticsGalway University Hospitals at the ASPAN Conference in Texas

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