Cardiovascular Disease

Introduction

This paper utilizes qualitative data drawn from a series of focus group discussions with patients living with coronary heart disease which explored their understanding of and adherence to a prescribed monitoring and medication regime. These findings are drawn upon in order to contextualize, from the patient’s perspective, the outcomes of the Departments of Health’s Coronary Heart Disease National Service Framework strategy.

The paper focuses attention on the consequences of this regulatory approach to clinical and risk management for those patients already living with coronary heart disease.

Case Study

Patient is 59 yrs old and had a myocardial infarction 2 years ago. He is obese, a smoker and poorly motivated. The case exemplifies many of the difficulties that frequently arise in managing cardiovascular disease, and suggests potential avenues for improving outcomes through the application of a disease management programme.

The Coronary Heart Disease National Service Framework

By the mid 1980s, it had been generally accepted by most clinicians that there was strong evidence to support the existence of a linear relationship between cholesterol levels and cardiac mortality (Shaper et al. 1985, Stamler et al. 1986), and that therefore lowering total cholesterol levels would reduce the risk of individuals developing coronary heart disease.

This opened the way to the process of establishing a recommended cholesterol threshold level at which treatment should be instigated (Leitch 1989). Since then, the trend has been towards setting ever-lower threshold targets for treatment for those designated as being at high risk of developing coronary heart disease and for those already living with the disease.

In 2000, the Department of Health published its Coronary Heart Disease National Service Framework which set out 12 standards for the prevention, diagnosis and treatment of the disease (Department of Health 2000). The National Service Framework standard Number 3 recommended that GPs identify and develop a register of diagnosed patients and those patients at high risk of developing coronary heart disease. Dietary and lifestyle advice (what the document terms ‘modifiable risk factors’) was to be offered to these patients, and their medication reviewed at least every 12 months. It was also recommended that statins be prescribed to anyone with coronary heart disease or having a 30% or greater 10-year risk of a ‘cardiac event,’ in order to lower their blood cholesterol levels to less than 5 mmol/l or by 30% (which ever is greater). These recommendations were vigorously promoted when they were incorporated into the new General Medical Services contract that came into operation in 2003.

The relative performance of an individual Primary Care Organization in meeting each of these indicators attracts points on a sliding scale that are then converted into payments for individual GPs. In relation to the management of patients with coronary heart disease, higher payments are received if a Primary Care Organization increases the percentage of patients with coronary heart disease who have their total serum cholesterol regularly monitored, and whose last cholesterol reading was less than 5 mmol/l (Department of Health 2004a).

The most recent Department of Health progress report on the National Service Framework argues that the massive growth in statin therapy since 2000; ‘. . . is one of the most important markers of progress on the NSF,’ and was directly saving up to 9,000 lives per year (Department of Health 2005: 19). Statin prescriptions have been rising at the rate of 30% per year since 2000, and in 2004/5 £750 million was spent on statins, equivalent to some 2.5 million people on statin therapy in England (Department of Health 2005). In July 2004, low doses of statins became available over the counter without prescription for the first time, for those at moderate risk.

The Public Health Discourse(S) Of Cardiac Risk

The application of risk discourses in the field of public health (or more precisely the ascription of health risk to particular behaviours) as conceptualized within those elements of the risk literature most influenced by Foucauldian notions of governmentality, are seen as serving to construct the socially recalcitrant as distinct from the responsible citizen (Foucault 1977, Turner 1987, Lupton 1995). In a similar way, Dean (1999) argues that once risk has been attributed to particular health behaviours, the distinction is then drawn within public health policies between ‘active citizens’ who are perceived as able to manage their own heath risks, and ‘at-risk’ social groups who become the object of targeted interventions designed to manage these risks.

Two distinct dimensions or approaches to the conceptualization and public health management of cardiac health risks also emerge from an examination of the ‘guiding values and principles’ which inform the Department of Health’s Coronary Heart Disease National Service Framework (Department of Health 2000).While one approach (described below as the ‘epidemiological’ model of risk) largely conforms to the individualized ‘at-risk’ discourse, a second discourse (described below as the ‘social’ model of risk) which is much more concerned with health risk at a social and material level can also be discerned within the National Service Framework. These two distinct and arguably competing discourses of risk point to a complexity in current public health policy that might not be anticipated from a reading of the governmentality literature alone.

The first conceptualization of cardiac risk within the Coronary Heart Disease National Service Framework is one that can be termed the ‘social’ model of health risk. This model essentially reflects a socio-economic understanding of the determinants of population health, and draws attention to the importance of addressing material, social and psychological risk factors in addition to the known biological factors in heart disease.

In the National Service Framework, this social model is reflected in the endorsement (albeit at a rhetorical level) of an interventionist role for the state in addressing these wider determinants of the disease: ‘The Government’s actions influence the wider determinants of health which include the distribution of wealth and income. A wide range of its policies will have an impact on coronary heart disease including social and legal policies and policies on transport, housing, employment, agriculture and food, environment and crime’ (Department of Health 2000: Section 1, Para 17). There is also an explicit acknowledgement that these risk factors disproportionately disadvantage particular sections of society, demonstrated in the higher incidence of coronary heart disease among the manual social classes. It is also acknowledged that there is inequity in health service provision; ‘. . . there are unjustifiable variations in quality and access to some coronary heart disease services,’ with many patients not receiving treatments of ‘proven effectiveness’ (Department of Health 2000: Section 1, Para 13).

This formal acknowledgement of the government’s role in addressing the wider social and economic influences on cardiac health risk could to some degree be said to conform to Beck’s (1992) notion of the ‘risk society’; wherein many of the health risks faced by the population are a consequence of unchecked scientific and industrial ‘progress.’ Beck asserts that in response a greater public awareness or ‘reflexivity’ of risk has emerged which reflects a shift from ignorance or private fears about the unknown to a widespread knowledge about the world we have created. The question of whether a reflexivity concerning the social and environmental factors associated with cardiac risk can be discerned in a patient’s own discourses of cardiac risk is something that will be explored in the discussion below.

The second risk discourse emergent within the National Service Framework (Department of Health 2000) is one which reflects a predominantly epidemiological understanding of health risk. In this model, the relative risk of an individual developing heart disease is based upon a calculation of the mean values associated with certain ‘lifestyle’ behaviours such as smoking, diet and exercise that are drawn from aggregated population data for heart disease incidence. This is a statistical approach that all too often perceives such calculated health risk factors as being realities or causative agents in their own right, often with little acknowledgement of the social and material context of these health behaviours.

Nevertheless, it is on the basis of this epidemiological model of health risk that the Department of Health has confidently set national guidelines that now require General

Values and principles underlying the CHD National Service Framework

Nine stated values underlying development of national policies for CHD

1. Provision of quality services irrespective of gender, disability, ethnicity or age.

2. Ready availability of consistent, accurate and relevant

   information for the public.

3. Consideration of health impact in regard to social and legal

   policies and policies on transport, housing, employment,

   agriculture and food, environment and crime.

4. Public health programmes led by health and local authorities

   to ensure targets for CHD are met.

5. Reduction in health inequalities. Resources will be targeted at

   those in greatest need and with the greatest potential to benefit.

6. Evidence-based. CHD policies are to be based on the best

   available evidence.

7. Integrated approach for the prevention and treatment of CHD in

   health policy, health promotion, primary care, community care and

   hospital care.

8. Maintenance of ethics and standards of professional practice.

9. Recognition of the importance of voluntary organizations and

   carers at home in addressing CHD.

Four stated principles underpinning the CHD NSF

. Reducing the burden of CHD is not just the responsibility of the NHS. It requires action right across society

. The quality of care depends on:

1. ready access to appropriate services

2. ii. the calibre of the interaction between individual patients and individual clinicians

3. iii. the quality of the organization and environment in which care takes place.

. Excellence requires that important, simple things are done right all the time.

. Delivering care in a more structured and systematic way will substantially improve the quality of care and reduce undesirable variations in its provision.

Practitioners to identify and monitor ‘high risk’ patients and to prescribe the recommended drug treatment regime. It can be argued that this regulatory or ‘managerialist’ approach to clinical decision-making constitutes a challenge to the discretion that has been traditionally enjoyed by general practitioners in relation to the clinical management of patients.

This second ‘official’ discourse of health risk could be seen as indicative of the regulatory and surveillance forms of governmentality identified within Foucauldian social theory. From this perspective, those social groups whose health behaviour or lifestyle are seen to fall outside the acceptable bounds of self-management then become constructed as ‘at-risk.’

These are social groups who are seen to, ‘deliberately expose themselves to health risks rather than rationally avoiding them, and therefore require greater surveillance and regulation’ (Lupton 1995: 76); once identified these groups and individuals then become subject to various health promotion or ‘health improvement’ initiatives.

Implicit in such forms of governmentality as applied within health policy interventions designed to manage risk are a set of assumptions about the nature of human action predicated on the notion of the ‘rational actor’ model. Jaeger, Renn, Rosa and Webler (2001) have argued such models of rationality operate at three levels of abstraction. In its most general form, it presupposes that humans are capable of acting in a strategic fashion by linking decisions with actions. That is, human beings are goal-orientated who have options available from which they are able to select a course of action appropriate to meeting these goals. The second level of abstraction which the authors term the ‘rational actor paradigm,’ and which is the level at which rationality is probably understood by policy-makers, contains the following assumptions: all actions are individual choices; individuals can distinguish between ends and means to achieve these ends; individuals are motivated to pursue their own self-chosen goals when making decisions about courses of action/behaviour; individuals will always choose a course of action that has maximum personal utility, that is it will lead to personal satisfaction; individuals possess the knowledge about the potential consequences of their actions when they make decisions. Finally, that rational actor theory is not only a normative theory of how people should make decisions about in this case health behaviour, but is also a descriptive model of how people select options and justify their actions (Jaeger et al. 2001: 33).

Many of these rational actor assumptions underpin and inform the Coronary Heart Disease National Service Framework. Such assumptions manifest themselves in a seemingly unproblematic approach to the promotion of ‘risky’ health behaviour change which plays down the influence of culture, habitus and the material basis of group socialization. This uncritical rationality also threatens the sustainability of the National Service Framework strategy in other ways. The social psychological and sociological literature see the notion of ‘trust’ as constituted through two dimensions, the deliberative or rational and the affective or non-rational.

As Peter Taylor-Gooby (2006) has pointed out in his work on the problematic of public policy reform, the rational deliberative processes associated with the achievement of greater efficiency in the provision of public services have unwittingly served to undermine the non-rational processes that contribute to the building of trust in public institutions and in public sector professionals. In this context, the National Service Framework will need to build trust both in terms of the presentation of the biomedical evidence for the effectiveness of statins and other cardiac drug interventions, as well as the more affective elements associated with the belief that the national targets are designed with the best interests of patients in mind rather than being driven by financial considerations alone.

Significantly, given its centrality to a ‘disease management’ strategy, neither the Coronary Heart Disease National Service Framework (Department of Health 2000) nor the NHS Improvement Plan (Department of Health 2004b) which sets out the governments priorities Coronary heart disease and the management of risk 363 for primary and secondary healthcare up to 2008, attempts to define the use of the term ‘risk,’ and by extension ‘higher risk.’ Nevertheless, the conception of risk that shapes the practical interventions proposed within both these strategy documents is clearly the epidemiological one that is described above. In the past, such public health interventions have been largely concerned with bringing about health behaviour change, however now the strategy would appear to be less focused on encouraging greater responsibility for the ‘self management’ of cardiac risk and more on ensuring compliance with clinical management regimes of monitoring and drug treatment.

Optimising Care Through Disease Management

In the last 15 years, there have been dramatic advances in the pharmacotherapy of heart disease, most notably the introduction of angiotensin converting enzyme (ACE) inhibitors. (Jaeger et al. 2001: 33) Unfortunately, numerous studies have suggested that ACE inhibitors are substantially underutilised in heart disease patients. Moreover, there are a multitude of factors which may confound heart disease management heart disease virtually never occurs in isolation, and comorbidities such as hypertension, diabetes, coronary artery disease, chronic pulmonary or renal disease and arthritis occur frequently.

The presence of these comorbid conditions may interfere with heart disease management in several ways. In PATIENT’s case, pre-existing renal insufficiency may have contributed to her intolerance to ACE inhibitors. In addition, her use of NSAIDs could promote salt and water retention and antagonise the antihypertensive effects of her other medications. (Jaeger et al. 2001: 33)

Multiple comorbidities may also result in polypharmacy, which, in turn, may compromise compliance and lead to undesirable drug interactions.

Adherence to dietary sodium restriction is often problematic (as in patient’s case), particularly in older individuals who are either not responsible for preparing their own meals, or who rely heavily on canned goods and prepared foods. Depression, anxiety and social isolation are common in patients with heart disease, and each may interfere with adherence to the heart disease regimen or with the patient’s willingness to seek prompt medical attention when symptoms recur. Similarly, the high cost of medications may limit access to therapy in patients with restricted incomes. Physical limitations, such as neuromuscular disorders (e.g. stroke or Parkinsonism), arthritis and sensory deficits (e.g. impaired visual acuity), may compromise the patient’s ability to understand and comply with treatment. Finally, cognitive dysfunction, which is not uncommon in elderly heart disease patients, may further confound heart disease management.

Impact on Clinical Outcomes

Despite the widely publicised effects of ACE inhibitors, b-blockers, angiotensin receptor blockers and other vasodilators on the clinical course of heart disease, morbidity and mortality rates in patients with established heart disease remains very high. heart disease is the leading cause for repetitive hospitalizations in adults, and in 1997 Krumholz et al. reported that 44% of older heart disease patients were rehospitalised at least once within 6 months of an initial heart disease admission. Remarkably, this rate was no better than that reported in several prior studies dating back to 1985. (Krumholz et al. 1998)

From the disease management perspective, it is important to recognise that the majority of heart disease readmissions are related to poor compliance and other psychosocial or behavioural factors, rather than to progressive heart disease or an acute cardiac event (e.g. myocardial infarction). Thus, Ghali et al. reported in 1988 that 64% of heart disease exacerbationswere attributable to noncompliance with diet, medications or both and that 26% were related to environmental or social factors. Similarly, in 1990 Vinson et al. (Vinson, 1995) found that over half of all readmissions were directly attributable to problems with compliance, lack of social support, or process-of care issues, and these authors concluded that up to 50% of all readmissions were potentially preventable.

More recently, Krumholz et al, reported that lack of emotional support among older heart disease patients was a strong independent predictor of adverse outcomes, including death and hospitalization

Rationale and Objectives

The above considerations provide the rationale for a ‘systems’ approach to heart disease management.

The objectives of this approach are as follows:

• To optimise the pharmacotherapy of heart disease in accordance with current consensus guidelines. (Vinson, 1990)

• To maximize compliance with prescribed medications and dietary restrictions.

• To identify and respond to any psychological, social or financial barriers that might interfere

• with compliance with the prescribed treatment regimen.

• To provide an appropriate level of follow-up through telephone contacts, home visits and

• outpatient clinic visits.

• To enhance functional capacity by providing an individualized programme of exercise and cardiac rehabilitation.

• To enhance self-efficacy by helping the patient and family understand that heart disease can be controlled, largely through the patient’s and family’s efforts.

• To reduce the frequency of acute heart disease exacerbations and hospitalizations.

• To reduce the overall cost of care.

The Disease Management Team

Although the composition of a disease management team may vary both from centre to centre and from patient to patient, a suggested list of team members are given below:

• nurse coordinator or case manager

• dietitian

• social services representative

• clinical pharmacist

• physical therapist/occupational therapist

• exercise/rehabilitation specialist · home health specialist

• patient and family

• primary care physician

• cardiologist/other consultants.

Each team member provides their own unique expertise and/or perspective, and these are then woven into an integrated package tailored to meet each individual patient’s needs, expectations, and circumstances. Importantly, not all patients will require the services of all team members, and it is therefore essential to identify a team leader. In most cases, this will be the nurse coordinator or case manager, who, in addition to being the patient’s primary contact person and educator, is also responsible for coordinating the efforts of other team members, including the selective activation of appropriate consultations on an individualized basis.

In addition to the team itself, several other components are essential for effective disease management. First, the patient and family should be provided with comprehensive information about heart disease, including common etiologies, symptoms and signs, standard diagnostic tests, medications, diet, activity, prognosis and the role of the patient and family in ensuring that heart disease remains under control.

This information should be provided in a readily understandable patient-friendly format and several patient-oriented heart disease brochures are now commercially available. In addition to these materials, the patient should be given a scale (if not already owned) and a chart to record daily weights, an accurate and detailed list of medications supplemented by medication aids if needed (e.g. a pill box), and specific information about when to contact the nurse, physician, or other team member in the event that questions or new symptoms arise. In this regard, the importance of establishing an effective one-on-one nurse-to-patient relationship cannot be overemphasized, as this interaction will often be critical to the early diagnosis and effective outpatient treatment of heart disease exacerbations.

Patient Perspective

While the above studies indicate a beneficial effect on costs, hospital readmissions, etc., they do not address concerns related to the patient’s perspective on this interdisciplinary care. What issues are important to the patient, and what the advantages are to the patient of participating in an heart disease disease management programme?

In recent years, it has become increasingly evident that it is insufficient to merely provide high quality medical services. In a competitive market, it is essential that the patient is also satisfied with the medical encounter, both in terms of the process of care as well as the clinical outcomes.

Healthcare is an industry, and like all industries, customer satisfaction is critically important. However, unlike most industries, which deal with a tangible product, the healthcare industry deals with a multifaceted service, the myriad qualities of which are difficult to quantify. As a result, the assessment of patient satisfaction is often complex, and the development of a valid and universally accepted instrument for measuring patient satisfaction has been elusive.

Despite these problems, several patient satisfaction questionnaires have been developed, (Garg, 1995) and these have been helpful in defining those issues which are important to patients, and in identifying specific concerns that patients often have with respect to current approaches to healthcare delivery. (Garg, 1995)

Factors which have been consistently shown to play a pivotal role in determining patient satisfaction include: communication, involvement in decision- making, respect for the individual, access to care and the quality of care provided. (Philbin, 1996) Not surprisingly, problems in each of these areas are frequently cited as factors which diminish patient satisfaction. Several components of the heart disease disease management system will be of direct assistance in answering patient’s questions and helping her cope with this new and frightening diagnosis. In particular, the nurse case manager will establish an effective rapport with the patient and her family, and provide an ongoing source of information and emotional support. The patient education brochure and other printed materials will help answer many of Patient’s questions and assist in relieving some of her anxieties.

The nurse, clinical pharmacist and physician (s) can provide detailed information and teaching about the medications used to treat heart disease, and the dietitian can directly address the dietary questions and provide an individualized diet that takes Patient’s current dietary practices and food preferences into account. The social service representative can assist patient with any financial concerns she may have, make provisions to ensure an adequate social support network, and serve as an additional source of emotional support. The physical therapist or exercise specialist can help in providing recommendations about activities and in the development of an exercise or rehabilitation programme.

The nurse case manager, social service representative, home care specialist, and physician will provide assistance to patient in making the transition from the hospital back to the home environment, and they also will ensure a high level of follow-up care. Perhaps most importantly, the comprehensive care provided by the disease management team will reassure patient that she truly is being cared for, and that all of her needs and concerns are being met.

Invariably, this will lead to a high level of patient satisfaction. In addition, in the case of patient there is good reason to believe that implementation of a disease management programme at the time of her initial hospitalization may have eliminated the need for a second hospitalization. (Young, 1995)

To the extent that patient might have to pay for some of the costs of readmission (e.g. deductible or copayment), the disease management programme would also save her money, a benefit which is universally viewed in a favorable light. And finally, based on compelling data from recent clinical trials, optimizing Patient’s medication regimen should translate not only into an improved quality of life, but also into increased survival.

Conclusion

In summary, heart disease management systems provide a win-win-win situation. They are a ‘win’ for the providers, because they improve clinical outcomes and quality of life. They are a ‘win’ for the payors, because effective disease management programmes decrease health care expenditures. And they are clearly a ‘win’ for the patients, who reap multiple benefits, including improved quality of life and well-being, enhanced self-efficacy due to a greater sense of health control, improved exercise tolerance and functionality, increased survival (as a result of more optimal utilisation of heart disease medications), and, in some cases, reduced out-of-pocket expenditures.

References

Department of Health (2000) National Service Framework for Coronary Heart Disease (London: DoH).

Department of Health (2004a) GMS Statement of Financial Entitlements (SFE) 2004/5 (London: DH).

Department of Health (2004b) The NHS Improvement Plan: Putting People at the Heart of Public Services Cm 6268 (London: The Stationary Office).

Department of Health (2005) The Coronary Heart Disease National Service Framework: Leading the Way-Progress Report 2005 (London: DH Publications).

Foucault, M. (1977) Discipline and Punish: The Birth of the Prison (London: Allen Lane).

Garg R, Yusuf S, for the Collaborative Group on ACE Inhibitor Trials. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995; 273: 1450-6

Ghali JK, Cooper R, Ford E. Trends in hospitalization rates for heart failure in the United States, 1973-1986. Evidence for increasing population prevalence. Arch Intern Med 1990; 150: 769-73

Jaeger, C., Renn, O., Rosa, E. and Webler, T. (2001) Risk, Uncertainty, and Rational Action (London: James & James/Earthscan).

Krumholz HM, Butler J, Miller J, et al. Prognostic importance of emotional support for elderly patients hospitalized with heart failure. Circulation 1998; 97: 958-64

Leitch, D. (1989) Who should have their cholesterol concentration measured? What experts in the United Kingdom suggest. British Medical Journal, 298(6688), 1615 – 1616.

Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body (London: Sage).

Philbin EF, Andreou C, Rocco TA, et al. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996; 77: 832-8

Redfern, J., MacKevitt, C. and

Graduating from a nursing program and accomplishing the long cherished journey to become Registered Nurse gives the sense of pride to many new graduate nurses. However, most nurses face challenges while separating from student life to professional life. According to Evans (2001) transition is a period of separation that causes uncertainty, insecurity and anxiety among new graduates. Moreover, Evans (2001) also identified that new graduates also expressed feelings of excitement, achievement, pride and motivation for the new role. Nevertheless, initial anxiety and happiness both the feelings are important for adapting the new role while facing the realities of professional life. The journey of transition for new graduates often remains challenging, stressful and frustrating. Most of the new graduates’ transition to the ward in the hospital environment often complains of an inability to perform their tasks within the time frame of their shift. The primary factors include increase nurse patient ratio, acuity of patients, paper documentation and complex electronic documentation, collaboration with multidisciplinary team etc. In addition, the beginning year for the new graduates usually overwhelming in terms of leaning new work environment, skills, policies and procedures, interacting with management and other healthcare professionals. It has been also observed that despite having intense clinical practicum and extensive orientation program, new graduates still feel lack of confidence while working independently in the hospital environment during transition phase. If this is a case for novice nurses working in wards, then critical care areas are even more complex and high tech skilled specialty to accommodate them.

Defining Critical Care Nursing

Critical care nursing requires licensed professional nurses to be able to provide competent care with confidence in the dynamic and critical environment where patient’s condition changes rapidly and unpredictably. Moreover, these rapid changes lead to life threatening situations which have to be dealt vigilantly. Freiburger (2002) stated that confidence in nursing practice is an important concern for the nurses working in critical care areas (intensive care units, cardiac care units, emergency departments, post anesthesia care rooms and so forth) as it is directly associated to competency. Critical care nursing is one of the most difficult, hectic, demanding and stressful specialty considered beyond the level of new graduates. Any complex practice depends on both extensive acquisition of set theoretical knowledge into practice (Benner, Sutphen, Leonard & Day, 2009). Critical Care Nurse (CCN) are the ones who depend on the specific body of knowledge, skills and expertise to provide optimal care, create healing and caring environment for not only patients but for the families or caregivers also. CCN perform clinical practice in a setting, where, patients necessitate complex assessment, high-intensity therapies, interventions, and continuous nursing observations. In addition, they should have expertise to be autonomous in making right decisions and clinical judgments to support patients and families (Vance, Koczen, Mcgee, Kuzma, & Butler, 2010). However, new graduates lack these skills, knowledge and experience to ensure patient safety, manage high-tech expertise and cope with work pressure under stressful environment (Carayon & Gurses, 2005). Moreover, the early and sudden entry of new graduates into the real world of high skilled specialty causes reality shock and often burn out. Therefore in my judgment I believe that new graduates should not assign in critical care areas right after the graduation.

Significance

According to Konvner, Brewer, Fairchild, Poornima, Kim and Djukic (2007) that 30% to 40% of new graduate nurses leave their first job within the first year due to facing a lot of challenges in critical care areas which includes lack of confidence, anxiety, critical thinking, monitoring hemodynamics and cardiovascular support and fear of managing life threatening situation. This attrition not only increases the nursing shortage but also will be costly for the hospital and other healthcare organization. New graduates often are stressful about lack of experience; lack of organizational skills, nursing procedures, clinical skills (assessing patients and administrating medications) and non-clinical skills (communicating with physicians, coordinating care and patient and family education) which ultimately lead to stressful transition or reality shock. Marlene Kramer (1979) was the first one who called this feeling which resulted from such a situation as reality shock and noted that the new graduate nurses often experience psychological stress and are less able to perceive the entire situation and to solve problems. As a result, the consequences of stress will lead to increase clinical errors which do not support safe patient care. Pellico, Brewer and Kovner (2009) investigated the experiences of newly licensed nurses’ stress which resulted from conflicting demands of practice realities, including compromised quality of patient care, time and workload pressures, staffing shortages, and the ideals of patient-centered, evidence-based, quality, and safe patient care.

Critical care units require nurses who are area specific qualified and experienced. The importance of specific knowledge practice gap and its impact in the initial phase of working in wards or critical care areas always has been a major challenge for the graduate nurses, senior nurses who provide mentorship and definitely the healthcare organization as whole. They feel unprepared to be accountable and responsible in taking care of critical patients and collaborate with healthcare professionals due to lack of knowledge and experience. In the academia, although student nurses are given intense education and skill practices under sheltered and secure environment. On the other hand, things are entirely different in the real practice settings to work independently especially in high-tech skilled clinical environment which creates anxiety and uncertainty among new nurses. Duchscher and Cowin (2004) supported the idea that the new graduates may experience inherent value discrepancies between the academic environment in which they have been raised and the real practice into which they are being initiated. However, Whitehead (2001) highlighted that the initial anxiety and feelings of uncertainty is a normal part of transition and it diminishes with experience only.

Novice nurses also feel uncomfortable in communicating and collaborating with physicians and other healthcare professionals at the entry level in the wards or critical areas. A study done by Hemani (1996) in Pakistan emphasized that due to nurse’s lack of technical and professional knowledge; doctors treated them as their handmaidens rather than as their colleagues. Critical care units comprises of multidisciplinary team where strong and effective communication skills and collaboration are the basic requirement in planning patient care. Lalani and Dias (2005) in their study found out the response of study participants who were new graduates that communicating with physicians is frightening and intimidating during the initial adjustment phase for them. Moreover, similar findings have been also reported by Duchscher (2001) in her study that the new graduates shared the fear of physicians and therefore he suggested that nurse-physician communication should be clear and effective as it directly affects the patient’s care. In addition, Boswell, Lowry and Wilhoit (2004) suggested that improvement of nurse-physician communication is essential as it enhances the ability of the new nurses to serve as an advocate for the patient.

Scenario

A novice nurse was working in ICU since 5 months and was assigned on one of a patient who was 20 years old, stable and about to transfer to the ward after having extensive treatment of acute respiratory distress syndrome (ARDS) and pneumonia. He was also inserted a chest tube due to pneumothorax and planned for the CT scan lungs before shifting to the ward. Doctor called the nurse to get ready the patient for the CT scan and then patient will be transferred to the ward directly after the scan. Nurse prepared everything and asked senior nurse to recheck her preparation. The senior nurse verified everything and signed off. But unfortunately when the senior nurse left, the novice nurse put the chest tube bottle on the bed and clamped it without asking from anyone as according to her she had learned somewhere that whenever patient goes for the scan or any procedure with chest tube, it has to be clamped. After clamping the chest tube the nurse was waiting for the doctor to accompany patient to the CT scan. It was observed that within 15 minutes of clamping, patient was gradually desaturating (spo2 from 97% to 80%), tachycardic (HR 120/min), hypotensive (BP 83/60mmhg) and the primary novice nurse was unable to assess the instability of hemodynamic. Eventually, at that time patient had a rush call having Pulseless electrical activity (HR 40/min) and code blue was announced. During CPR it was identified by the team leader that the chest tube which was inserted for the pneumothorax was clamped. It should not be clamped as air accumulated in the lungs and compressed the heart to function. Then the doctor unclamped chest tube and after 5 minutes of resuscitation, patient revived. The doctor investigated the whole situation and was very annoyed with the novice nurse. The whole situation was devastating for all of us at that moment as the patient life was at risk. This seems that even working on the stable patient, new graduates do not aware of the basic knowledge and practices. Moreover, they are also not prepared how to respond such life threatening condition and making the right clinical judgment for the patient.

Analysis & Conceptual Framework

Transition Shock in New Graduates’ Working in Critical Care Areas

The journey of new graduates is usually stressful, frustrating and discouraging also when they experience conflict role ambiguity and overwhelmed work environment. Duchscher (2007) viewed the transition shock in new graduates when they enter in the process of professional role adaptation. Especially nurses who work in intensive care areas are more prone to experience transition shock because of the complex and high skilled care setting where patient’s condition changes rapidly. Duchscher (2007) presented a transition shock model which highlights the journey of the students from the known role to less familiar role as a professional nurse. New graduates often experience contrast between the roles, responsibilities, knowledge and performance expectations which is required by the less familiar specific patient care settings such as critical care areas (refer appendix A). These areas require quick reflexes of the nurse to respond to critical situations of the patients, collaboration with physicians based on their specialized care knowledge, intuitions and experience which the new graduates are usually deprived of. In the scenario the novice nurse was having lack of knowledge that how to deal with the patient having chest tube for pneumothorax and she clamped it without knowing the consequences of it. Moreover, she did not even know how to relate the instability of hemodynamics of the patient which was caused because of the clamped chest tube. How can we ensure patient safety here or how can we say that our patients are in the safe hands? However, I believe that although the novice nurse was responsible for the patient at that time but who should be blame for? A novice nurse who has just finished her 5 months only in critical care area and still in transition phase and learning things or the healthcare institution who hire new graduates in critical care areas where patient collapse in minutes and requires experienced nurses only? The new graduates lack the depth and breadth that comes with experience (Roberts & Farrell 2003). The expectations from nurses in critical care areas are usually high and demanding which entail confidence in dealing crises situation and clinical judgment, administrating high alerts and life saving medications, and managing extensive clinical and non clinical interventions. The initial 3-4 months for the new graduates are crucial to overcome transition shock and get adjusted with the less critical area like wards where they can practice skills and learn routine work and also the processes in responding efficiently to life threatening conditions.

Stages of New Graduates’ Transition in Critical Care Areas

The newly graduates nurses when entering into professional practice; go through the process of adjustment at the beginning of initial 12 months. This initial period of work experience includes a complex but also a group of emotional, physical, intellectual, sociocultural and developmental concerns in adjustment phase. The sudden thrush of new nurses into the world of high technical or critical care area would be challenging, stress causing, and depressing while working with critical, death and dying patients. Therefore, new graduates should evolve through the stages of doing, being and knowing in the wards initially where they can have the grip of clinical expertise gradually and prepare themselves to manage patients in complex care settings (refer appendix B). The stage of “doing” involves learning, performing, concealing, adjusting, and accommodating. The stage of “being” includes searching, examining, doubting, questioning, and revealing. And the last stage is “knowing” which includes separating, exploring, recovering, critiquing and accepting the working environment (Duchscher, 2008).

Doing

The first stage doing encompasses 3 to 4 months for the new graduates in clinical area. In this stage new graduates entry marked by the instability of emotions and feeling of anxiety though the process of learning, and subsequently performing skills. They are at the primary level of understanding that what is expected from them and doing it well to complete their tasks on timely basis. However, in complex clinical context, advanced knowledge and application of skills become challenging because of lack of confidence, knowledge, experience, critical thinking, and unfamiliarity with the environment. As I mentioned in the scenario that the novice nurse was having lack of knowledge and experience of handling chest tube for the pneumothorax. Moreover, she was also not confident in assessing the instability of hemodynamics of the patient in order to take safe action on time and finally the patient was collapsed. Nevertheless, in the probation period they are budded for 3 months initially with preceptors and are given training in handling life threatening situation but 3 months are not enough to learn this complex task. Besides this, new graduates are also expected to do multi-tasking like managing unstable or dying patients, dealing with family issues, collaborate with physicians, administrating high alert medications which also require enough knowledge about the drugs, performing routine tasks and so forth. These all tasks for new graduates create stress and may lead to increase chances of errors where patients’ safety remains questionable.

Being

The second stage being encompasses next 4 to 5 months for the new graduates post orientation. This stage consists of rapid advancement in thinking, knowledge and skills as this stage advances the transition in searching, examining and revealing further knowledge and practices. In this stages novice nurses are confirming and clarifying their thoughts and actions. This motivates them in making clinical decisions to some extent and intervene nursing skills that are safe for the patients. Similarly, in relation to the scenario if the novice nurse had some previous experience of handling patients in critical situation in less complex clinical setting such as in wards, she will able to make clinical judgment at that time to act immediately to the crises situation. New graduates are also given further challenging task gradually such as unit assignments, managing stock medications, handling crash cart, and presenting case studies etc. to perform additional tasks beside nursing care. As time evolves with growing confidence, graduates feel more comfortable in adjusting with working environment. In addition, eventually they will require less physical, mental and emotional energy to manage with familiar nursing skills and clinical situations.

Knowing

The final Stage of transition “knowing” involves the initial 12 months post orientation for new graduates. This stage allows them to move from learning phase to the perceived phase with greater expectation where they can explore, recover and accept the work environment. They will be able to manage with roles, responsibilities and routine at more comfortable level. Furthermore, the critical thinking, clinical judgment and decision making skills will be more enhanced in order to respond quickly in life threatening situations and plan patient care accordingly. After going through with all three stages and completing the 12 months of transition period, these graduate nurses can be promoted to assign in critical care areas where they can utilized their learned knowledge and skills independently with more confidence. Moreover, later they can be enrolled in the specialty course (critical care certification program) gradually to be expert in their relative field.

Recommendations/Strategies

The demand of the critical care specialty can lead to frustration and burnout at very high rates among new graduates due to role transition anxiety. Therefore, to have a realistic view of smooth transition and to achieve job satisfaction among new graduates is crucial to retain nurses and overcome nursing shortage globally. Managing transition shock, assigning preceptors and coaches, making nursing peer support group and enrolling nurses in specialized critical care nursing certification program are some of the recommendations/strategies to provide safe patient care.

Solutions for Transition shock

The successful integration of new graduates in the real world of practice is a primary responsibility of the employers to accommodate them in smooth transition phase. They should be given less critical areas at the entry level to learn, understand, and adjust with the working environment. The role of clinical nurse instructor or supervisors is to arrange for experiences that would help them gaining increased competence in clinical practices. They should be given clinical responsibility and practice autonomy slowly to overcome transition shock (Roberts & Farrell, 2003). Besides this, new graduates should evaluate their own competencies, and self-appraise to analyze their own ability to function according to the expectations. If there is a lack in certain training skills, they should seek extra time to increase confidence and competency.

Preceptors and Coaches

Many new graduates are assigned to the preceptors, coaches and mentors as a part in orientation and probation period. The senior nurses’ are usually given the role of preceptor to assist novice nurses and has responsibility for supervising and evaluating the work. The preceptor-preceptee approach not only guides new nurses to become competent in practices but also develop relationship among junior and senior nurses. On the other hand, critical care areas do have preceptor-preceptee approach but the area usually gets so busy because of unstable patients almost all the time that preceptor sometimes cannot give full attention to the novice nurses which hinders their learning. Moreover, critical care areas require immediate clinical interventions and responses from experienced nurses in crises situations where novice nurses cannot respond quickly as they are still in learning and adjustment phase. Therefore, after completing the first 12 months of transition in wards, when they assign to the critical care areas they will still be given strong, supportive, prolonged preceptorship in order to understand the norms, culture and the nature of working environment of the specific area. But at that level they must have enhanced critical thinking, knowledge and experience to the extent where they can work independently and will be learning more advance technical skills on daily basis.

Nursing Peer Support

New nurses often experience more anxiety and stress after detaching from the preceptor and moving to independent practice. Therefore, peer support group plays a vital role here to provide comfort and assistance to new nurses’ in working independently. This also helps them to ask questions confidently, seek clarifications from the peer, and establish friendly relationship and environment as well. Moreover, nursing peer support group gives an environment where new nurses feel more comfortable, learn without hesitation, and feel encouragement by working together.

Specialized Orientation Program or Certifications

According to American Association of Critical Care Nurses’ (AACN), most acute care hospitals offer prolonged orientation program and almost 6-12 weeks of critical care course for the nurses to have professional knowledge and proficient in technological skills. Moreover, AACN also offers special certification course of Critical Care Registered Nurse (CCRN) – Acute/Critical Care Nursing (Adult, Pediatric & Neonatal) to deliver quality of care based on standard and specific area of knowledge and expertise. However, novice nurses in the initial stage only learn the routine tasks as well as building knowledge and experience in order to jump into the more complex expert area. This can be achieve once they complete the first 12 months of the clinical experience and can be enrolled or nominated in critical care courses to enhance further knowledge and practices. In 2006, Aga Khan university Hospital, Karachi, Pakistan had started Critical Care Diploma distance learning program of 1 year with the affiliation of George Brown university in Ontario, Canada for critical care area’s nurses’ to learn specialized course to be expert in delivering patient care in critical care units.

Limitations

One of the biggest challenge and limitation in the nursing profession is nursing shortage. The current global shortage of nurses is growing faster than the rate at which new nurses are graduating (Duchscher, 2008). Therefore, nurses are required in all the areas including critical care units. The question is that can novice nurses replace seniors nurse in critical care areas? Roberts and Farrell (2003) stated that growing rates of nurse resulting in the replacement of highly competent and experienced practitioners with newly graduated nurses who have neither the practice expertise nor the confidence to navigate a clinical environment burdened by escalating levels of patient acuity and subsequent nursing workload intensity. According to AACN (2004), in this critical situation as an option only we can assign novice nurses in critical care areas provided with intense expert mentoring, prolonged preceptorship, time and guidance to mature them as experts. Moreover, in support Proulx and Bourcier (2008) acknowledged that a specialized course program for orienting new nurses in the intensive care units should focus on helping them become technically proficient quickly and providing consistent instruction. On the other hand, AACN (2004) also stated that although new graduate nurses are needed by critical care units but they lack confidence, clinical judgment, and critical decision making and problem solving skills to respond in crises or life threatening conditions. But again, patient’s safety is at risk if they do not get enough knowledge and experience opportunity in healthcare facility.

Conclusion

The new graduates generally have limited practical nursing experience, lack social and developmental maturity and struggle with basic clinical work management skills and also balancing time with responsibilities and task. In general, they comforts with the routines of their unit and their familiarity with roles and responsibilities that have been established by the experiences gained during the initial months of their transition serve as a foundation from which they can predict and respond to presenting situations (Duchscher, 2008). On the other hand, nurse working in critical care areas have to be vigilant, competent and expert to provide quality of care to the patients. In addition, the expert level is much more flexible and skilled at integrating the elements on timely performance such as clinical grasp of an entire situation using anticipatory thinking, ethical care giving to patients and families, skillful engagement and respectful relationships with patients, families and co-workers, the management of breakdown and technical hazard, communication and negotiation skills and competency in critical thinking and clinical judgment to respond to life threatening situations.

Warfarin is an oral anticoagulant used mainly in prevention of atrial fibrillation (AF) to treat a confirmed episode of pulmonanary embolism (PE) and deep vein thrombosis (DVT). Warfarin is an antagonist of vitamin K which is needed for the synthesis of clotting factor. It takes 2-3 days to exert its full effect. In some cases immediate anticoagulation is needed, in which case low molecular weight heparin should concurrently be given with warfarin.

The possibility of developing arterial embolism in patients with uncomplicated AF has been quoted to be about 5% per year, approximately 0.01% per day3. Although this is a serious threat, these patients are not in very immediate danger. Therefore, it can be argued that there is no urgency in achieving effective thromboprophylaxis with aggressive anticoagulation and daily monitoring. Slow loading of warfarin in an anticoagulant clinic is a more suitable option, proving to be safer and more convenient for the patients. In DVT and PE patients, achieving faster anticoagulation is appropriate in order to prevent futher embolism in occuring

The effect of warfarin on the blood is measured using the International Normalised Ratio (INR) and the ideal INR in uncomplicated AF, DVT and PE patients is between 2 and 3. However in certain patients this range will vary depending on the risk of developing clots. Since warfarin has a long half life (36-45 hours)3 and individualised maintenance doses must be determined for each patient, it can be difficult to determine the ideal maintenance dose rapidly in warfarin patients. Use of

warfarin is complicated by a considerable risk for hemorrhagic side effects, which is increased in patients with low dose requirements. There is a large variability of dose requirements part of this is due to demographic and clinical facrors such as drug interaction, comordities, age, vitamin k intake, but the main factor is thought to be genetic.

At Airedale hospital, patients who are initiated on warfarin go through an Anticoagulant Risk Score (AARS). Unlike some of the other protocols, AARS takes into account age, weight, liver bone profile tests, and comorbidites into account before initiation of warfarin. Pharmacists who initiate warfarin use AARS , but sometimes this is not complied with the patient may score zero but might not look appropriate for example to give the dose according to AARS. The study will determine if the protocol is followed and weather it is effective in achieving target INR and preventing very high INRs. This audit was designed to measure any differences in outcome when a protocol was or not applied during warfarin initiation.

Several protocols have been developed to standardise warfarin initiation, and minimise the amount of time required to achieve stability, however there is no evidence suggesting the preference of one protocol over the others. The Fennerty protocol is a well known protocol, it was the first published protocol of its kind to be used for warfarin initiation. It involves dosing patients 10mg per day potentially for 4 days which could produce dangourously very high INRs.

After the initiation stage, which is typically three days at Airedale, a maintainance dose needs to be determined, again there are several protocols that exist. Complications can arise at this stage if the patient is slow metaboliser of warfarin, extra loading dose can be given at initial if the INR measursement has seen no change.

Bleeding is the most significant side effect of warfarin. The incidence of

Bleeding or haemorrage is proportional to the prothrombin time.4

so the international normalised ratio should be maintained close to the target INR range as possible.

A thorough literature review was conducted using the following databases:

EMBASE: 1980 to november 2010

Ovid MEDLINE (R): 1950 to november 2009

The search engine OVID was used to facilitate simultaneous searching of all the databases.

The following keywords were used:

Warfarin · Initiation

Atrial fibrillation · Commencement

Anticoagulation · Loading

Thromboprophylaxis

DVT

PE

Aim: –

To determine whether the current Airedale Anticoagulant Risk Score (AARS) protocol is applied to all patients and its effectiveness in producing a therapeutic INR

Objectives

To determine whether clotting screen/INR done prior to warfarin initiation

To determine whether predicted dose according to AARS is;

i)used fully,

ii)used but not complied (risk score used, clinical assessment of patient dose changed)

iii)not used at all.

To find out time taken until two INR’s in range using AARS compared to pharmacists own dosing

Find out any INR’s <1.5 or more than 4 within first week of therapy

Audit Standards

There are various recognised protocols e.g. fennerty et al; each with its own advantages and limitations. The audit will review the adherence to the AARS protocol and determine any of this protocols limitations.

Method

In order to fulfil the aims and objectives of the audit, the research design included all patients started on warfarin between 1st august 2009 and 31st January 2010. The current AARS protocol was developed in 2008. This study will examine if the protocol is complied with and if it is effective in providing efficient and safe anticoagulation. The time period of August to January was used to ensured that the current version of AARS was used. As it is a relatively long period of time it is possible a number of pharmacists could of initiated the warfarin and therefore reduce bias. It had also been nearly one year since the new version was amended therefore audit was due.

This audit was approved by the clinical effectiveness audit committe at Airedale NHS Foundation Trust in order to carry out the study.

Since the final data will consisted of quantitative data, the ideal method of collection was a data collection form. Closed questions made up most of the data collection form to make both collecting and analysing the data simpler.

The patients were identified using DAWN; an anticoagulant programme by producing a list of patients initiated within these six months. A list of 250 patients were generated from DAWN detailing patient name, date of birth, hospital number and use of warfarin. A sample of fifty patients was then selected from the resulting list. Fifty patients were chosen to ensure that enough data was collected to allow analysis.

The data was sampled by using the every fifth patient on the alphabetical list. Using every fifth patient would give a random sample. If there was a patient who was on the list but met the exclusion criteria, the next name on list was selected; if a record was missing then again the next patient will be selected.

The main outcomes measured were; if AARS protocol was complied, time taken for first INR to reach range and time taken to reach stability , secondary outcomes were very high or low INRs within first week,

Therapeutic INR will be defined as between 2-3 in this study, all the patients in this study had target range between 2-3. A minimum of two consecutive therapeutic INR measurements was denoted stable anticoagulation. Many literature sources defined stable as consecutive as two INR measurements in range.

If the INRis not stable for a 3 months or more,

The inclusion criteria was all patients started on warfarin from 1st august to 31st January. It included all patients started in hospital and referrals from GP’s.

The exclusion criteria were patients:

Anticoagualted by other than warfarin,

Who restarted warfarin after an operation

Patients who were initiated elsewhere but transferred to Airedale.

Microsoft Excel 2007 will be used for analysis of the results.

Results:

A thorough literatures search for applicable protocols produced four publications. These publications were analysed and compared with each other as well as the AARS protocol:

Table 1: Protocols

Author

Starting dose

Days for INR testing

Average time to reach stability

Advantages

Disadvantages

Fennerty

10mg/day

Days 1,2,3,4

4 days

Rapid stabilisation

Many high INRs

Daily monitoring required

Tait & Sefcick

5mg/day

Days 5,8,15

8 days

Safer than Fennerty

Accurate prediction of maintenance dose

First 4 days at 5mg/day could be dangerous

Pengo

5mg/day

Day 5

Safer than Fennerty

Accurate prediction of maintenance dose

First 4 days at 5mg/day could be dangerous

Oates et al

2mg/day

Days 8,15

6 weeks

(43 days)

Safer than previous

Accurate prediction of maintenance dose

Prediction took sex of patient into consideration

No dose change for 2 weeks

Time to reach stability 6 weeks

Janes et al

3mg/day

Days 8,15

Day 15: 86%

Day 22: 98%

Fewer episodes of high INRs, no reports of bleeding complications

Safe for elderly

No guidance on dosing for Day 15 if INR <1.4 in Day 8

AARS

Booth

Dependent on risk score

Baseline

Days 2 or 3, ab

Prediction took various aspects into consideration

Useful for initiation only, no guidance on maintainance

Demographics of participants:

There were 30 males and 20 females. The ages ranged from 40’s to 80’s with a median age in the 70’s.

Description of Sample Group:

Thirty patients who were started on warfarin were for AF, seven patient for DVT, whilst six patients for PE and seven patients in the others category.

The AARS protocol was used in nearly half the patients (24) whist in fifteen patients it was not used at all and in the others it was appreciated but not used, due to certain factors such as other medications that could interact with warfarin or just pharmacist’s experience. This is illustrated in figure 2.

Figure 2: Sample Group

Time to Reach Stability:

In this study, stability was achieved when the patient had reached the target INR for two consecutive results. This was a standard definition of stability used in several published protocols3-5. Results of the time to reach stability in the sample group are shown in Figure 3. When analysing the control group, 22% of patients were stable by week 2, and 37% were stable by week 3. On the other hand, 39% of patients in the sample group were stable by week 2, and 50% had reached stability by week 3. Although paired sample statistics did not render this difference to be statistically significant (P = 0.054), there was a 62% drop in the mean number of weeks required to

achieve stability from the control group to the sample group. The mean weeks to stability in the control and sample groups were 4.33 and 2.67 weeks respectively.

Figure 3: Weeks to reach stability

Percent stabilized

Sample

Control

weeks

INR measurements:

INR measurements were recorded and analysed from the day that warfarin was uninitiated until the patient reached stability. These measurements revealed the number of times that INRs have been recorded above or below the target level. If a group of patients were stabilised more effectively, a greater percentage of INRs would have been recorded within the target. Table 3 describes the differences in INR values prior to stability.

Another outcome measure affected by stability is the number of visits required before stability is reached. Figure 4 shows the number of visits required to reach stability in the control group and sample group. This figure shows that 33% of the patients in the sample group reached stability after 2 visits and only one patient (5.6%) required 8 visits to achieve stability. Alternatively, only 20% of patients in the control group were stabilised after 2 visits, and four patients (8%) required over 8 visits to achieve stability. Although these results seem to show a large decrease in visits required for stabilisation, the data is not statistically significant (P=0.054).

Control

Total Number

50

Male

60%

Female

40%

Minimum age

41

Maximum age

87

Median age

72

The INR can then be raised markedly once warfarin is in the system. Sometimes the maintainance dose of a patient can be 15mg, the maximum loading dose per day is 10mg, hence these patients cannot be predicted by AARS during initiation stage. These patients would take longer to stablise, as a higher dose has to be tried until stableisation