LARK leadership and catheters recharge career

June 2015 Vol 15 (3)

After two decades in aged care without any study, Sabya Mohan is now enrolled for not one but two diplomas and is on the clinical nurse specialist pathway. She tells FIONA CASSIE how Waikato’s LARK leadership programme, and her change project on catheterisation, reinvigorated her career.

Sabya Mohan
Sabya Mohan

It was the drawcard of permanent daytime shifts that drew Sabya Mohan to her first nursing job in residential aged care.

Fijian-born and trained, Mohan has nursed in New Zealand for 26 years of her 30-year career. She had a variety of nursing jobs and was working shifts at Waikato Hospital when, about 20 years ago, she and her husband bought a small business and she sought a daytime job so she could manage the business in the afternoons.
The family business has since gone but she developed expertise, familiarity and a passion for the aged care sector. “So I started in aged care, kept going and never looked back.” For the past eight years, she has been at Selwyn Wilson Carlile Village’s rest home and hospital as a clinical coordinator and nurse.

Overcoming initial doubts

When her manager nominated her for the LARK leadership development programme, offered by Waikato District Health Board, it was the first extended training she had done in decades. At first she had doubts whether a leadership course was for her.
“In the beginning, when I first went to LARK it didn’t make sense to me. But I started realising we are leaders in our field.” She also found she was comfortable being in a course surrounded by fellow aged care nurses who shared her expertise, knowledge and experiences. “So when we discussed things we were on the same planet.”
A major component of the LARK programme is completing and reporting on a change project, which at first had Mohan panicking on what she should do. Then it dawned on her that she was already working on a change project – she just hadn’t given it that label as the project was just what she needed to do to better meet the clinical needs of some of her patients.

Catheterisation project an urgent need

The project was prompted by a letter from Waikato DHB’s gerontology nurse specialist Julie Daltrey noting that some of the facility’s patients had been making frequent night trips to Waikato Hospital’s emergency department.

Mohan instantly knew what the issue was. At that stage the facility had several patients with complex comorbidities and longstanding indwelling catheters that were prone to blocking or being pulled out – and this mostly occurred at night. The night duty nurse then sent them by ambulance into ED for the blockage to be cleared or the catheter to be reinserted. It seemed the right thing to do at the time.
“But this was causing a lot of trauma and distress for the frail residents. They were sitting in the cold in ED for two, three and sometimes up to five hours before it was fixed and they were sent back.” The men’s relatives were also being woken up in the middle of the night to sit and wait with them in ED. One family she approached about the issue were tearful as they talked about the long wait in the wee hours.
Mohan spoke to Daltrey and, after examining the ED reports with her, realised that if the facility’s nursing staff were competent in managing catheterisation, including reinsertion, then the patients and their families could be spared this distress.

Comorbidities cause added difficulties

Urine

Technically, it was a simple procedure that could be managed at the rest home but what made it more difficult were the complex comorbidities of the patients involved, including the fact that the most common cause of trips to ED was the catheter being blocked due to bleeding caused by trauma from the patients pulling on the tubing.
“So we had to involve a lot of people, including the families, the gerontology clinical nurse specialist, the wound care nurse practitioner, the incontinence nurse, the urology nurse, the GP and the facility manager.”
A first step was having the patients reassessed by the urology nurse to see whether they needed the catheter to pass urine, and it was confirmed that they did.

Mohan had earlier identified that the patients’ visits to ED were happening every 8 to 14 days and so the next step was reviewing with the incontinence nurse the possible reasons for the pattern. They concluded the patients only pulled on the catheter when the tube began to irritate them.

Successful two-pronged approach

The answer was two-pronged: firstly to try a different catheter product and secondly – though the norm for changing indwelling catheters was three-monthly – they decided to change the tube fortnightly to reduce the risk of irritation and the risk of more trauma from the catheter being pulled by the distressed patient.
The next step was to ask the DHB incontinence nurse to train the facility’s nursing staff so they were competent and confident in changing and managing catheters for these complex patients.

They opted for a ‘train the trainer’ approach, with Mohan to be the trainer. So Mohan was trained during a fortnightly catheter changing by the incontinence nurse, then for the next two changes Mohan did it herself under her trainer’s supervision. She then developed a three-month training plan for the other five nurses (using the same observation/supervision training model) beginning with the most vulnerable staff – the nurse on the night shift – when historically the catheter-pulling had been most likely to happen. Training on managing the catheter bag was also given to all nurses and caregivers to ensure it was strapped correctly to reduce the risk of trauma.

Patient trauma slashed

Most importantly, the project worked. The catheter patients’ visits to the emergency department came to a halt. The patient trauma was reduced dramatically, the families were no longer being disturbed in the night, the ED was pleased and the facility’s nurses were competent and confident in a new skill, with the night nurse in particular feeling more secure. It also saved the facility the $400 ambulance cost of transporting a patient to and from ED. Another bonus was the patient’s infection rate went down, with infection being another cause of the catheter being blocked.

Significant personal achievement

For Mohan, the success of the project and the LARK course opened up to her another dimension to nursing older people and what leadership can achieve.

“It made me proud, it made my patients more settled and happy, my family were happy and the staff benefited. So you experience this achievement not only for yourself but for others too.”

From being uncertain whether LARK was for her, she is now regularly invited by LARK training leader Lindsay Duncan to be a mentor for new LARK leadership trainees and share her experience. Mohan says aged care is clinically demanding and can suffer from lack of support but her project, and the support of CNS Julie Daltrey, had shown her that if she asked for help from the DHB and other colleagues then the help was there.

LARK, and its focus on career planning, has also spurred her to start studying. Last year she did two papers to complete a postgraduate certificate and this year she has enrolled in a further two papers towards her diploma in elderly care. She has now firmly taken her first steps along the pathway to a master’s degree and becoming a clinical nurse specialist in her own right.

Not content with just that, she also earned a scholarship and enrolled herself into a diploma in adult teaching to help her in her role of educating facility staff. It is a lot of study, but Mohan appears far from daunted, is relishing the challenges and is grateful to Lindsay and the LARK team for inspiring her to pursue new goals.

She laughs when asked whether she had done much studying leading up to LARK: “In 20 years of aged care I’d done no study!” But she is definitely making up for it now and gerontology nursing is the winner.

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