Transcript The Hyperemesis Action Research Project

The Hyperemesis Action
Research Project
Zoe Power
Prof. Heather Waterman
The University of Manchester.
Prof. Henry Kitchener
Central Manchester Hospitals NHS
Trust.
The Burdett Trust for Nursing.
Hyperemesis Gravidarum
(HG)
Persistent nausea and
vomiting of pregnancy
leading to dehydration,
ketonuria, electrolyte
disturbance and weight loss
greater than 5% of prepregnancy weight.
(Koren et al 2002, Davis 2004, Prodigy 2005).
Research Questions
Why do we have so many women
admitted with HG?
Why do so many of the women with HG
have repeat admissions?
Project Objectives
To describe the experience of HG from
the perspective of effected women.
To explore with health care professionals
(hcp’s) the barriers and facilitators to
caring for women with HG.
To identify from women and hcp’s their
views on how care and services for HG
could be strengthened and improved.
Plan of Investigation
Focus group interviews with medical and nursing
staff, (n= 4 groups, ave. 10 participants per
group).
Interviews with admitted women (n=10 women x
3 interviews).
Retrospective review of medical records. n = 119
(2 years).
Survey of anxiety and depression –HADS.
(n=200 women, 100 women with hyperemesis,
100 controls) .
Action Research group meetings (monthly).
Results: Staff Focus Groups
Three Main Themes
Unpopular-“Heart-sink” patients.
Validity of admissions (disbelief in
physical symptoms, actually
psycho-social problems).
Staff feel let down by primary care
as a frontline filter.
Unpopular group
“Some of these ladies actually believe the
hospital is a 5 star hotel, where you can just
come and chill out and get taken care of and will
have the nurses doing everything for them, get
me this get me that. Too lazy, won’t stand up and
get something from the cupboard. Some of them
have this notion that that is what the ward is
supposed to be and these are the type that will
keep coming back with vague symptoms and no
matter what you do.”[dr1sfg1]
“Heart-sink” patients (time-wasters)
[2fg2] – “It’s a bit of a waste of resources, you’re
just doing it to cover yourself. You could use the
bed for something else, but if the patients very
insistent that they want to come in, then it’s very
difficult to do otherwise.”
[4sf2]- “If they bother to wait 3 hours in A and E
and then for you, another 2 hours they have a
problem.”
[2sf2]- “But it might not be hyperemesis. It seems
quite an inappropriate way to manage them, but
I don’t know how else you can do it.”
“I think, we actually have jobs that are
terribly, terribly satisfying because we do
things and we see results and it’s that
continuity that makes your job great and
we don’t get any of that from these, do
we? I don’t know maybe we should just
dump it onto obstetrics? Maybe if you saw
them at 20 weeks and they were getting
better and they said oh thank you, you
were so good when I was vomiting and I
now feel great thank you, maybe that
would then reinforce the care that we
give.”[carg1]
Disbelief
“Most of it’s psychological anyway.” [4fg1]
“I’d say you wouldn’t see a true hyperemesis person that
often, would you? Really, a genuine.” [1fg5]
“Some women will actually starve themselves and
induce a form of hyperemesis to get away from their
home circumstances and they are inappropriate referrals
to the ward area. So, when they are there, they are noncompliant, because they see that if they get better they
are going back to the same social circumstances.” [1fg4].
Psycho-social admissions
“ Many of us perceive that many women admitted
have no support at home and there must be
many more people out there who are equally as
sick, but have a supportive family. They can sit
and rest and their family will look after the
existing family, do the ironing and cook the
dinner. Many come from unsupportive families.
The reason they come back so quickly, is
because, as soon as they get home, it is “back in
the kitchen and make my dinner”. A few we
have suspected are in an abusive relationship.”
[dr15sfg3]
Ineffective Primary Care
“Sometimes GP’s who refer ladies saying
they are very dehydrated haven’t really tested
any urine or taken their blood or even tried
anti-emetics and they’re sent as an urgency
and almost always admitted.” [nu2sfg1]
Results: Interviews with women
with Hyperemesis
Broad theme of “symptoms.”
Managing life with hyperemesis.
Hospital as a “cycle breaker” and
“burden lifter”.
Disbelief and invalidation as a
person worthy of medical attention.
Symptoms
“I felt that I was dying. I was completely dry, I
couldn’t even sip water, I couldn’t even
swallow, I had no saliva. I think, the nausea
and the vomiting gave me dehydration, and
together made me… because of dehydration I
couldn’t even stand-up myself, I couldn’t do
anything. I was simply feeling I was dying and
the feeling of nausea, and nothing to come out,
I was vomiting, but there was nothing to come
out.” [pt1/2]
“Anything I’ve eaten since Sunday has just
been coming out. So yesterday, all day, I
just didn’t eat anything. You’re starving as
well, which is funny, because you want to
eat as well, but you can’t keep it in. and
the vomiting makes you feel worse,
because it makes you feel so weak and I
start to feel very cold, just freezing, so it’s
not nice at all.” [pt8/1]
Hospital as a Burden Lifter
and Cycle Breaker
“I think I needed to come in and get that… it is
kind of a control thing because it does spiral out
of control and you can’t get it back by yourself
really … and it’s a relief even yesterday when I
was sat in the waiting room and I was sick in the
bin because I felt really terrible, even just kind of
being here and knowing that there are people
that are going to kind of look after me and take
me serious and stuff does make a huge
difference.” [pt9/1]
Disbelief and Invalidation
“I think the doctor wasn’t too good to be honest.
He was very harsh, he was just putting injections
all over me, quite roughly and it was like he
wouldn’t believe what I’m saying, that I’ve been
sick and everything, literally. He was just like,
nothing’s wrong with you and I was like…, that
day I was so bad, I couldn’t even talk properly,
so I felt a bit terrible. So that was just the thing,
I’m not going to lie about it, nobody would if your
not well, so that was a bit funny.” [pt8/1]
Conclusions - Staff
Hyperemesis patients a generally
unpopular group.
Hyperemesis believed by staff to
have a significant psycho-social
aspect.
Staff feel unsupported by primary
care in hyperemesis management.
Conclusions - Women
Women describe severe sometimes
debilitating symptoms.
Women tend to come to hospital
when symptoms become unmanageable (cycle breaking).
Women sometimes find hospital staff
dismissive regarding the severity of
their symptoms.
Why are women with HG an
unpopular group?
Why are these women
disbelieved?
“True Hyperemesis”?
Is HG stigmatised?
Changing Practice
“We’ve really got to try to like them” [1fg7]
Understanding patient experience
Highlighting problems/ issues
Integrated Care Pathway
HIS assessment questionnaire-NIHR
funded RCT.
Publications for dissemination and peer
review
Acknowledgements
Prof. Heather Waterman. School of Nursing,
Midwifery and Social Work, University of Manchester.
Prof. Henry Kitchener. School of Medicine University
of Manchester / St. Mary’s Hospital, Central Manchester
Hospitals NHS Trust.
Pam Kilcoyne. Modern Matron Gynaecology, Central
Manchester Hospitals NHS Trust.
Wards SM10 and SM9, Central Manchester
Hospitals NHS Trust.
The Burdett Trust for Nursing.