The curriculum development in pre-registration health at Northumbria University is a collaborative venture involving not just academic staff and current and previous students but also patients, carers and staff from NHS Trusts and other relevant organisations. Senior Lecturer Siân O’Dea summarises the processes from 2011 to date which resulted in the inclusion of topics of relevance to the care of people with Addison’s disease in the pre-registration adult nursing programme.
The catalyst for this venture was the observation of qualified healthcare staff in a number of different settings. This revealed that even when staff had knowledge of the risk of adrenal crisis, they did not always act promptly to prevent it or consider it a possibility when patient deterioration occurred. A review of the literature, including accounts of the experiences of people with Addison’s disease published in the Addison’s Disease Self Help Group newsletter, confirmed that care for people at risk of adrenal crisis was sometimes below the standard expected. This finding was timely as the department was in the process of developing a new curriculum for pre-registration health programmes for implementation from September 2012. This is the first curriculum in which all of the nursing students at Northumbria University are studying at degree level or above and it gave staff an opportunity to review the current provision and build on it using patient experiences.
Getting recognition for adrenal crisis
The first of the learning resources developed in the department was a handout, which focused on recognising, preventing and managing adrenal crisis. Dr Petros Perros, Consultant Endocrinologist at the Newcastle upon Tyne Hospitals NHS Foundation Trust, provided expert advice on the content of the handout. His support was much appreciated and proved invaluable, particularly as it soon became clear that there were some slight differences in the literature regarding aspects of this topic. The handout includes a ‘Top ten tips’ guide (see below), which advises students how to use the knowledge they have gained about adrenal crisis in day-to-day nursing practice. In other words it aims to bridge the gap between theory and practice. A group of senior students from the previous curriculum reviewed a draft of the handout to assess whether it met their needs and they made some most helpful comments. The handout was distributed to students from this curriculum too.
Peri-operative nursing care
More recently, staff have focused on nursing care before, during and after operations. The students have lectures on the general principles of pre- and post-operative care. To supplement these, Claire Ford, a very enthusiastic Graduate Tutor with recent clinical experience of working in theatre, led the design of directed study learning resources (which were also reviewed by other lecturers in the field). These resources consider the additional needs of three groups of patients who may be at risk when having surgery or other procedures. One of these groups is people taking steroids. This learning resource makes reference to the Surgical Guidelines developed by the ADSHG Clinical Advisory Panel.
Learning through role play
Another relevant learning experience that lecturers planned during the curriculum design is a ward management exercise in the University Clinical Skills Centre. This occurs during the third year of the programme in a module on leading and improving nursing. Michael Kelleher, a Senior Lecturer with considerable experience of designing simulated clinical learning opportunities, helped to develop this exercise and with the module team delivered it for the first time earlier this year. The students have to manage a group of ‘patients’ in an Emergency Admissions Unit. One of the patients in this role play is an 18-year-old student with Addison’s disease who has just been admitted with vomiting, has not been given hydrocortisone and has signs and symptoms of adrenal crisis. The students have to manage this situation in which the doctor’s brief is to be dismissive of requests for hydrocortisone and the patient’s mother arrives after an hour with an ADSHG hospital pack. This scenario (which was partly inspired by reading personal accounts in the ADSHG newsletters) has generated much discussion. In a first aid session in year two, students also have the opportunity to look at examples of external clues that a casualty might have, including medical alert jewellery, a steroid card, an adrenal crisis card and a hydrocortisone emergency injection kit.
Staff hope that these experiences will enable students at Northumbria University to be better prepared for when they encounter steroid dependent patients in practice, both in terms of day-to-day care and allowing them to recognise and treat patients with adrenal crisis in a timely and effective manner.
Siân O’Dea is a Senior Lecturer in Adult Nursing in the Department of Healthcare which is part of the Faculty of Health and Life Sciences at Northumbria University. She teaches theory underpinning practice, clinical skills and first aid to undergraduate nursing and other healthcare students.
TOP TEN TIPS
To prevent adrenal crisis:
1. Routinely check on admission whether patients are taking steroids or have done so in the last year.
2. If so, check immediately that these have been prescribed and confirm with the doctor that:
- if required, the individual’s usual dose of steroids has been increased to cope with the stress of their illness, particularly infection, injury or surgery
- the steroid has been prescribed by an appropriate route – the patient may be given intravenous or intramuscular hydrocortisone instead of their usual steroid
- fluid resuscitation has been commenced, if needed.
3. Administer the prescribed steroid – on time, every time – like Parkinson’s medications. This may be at non-standard times, e.g. people with Addison’s disease need to take their first dose of hydrocortisone as soon as they wake up.
4. Listen to patient concerns about their steroids – they and their family may be experts on this. Check if they have written information for staff, e.g. an Addison’s disease hospital pack containing detailed leaflets for doctors and nurses about their steroid treatment and adrenal crisis, as well as ‘steroid-dependent’ stickers for their medical/nursing records/charts.
5. Document in the nursing record that the patient is at risk of adrenal crisis.
6. Include this information in the handover report.
7. Monitor patients closely, including their lying and standing blood pressure. Remember that any deterioration may be an early warning sign of adrenal crisis – so request urgent medical review – prompt action might save the patient’s life.
8. If a patient becomes unwell during their hospital stay, e.g. develops an infection, starts vomiting, or needs surgery, make sure their steroid prescription is reviewed and increased/changed to a different route, if needed. Remember this too if the patient is nil by mouth – steroid doses cannot be missed (or late).
9. Remind medical staff that the endocrinology team can be contacted for advice.
10. Educate the patient/family before discharge and make sure they have:
- a steroid card
- written information about steroids and adrenal crisis
- alerts set on their hospital and ambulance service records indicating they are steroid-dependent and at risk of adrenal crisis.
From: O’Dea, S. 2013. Information for nurses.Steroids… what you really need to know… Newcastle upon Tyne: Northumbria University
Curriculum content relating to steroid dependency for
Pre-registration Adult Nursing programmes at Northumbria University
This article was first published in the June 2015 edition of the ADSHG newsletter.