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Nurses and Interprofessional Teamwork. Where do we stand? Roberta Heale, Associate Editor, EBN @robertaheale Join Twitter Chat Wed, Sept 3, 8-9pm UK time #ebnjc

30 Aug, 14 | by rheale

The past decade has seen a push toward the evaluation of teamwork in healthcare, particularly interprofessional teamwork. The World Health Organization indicates that ‘interprofessional collaboration in education and practice…will play an important role in mitigating the global health workforce crisis” (2010, p. 7). In addition, Effective teamwork promotes a work environment that has a positive impact on both staff and patients. However, simply working together doesn’t necessarily mean that there will be effective teamwork (Kalisch & Lee, 2009).

There is a wealth of research data related to interprofessional teamwork. There is recognition of interprofessional teamwork in acute care and a primary healthcare reform across the globe that includes the development of interprofessional teams. So…what does interprofessional teamwork mean to nurses?

Nurses have traditionally worked within teams. Hospital units are characterized by teams of nursing staff who are often the ‘permanent’ staff on a unit. Other health care providers including physicians, social workers, respiratory care etc. filter in and out of the unit and work in collaboration with the nursing staff to ensure optimal patient care. Research has found that positive teamwork was associated with greater staff retention and less job stress and burnout (Rafferty et al., 2001). However, there are many barriers to positive interprofessional teamwork. Collaboration among team members is one of the ongoing issues of teamwork. For example, a poor physician/nurse relationship was the number one reason for intention to leave the nursing profession in a research study of nurses in Europe (Heinen et al., 2013).

Barriers and facilitators to interprofessional teamwork are understood, however, the impact of these on team functioning isn’t well known. I, along with colleagues, developed the Interprofessional Team Functioning Survey. It captures a team members’ perception on how well a team is functioning. Items reflect the typical barriers to teamwork including communication, education about teamwork, an understanding of other team member’s roles and organizational policies to facilitate teamwork. Also included is a question about the member’s perception of hierarchy among team members. A study of primary health care nurse practitioners in Ontario, Canada demonstrated well functioning interprofessional teams, however, there is a need for better organizational support and formal education about interprofessional teams to facilitate better teamwork.

This is a brief snapshot into the perceptions of a small group of specialized nurses.  Given the prevalence of inter professional teamwork, it is helpful to explore this phenomenon among all nurses.

EBN’s Twitter Chat on Wednesday, September 3 from 8-9 pm UK time will focus on nurses’ experience with interprofessional teamwork.

Points to consider for the chat:

1. What has your experience been with interprofessional teams?

2. Do interprofessional teams help, or hinder nursing care and patient health outcomes?

3. What work needs to be done to improve interprofessional team functioning?

Participating in the EBN Twitter Journal Chat

To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

• You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter

• Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag). NB not including #ebnjc means people following the chat won’t be able to see your contribution.


Heale, R., Dickieson, P., Wenghofer, E., & Carter, L. (2013). Nurse practitioners’ perceptions of interprofessional team functioning with implications for nurse managers. Journal of Nursing Management. DOI: 10.1111/jonm.12054

Heinen, M. M., van Achterberg, T., Schwendimann, R., Zander, B., Matthews, A., Kózka, M., et al. (2013). Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries. International Journal of Nursing Studies, 50(2), 174–184. doi:10.1016/j.ijnurstu.2012.09.019

Kalisch, B.J. & Lee, H. (2009). Nursing teamwork, staff characteristics, work schedules, and staffing. Health Care Management Review, 34(4), 323-333.

Rafferty, A.M., Ball, J., & Aiken, L.H. (2001). Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Quality in Health Care, 10, ii32-ii37. World Health Organization (WHO) (2010) Framework for Action on Interprofessional Education and Collaborative Practice Available at:

The Blue Gym – Oceans and Human Health by Dr Fiona McGowan Senior Lecturer School of Health, Sport and Bioscience University of East London

23 Aug, 14 | by Calvin Moorley, Associate Editor

Recently I was invited to join the editorial board of the Journal of the Marine Biological Association. With a background in health and social care, a PhD in medical sociology and my current role as a Senior Lecturer in Public Health and Health Promotion, I would seem to be rather an ‘atypical’ candidate for this role. My knowledge of biscuits is quite extensive but still limited to those, which are edible, and more usually prefixed with the word ‘chocolate’ rather than ‘sea’!!

However, this opportunity to contribute to a markedly different subject area, indicates something of a sea change (!!) Increasingly, as we learn (and experience) more about climate change, ocean acidification, pollution, the links between human health and the marine environment become ever more apparent. Though it is not all negative. For example, the concept of the ‘blue gym’ is a new area of research that explores how health and wellbeing are correlated to living near the coast and reveals the benefits of proximity to the sea on both physical and mental health.

The importance of ‘green space’ in improving mental health by alleviating stress and depression, enhancing and promoting physical activity is now well established. In comparison the ‘natural ‘ environment relating to water – the coasts and seas – is only just emerging as an influential determinant of population and individual health. Yet, this relationship is becoming increasingly important in light of rapidly growing coastal populations and climate change. Significant public health benefits can be bought about through a better understanding of the highly complex marine environment and human health interactions click on link below.

Oceans and humans

This illustrates some of the key areas where the risks and benefits for human health and wellbeing are linked to the marine environment.


These developments signal the need for greater interdisciplinary projects, partnerships and collaborations. My associate editorship is one small indicator of this. I am now involved in the planning of two special issues of the JMBA which will have a much broader remit, with contributions from those working in public health and health promotion, biological and environmental sciences, behavioural and social sciences – reflecting that though the focus of marine biology has traditionally reflected a reductionist ‘hard science’ approach, there is now a real need to be more inclusive, collaborating with academics, researchers, practitioners and professionals with wider areas of expertise relating to human health and wellbeing.


A further development is the Oceans and Human Health integrated research project – an interdisciplinary project which brings experts together not only from the field of marine science but also those representing environmental and social science, medicine and public health. Last month, the European Centre for Environment and Human Health (ECEHH) and the European Marine Board jointly organised the first OHH workshop where a number of key professionals, researchers and academics gathered to identify and discuss the risks and benefits from interactions with the coastal and marine environment. Most symbolic is that this event demonstrated the necessity of knowledge exchange, information sharing and wider community engagement. One of the key aims of OHH is to build an effective collaborative body of researchers and professionals working together to realise the ways in which human health and the blue environment impact each other– negatively and positively, indirectly and directly. For both, there are consequences, both damaging and beneficial, some more immediate than others – BUT only by gaining greater understanding and adding ‘weight’ through projects such as OHH can any meaningful action result.


As mentioned earlier, the intention of the forthcoming JMBA issues will be to promote, facilitate and encourage knowledge exchange between a wide range of disciplines. The common objective for ALL is to gain a better appreciation and greater understanding of the interdependency of human health and the oceans, seas and coasts.


For more information visit

( See ‘ A message from Bedruthan’ in the list of documents)

Dr Fiona McGowan

Senior Lecturer Public Health/ Health Promotion





Ebola – a global health problem?

17 Aug, 14 | by josmith

I will be hosting this week’s ENB twitter chat on Wednesday the 20th of August between 8-9pm focusing on ‘Ebola viral disease – a global health problem?’ Participating in the twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account contributing is straightforward – follow the discussion by searching links to #ebnjc @EBNursingBMJ, or better still, create a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

This past week, the Ebola outbreak in Africa has been reported extensively. Ebola viral disease is a severe, often fatal illness caused by the Ebola virus, with a 90% fatality rate. Transmission of the virus to humans is by contact with blood or bodily fluids from infected animals most commonly monkeys or fruit bats (thought to be the natural host for the Ebola virus); once in the population human-human spread rapidly occurs. Outbreaks primarily occur in tropical rainforests such as the remote villages in Central and West Africa. Ebola viral disease is named after the Ebola River in Zaire, where the first outbreak in Sudan and Zaire was reported in 1976; over 284 people were infected and 53% of infected people died. A second outbreak followed a few months later in Yambuku, Zaire with a different virus strain (Ebola-Zair or EBOZ) which had a higher mortality rate (88% of the 318 infected people died). There have been other strains of the Ebola virus, the last known being Ebola Cote d’Ivoire (EBO-CI) identified in 1994. The current outbreak of Ebola viral disease is the largest to-date affecting  Guinea, Sierra Leone, Liberia and Nigeria with more than 1,750 suspected cases reported.

Symptoms of Ebola viral disease occur two days to three weeks after being in contact with the virus and include fever, sore throat, muscle pain, headache, nausea, vomiting, and diarrhoea, which can result in decreased liver and kidney function, and can cause internal and external haemorrhaging (hence it was formerly known as Ebola haemorrhagic fever). There are currently no licensed treatments or vaccines available for Ebloa viral disease; care is supportive and symptom management, with severely ill patients requiring intensive supportive care. Several experimental treatments for Ebola viral disease are in development (Zmapp and Tekmira) and although results are encouraging have only undergone animal testing and testing on a small number of healthy human volunteers. A number of prototype vaccines again are in early development and potential vaccines may be available as early as 2016.

Stigma and victimisation are features of Ebola epidemics, with reports of infected individuals and health workers being ostracised by the community, unable to find work, abandoned by their partners and the possessions and homes of some survivors burned. In this current outbreak there have been reports that a quarantine centre for suspected Ebola patients in the Liberian capital of Monrovia have been attacked.

The World Heath Organisation has issues two statements this month in relation to viral disease:

Ethical considerations for use of unregistered interventions for Ebola viral disease (EVD) 12 August 2014

Panel identified areas that need more detailed analysis and discussion, such as:

  • Ethical ways to gather data while striving to provide optimal care under the prevailing circumstances;
  • Ethical criteria to prioritize the use of unregistered experimental therapies and vaccines;
  • Ethical criteria for achieving fair distribution in communities and among countries, in the face of a growing number of possible new interventions, none of which is likely to meet demand in the short term.

WHO Statement on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa 8 August 2014

The Committee advised that:

  • The Ebola outbreak in West Africa constitutes an ‘extraordinary event’ and a public health risk to other States;
  • The possible consequences of further international spread are particularly serious in view of the virulence of the virus, the intensive community and health facility transmission patterns, and the weak health systems in the currently affected and most at-risk countries;
  • A coordinated international response is deemed essential to stop and reverse the international spread of Ebola.

Questions for consideration:

  • Malaria, tuberculosis and measles (measles caused 122,000 deaths in 2012 remain worldwide killer diseases, is the current media focus on Ebola justified?
  • Does the Ebola epidemic highlight that vaccination uptake for infectious diseases, such as measles, rubella and pertussis which are increasing, should be a public health priority?
  • What role should developed countries take in relation to Ebola viral disease, if any?
  • What ethical and research principles, such as informed consent, apply when faced with a health crisis and in different cultures?
  • How will the media and world health community respond and what are the consequences of introducing a ‘trial’ drug, particularly if the drugs are ineffective or cause harmful reactions?  What are the implications of not offering these ‘trial’ drugs?
  • While Ebola remains a genuine concern in West Africa, would the outcome in terms of mortality be similar in countries with well developed healthcare systems?

Sources of information

Joanna Smith, Senior Lecturer Children’s Nursing, University of Huddersfield, Associate Editor EBN.   Tweet me @josmith175

Join in the twitter chat #ebnjc@EBNursingBMJ

Recognising the care needs of older gay and lesbian people. By Calvin R Moorley Twitter @CalvinMoorley

11 Aug, 14 | by Calvin Moorley, Associate Editor


I lead a course on later life and health promotion; one of the topics covered was the care needs of older gay and lesbian people. We had an external speaker for part of the lecture who shared his experience as an older gay man when his partner was in hospital. At the end of each lecture students are asked to write a blog sharing their views.

The students on my course blogged that older people care needs are often overlooked as the sexuality of older people is generally not incorporated as part of care needs as physical and functional care becomes the focus. Some blogged about equality and diversity training for care staff, others on the lack of intergenerational support, one student blogged on coming out of a closeted period to an open era and that the person concerned may not always feel confortable with this openness and due consideration is needed when caring for older LGBT patients.

On reflection of the students blogs’ I went into my clinical practice area and started to make notes on how we care for people based on sexual orientation, by talking to colleagues, most gave the textbook answers but also said that it can be difficult. I beg to differ simple actions such as including the partner or close friends, asking partners how you can call or refer to them, sends the message that you recognise the value of gay and lesbian relationships. One colleague said to me we may find that older people who have lived an openly gay lifestyle may find themselves re-entering a ‘closeted’ lifestyle so that they are not discriminated against. This simply means that an older person may hide their sexual orientation for fear of not receiving equal care. What is equal care I hear you ask? Simply put you treat each patient regardless of their age, gender, race, ability, social class, sexual orientation, or any other labels they may be assigned in the same manner, with the same respect and care afforded to all. Importantly that particular patient should feel confortable to express their care needs and wishes to the health professional with no fear of different treatment. I wonder how much the change in legislation to gay and lesbian couples in terms of civil partnerships, unions and marriage has impacted on the way we provide care to this group of patients. The change in legislation may boost confidence in older gay and lesbian patients to express themselves and who and how they want to be cared for. The point I’m trying to make is that people’s sexual orientation is central to who they are and how they will like to be treated.

In last week’s blog and #EBNJC Nova Corcoran discussed hard to reach groups, and the strategies that we employ to meet the public health and health promotion needs of such groups. One participant @BenScott said he works with older people and falls in a rural community, can you imagine the double isolation the older person who is gay or lesbian may experience in such situations? I live and work in London and most, not all times the majority of the general population is accepting of such groups but in rural community without the right support networks and training for staff such groups access and health care treatment can be adversely affected.

My final thoughts are where is the evidence in caring for such groups, in the UK we have set up link/champion roles for ward nurses such as infection control, manual handling, diabetes etc. The time has come for hospitals to show their commitment to caring for gay and lesbian patients and have a gay champion in wards and departments.

Reaching unreachable Groups by Nova Corcoran, Senior Lecturer, University of South Wales. Twitter @NovaCorks

3 Aug, 14 | by Calvin Moorley, Associate Editor



Firstly, the title of this blog is misleading. No group is unreachable. A better term is ‘hard to reach’ as this implies the possibility that they can be reached. Why are they hard to reach? Here are two suggestions. Firstly, the very nature of society and our norms, values and practices exclude certain people so they become removed from participation in society. For example the common belief that poor people are poor due to their own personal failing; notably the belief that “they” are lazy, addicted to drink and drugs and don’t manage their money properly (See the OXFAM 2013 Truth and Lies debate on Poverty for more on this) perpetuates how individuals respond to those who are poor and how society responds to poverty elimination. Secondly, if we are not reaching certain groups we are probably using the wrong approach and are unable to engage these groups in a meaningful way. Both of these arguments are not a criticism of individual healthcare workers but they are the result of the way society responds to socially excluded and minority groups. In turn this influences the ways we work and respond to the diversity of need in these groups at all levels of practice, from the healthcare university curriculum to the allocation of healthcare resources at national level.

Groups that are perceived as unreachable are those that are hard to engage in a meaningful way. In healthcare this may be people who disengage with treatment, are lost to follow-up or who do not follow preventive care or advice. It may also be people who find it difficult to access healthcare services, do not know about services available, or do not perceive a need to engage with or access healthcare. They are often groups who are a minority group in relation to their culture, ethnicity, language or social circumstances. For example, in the area of TB hard to reach groups include homeless, substance misusers, prisoners, vulnerable and migrants. NICE (2012) note that these groups are hard to reach as they are difficult to engage in treatment, have low levels of compliance and high levels of non-completion of drug regimens.

Unreachable groups may also experience multiple barriers in accessing health care and following healthcare advice. Structural barriers include transport, cost, time, language or culture. There may be individual knowledge deficits, conflicting beliefs, misperceptions of healthcare, negative experiences of healthcare or lack of confidence and support in changing behaviour. This is not a problem specific to the UK and many of the debates around unreachable groups are the same across the globe. For example a study on the ‘unreachable poor’ in Bangladesh note that lack of awareness of healthcare services, inconsistency in services, not living in close proximity to services and perceptions that services do not meet needs were cited as reasons for non-access (Ahmed et al. 2006). These reasons are no different to what people might say about non-access of healthcare in the UK.

As practitioners we need to reflect on our practice, and consider how to include those who are ‘unreachable’ into the scope of our healthcare discipline. With this idea in mind what follows is a list of nine ideas to help turn unreachable into reachable.

  1. You are the right person

Who you are should not stop you from reaching out to groups, you just need to go about it in the right way so do not let it be a barrier just because you might be demographically or socially different. Look around you for ideas; for example there are also some great internet handbooks available such as the FPA (2007) handbook for people working with refugees and asylum seekers in the area of sexual health.

  1. Positive connections

To engage people you need to find what it is that motivates them to connect to what you are saying. Asking encouraging, open ended questions can facilitate discussion and remember the context in which people live as this can help make connections with people. Go to the places where people live, consider what they are interested in, what they like and what they do. Look at what resources are available in the area as this will give you a much better understanding of the situations facing people and will help you to make connections.

  1. Review what you are offering

The marketing term AIDA (Attention, Interest, Desire, Action) may be useful to frame what you would like people to do and how you encourage them to do this. You need to engage their attention (A), keep their interest (I) Explain what it is they need to achieve and how this is going to help them in a meaningful way (D) Be very clear about the action you want people to take (A). The more you understand the circumstances in which a person lives, the more you can tailor this to their individual needs.

  1. Use your target group

The more you involve your target group in what you want to do the better. Whether this is how a new service should run, what a leaflet should look like, when a clinic should open or how to reach people; involvement of the target group is essential. Netto et al. (2013) and Corcoran (2011) provide guidance on cultural tailoring to specific ethnic groups as a starting point.

  1. Use diverse settings

Social spaces may be better locations to provide services than healthcare facilities. The main bonus being that they are situated in the communities they serve; hence the rationale behind mobile breast-screening units in supermarket car parks or sexual health clinics in shopping centres. Cafes, hairdressers, barbers, clubs or places of worship all have elements that are inclusive and reach groups who may not traditionally access healthcare facilities. They have partnership potential, a community focus, they may offer supportive relationships or have useful facilities i.e. space (Moorley & Corcoran 2014). A good example is the Black Barber shop programme (Releford et al. 2010) in the US which offers blood pressure checks and lifestyle advice in barbershops.

  1. Use Gatekeepers

Those who are living in a local community and who have a degree of respect within that community are in a good position to advocate and mediate for change. A good example in the context of healthcare are ‘promotores de salud’ or community health workers in the US who work with Hispanic groups who traditionally lack access to healthcare; they live in the communities they work and share many of the characteristics of their target groups (CDC 2004). Other gate-keepers include key people who may be a focus for a group gathering, for example church leaders, pro-active service users, influential peers or those running community groups. They may also have access to groups who are less visible, i.e. housebound, or specific ethnic groups.

  1. Judgments and stereotypes

It can be easy to stereotype people into categories based on their culture, ethnicity or appearance. Don’t do it! Never make an immediate assumption about someone based on what you see or your previous experiences. Everyone is different and will therefore respond to you differently so try and keep an open mind and be flexible in your approach.

  1. Know you area

Back up what you say by what is happening around you. You cannot tell a patient to take up swimming if there isn’t a local swimming pool nearby. The patients’ that you see live in the local area so have an idea of what exists to support them in their preventive and curative behaviours. What assets do they have as individuals? Having a dog (can help increase exercise), a friend in a similar situation (peer support) is just as important as community support groups, weight loss classes, safe places to exercise or social groups.

  1. Learn from others

Take a moment to think about this; who do you listen to and why do you listen to them? AND who do you talk to and why do you talk to them? Communication is a two way process. What others do that encourages you to listen and talk should be emulated in your own practice. In addition those we label as ‘unreachable’ have much to teach us, so if we talk ‘with’ them (not ‘to’ them) and listen to their voices, this will help us to develop our understanding and skills in working with hard to reach groups.

These ideas are really only starting points and the reason that I chose nine points instead of ten. There is much that could be added and I am hoping that our journal club discussion will be able to come up with the tenth point. So if you have any ideas or examples of working with hard to reach groups join the debate on this topic in the: Evidence Based Nursing twitter journal club on Wednesday 06th 2014: 20.00-21.00 #ebnjc and add any more ideas or experiences to the list.

Participating in the EBN Twitter Journal Chat

To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

  • You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
  • Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
  • NB not including #ebnjc means people following the chat won’t be able to see your contribution.



Corcoran N (2011) Working on Health Communication Sage, London

CDC (2004) Community Health Workers/Promotores de Salud: Critical Connections in

FPA (2007) Sexual health, asylum seekers and refugees; A handbook for people working with refugees and asylum seekers in England available at…/sexual-health-asylum-seekers-and-refugees.pdf


Moorley C & Corcoran N (2014) Defining, profiling and locating older people: An inner city Afri-Caribbean experience. Editorial. Journal of Clinical Nursing 23 2083-2085 available at

Netto G, Bhopal, R, Lederle N, Khatoon J & Jackson A (2013) How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 25 (2) 248-57. Abstract available at

NICE (2012) Identifying and managing tuberculosis among hard to reach groups PH37 available at

Oxfam (2013) Trust and lies about poverty available at

Releford BJ, Frencher SK, Yancey AK, Norris K (2010) Cardiovascular disease control through barbershops: Design of a nationwide outreach program. J Natl Med Assoc. Apr 2010; 102(4): 336–345. Abstract available at

Mentoring and supporting student nurses by Suzanne Van Zyl, Senior Sister Critical Care Unit, The London Clinic

27 Jul, 14 | by Calvin Moorley, Associate Editor

I work in a critical care unit and one of my roles is to organize the overall support and mentoring for student nurses on placement on my unit. Having undertaken this role for a number of years. I know that there are different types of learners, auditory (hear), visual (see) and kinesthetic (touch) (Honey and Mumford, 2006) and some learners can present a combination of these learning types. I believe that each student learn and develop at a different pace. I have also found that auditory learners tend to be natural listeners and may oftentimes speak slowly, visual learners on the other hand tend to be speak quickly, interrupt the speaker and their language exhibit words that evoke visual images and the kinesthetic learners tend to be the slowest talkers of all they are not quick to make decisions like the previous two but are slow in the decision making processes. I put this down to the fact that they may be engaging all their senses to make the best decision. My take is that auditory learners learn best by listening and verbalizing, visual learners learn by seeing and visualizing and kinesthetic learners learn by doing and solving or trial and error they prefer the ‘hands on’ approach, which most mentors probably prefer i.e. a student who gets on with it! (Albeit safely as they would have engaged all their sense).

Taking this reflective stance further I am beginning to wonder why it is that with some students I encounter in their 3rd year or final placements who have been awarded a C, D or B, or what ever scale system you use for grading a skill will try and negotiate for a higher grade. Don’t misunderstand me, I want nurses, as students to question what is happening around them if they feel uncomfortable with the situation and it’s great that this starts at the student level. This will give them confidence to question and search for answers in their nursing career. It’s something that doesn’t happen often enough, sometimes much to the detriment of patients that are placed in their care. The sooner learnt the better!

There have been times when listening to the students rationale for a higher score, I’d take a step back and decide they have a point and on talking through and redoing the particular skill I’ll award them a higher grade because they have proven their ability.

It is the reasons (note they are reason not academic or clinical discussions based on the skill assessed) that student nurses provide for a higher score that I find difficult to understand here are some I have had, ‘well its not really that difficult so I think I should be awarded an A’; ‘I’ve consistently had ‘A’ in my 1st and 2nd year if you don’t give me an A now I wont be awarded a good degree and it’ll be your fault’ (yes I have had this!) and ‘My colleague got an A so I should get one too’.

When you are confronted by such statements you may begin to doubt yourself I certainly started to doubt myself as a mentor, asking those reflective questions: was I too strict? Had I misunderstood the guidelines? I have after all been a mentor for many years and I continue to attend regular updates (I hear some of you groan) but I enjoy doing it.

Working in a critical care setting I feel that the students placed with us are privileged to be able to have a large amount of essential and non-essential skills achieved in the time they spend with us. I want to nurture them and build in them an appetite that will encourage them to want to return to critical care as they will have left with a large amount of unanswered questions (as there is only so much they can learn in such a short space of time) and they may want to return to find those answers and investigate what else there is to learn in this stimulating field.

But at the same time I have to be sure that the student I send away is safe and competent in the skills that have been signed off. I need to make their next mentor aware that although the skill has been signed off they will still have to build on that skill as it’s not perfect thus the ‘B’ ‘C’ or ‘D’ and a student can easily become complacent and lapse in a skill achieved at an A or let’s not get into the debate assessed as an A by a mentor under duress by said learner fuelling the failing to fail debate.

If I have awarded an ‘A’ the next mentor can believe that I have sent a student who is wholly competent and understands the rationale in that particular skill or task and most importantly their patients will be safe.

I have come across students who have been awarded ‘A’ and ‘B’ for skills in their 1st and 2nd year placements and when performing these skills in the 3rd year fail miserably.

Surely our nursing training, and beyond involves ongoing assessment and learning? Or do we assume, what’s done is done, assessed, signed off, that’s it. I hope not as this attitude will not bode well for our profession and patient care and safety. I would like to believe that the criteria for awarding ‘A’ ‘B’ ‘C’ or ‘D’ is the same whether the students are in the very 1st or final placement.

I am looking forward to a couple of students in the next few months again. I will not be looking to failing to fail but to be fair to the student, their course, the protocols set up by the University and sending them to the next and in some cases the final stage of a long and fulfilling course and a wonderful and exciting career ahead of them.

If you are a mentor and experienced similar situations when assessing student nurses please feel free to leave a comment.


Honey, P & Mumford, A (2006). The Learning Styles Questionnaire, 80-item version. Maidenhead, UK, Peter Honey Publications

The need to focus on public health nursing by Wendy J Nicholson, Department of Health 
Public Health Nursing 
Professional Officer – School and Community Nursing. Twitter @WendyJNicholson

20 Jul, 14 | by Calvin Moorley, Associate Editor

The next EBN TWITTER journal chat will take place on Wednesday 23rd July 2014 8-9 pm (UK time) and focus on public health nursing challenges and roles. Before joining in the Twitter Chat you might like to read the associated Blog


Over the last few years we have been fortunate to work with a number of young people who are clearly considering their career pathways – few had even thought about nursing, those that had told me they wanted the drama and excitement of A&E, ITU and theatre, sadly public health nursing wasn’t on their radar. Nothing new you might be thinking, the media stereotypes of nursing really haven’t changed and there is still an overwhelming emphasis on ‘hospitals’.   There is a desire to shift care closer to local communities and to empower individuals to self-manage but can we achieve this with a substantial focus on hospitals or ‘acute’ care? Perhaps the starting point is to challenge the misconceptions –acute care IS provided at home, in local communities and we can avoid hospital admissions, crisis intervention through early support and public health interventions. Supporting individuals at home, in local communities requires skills, expertise and confidence – so why do public health nurses not get the same profile as nurses working in hospital settings? And why can’t we have more creative and community approaches to delivery?

Given the challenges we face as a society care and approaches to population health need to change. We are seeing an increase in long-term conditions, mental health issues and obesity across the life course. It seems timely to focus on public health nursing and their incredible contribution to improving health outcomes and population health.

Public health nursing contribution

Without a doubt the Health Visitor Implementation plan and School Nurse Development plan has led to a focus on the importance of public health nursing input for children, young people and families. We know support during the early years and throughout childhood is incredibility important as it lays down the foundations for healthy individuals and supports the development of healthy communities in the long term. Health visitors and school nurses deal with a myriad of complexities within families and local communities, which draws upon their specialist public health skills and leadership role.

Support and the need to improve health outcomes is not restricted to childhood, consideration needs to be given to support across the whole life course. It’s worth noting there were 300 million GP consultations in 2008/9. General practice nurses are well placed to support those individuals and provide personalised care thus promoting self-care and avoiding un-necessary hospital admissions. The general practice nurse role can have a far reaching community role, supporting individuals and local communities across the life course.

The new and emerging Public Health Nursing Framework was launched recently, it provides a comprehensive framework to support nurses and AHPs in their public health role. It is clear in that ALL nurses have a public health role, with this in mind nurses really do need to ensure they make every contact count and maximise opportunities regardless of the setting!


Questions for the #EBNJC

We know nurses have incredible reach across a variety of communities and settings, we therefore need to harness their skills to ensure every contact counts for every individual or local community there is without a doubt opportunities to really make a difference but perhaps we need to consider:

  • Can we shift the emphasis from hospital to self-care and public health interventions?
  • How do we maintain the re-address the balance and promote the importance of public health?
  • Do all nurses recognise their public health role?
  • Is there a need for more training and support for nurses to realise their potential in public health delivery?

Participating in the EBN Twitter Journal Chat

To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

  • You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
  • Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
  • NB not including #ebnjc means people following the chat won’t be able to see your contribution.

RN Staffing in Hospitals…Are We Asking the Right Question?

15 Jul, 14 | by rheale

By Roberta Heale, Associate Editor

I’ve been working with a number of students in a nursing masters program who have chosen to study teamwork. One study includes a survey question about the percentage of time that a nurse feels that his/her unit is appropriately staffed. I’ve been thinking about this issue and I think that simply asking for the nurses’ perception of staffing is skimming a much more complex issue.

We read stories from around the world about the outrageous workloads of nurses. Stress, burnout, and intention to leave are the buzzwords and the reality for many. Although there are descriptions of the type of work that nurses do, the cause of the nursing work life stresses are rarely addressed. I started working as an RN in the late 1980’s on a medical floor. An RN who had been working there for 30 years told me that when she started it was rare to have a patient with an IV and, if there was one, the doctor had to insert it. By the time I started on that unit, every patient had at least one IV, and there were also many tube feedings, chest tubes, catheters, telemetry monitoring and more. Yet, during those 30 years between her start date and mine, the number of nurses on the unit each day and night shift hadn’t increased. I’m sure that since then with the push for faster hospital discharges and, subsequent increased patient acuity, the workload on that unit has increased even more … without additional RNs. So, even if today’s nurses are asked if they are appropriately staffed on their unit, they’ll likely be answering from today’s perspective…do we have the full number of RNs we are allotted, rather than do we really have the number of RNs we need to safely care for these patients? Instead of answering and addressing the real issue, nurses become stressed, frustrated, overworked and many leave hospital care, or nursing altogether, creating even greater problems in the profession.

We can’t reduce the acuity of patients and that it isn’t ethical to withhold technology to assist patients and their healthcare needs. So, one solution seems to be that the number of  RN staff on a unit should be increased to match the current health care environment. In 2004, California enacted mandatory nurse-patient staffing ratios which has increased RN staffing in hospital settings. The result has been improved patient outcomes and increased nursing satisfaction (Aiken et al., 2010).

Nurses and nursing care is constantly scrutinized and studied. Policies and money often follow the findings. We need to ensure that when we’re asked to complete surveys or take part in studies, that we are asked questions that truly reflect our current practice and we should insist on being part of the interpretation of the findings. Otherwise, I can’t help but feel that things will only get worse.

Aiken, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H.L. (2010). Implications of the California nurse staffing mandate for other states. Health Research and Educational Trust, 45(4), 904-921. doi: 10.1111/j.1475- 6773.2010.01114.x

Can Qualitative research help us to deliver better primary care services? By Calvin Moorley and Josephine Bardi.

6 Jul, 14 | by Calvin Moorley, Associate Editor

On Twitter @CalvinMoorley @JoBardi01

I have recently been collecting data for a research project on life after stroke funded under the Mary Seacole award for Leadership in Nursing. The data collection method is semi structured indepth interviewing and by its given nature is qualitative research (Robson 2011). My project investigates the lived experience of stroke carers within the family setting; it seeks to identify to what extent care giving in life after stroke is influenced by culture. I also had a conversation with one of my MSc Public Health students Josephine Bardi (co-author of this blog) on how qualitative research can help us to understand maternal mortality. In this conversation we discussed what we already know about qualitative research and how it can help us to deliver better primary care and ultimately public health services.

What do we know about qualitative research for health?

  • Qualitative research is robust despite what its critics say for example Tong et al. 2007 have provided a set of criteria for qualitative research
  • Qualitative research is based on the subjective and allows the researcher an insider look into the lives of participants or certain groups.
  • In health care qualitative research can be described as interviews and focus groups (Soafer 2002) and explores complex phenomena experienced by health care workers and clinicians qualitative research
  • Using qualitative research in health care can help us unravel and make sense of the participants experiences.

An example

In my area of research, life after stroke I have found that qualitative research can also help to support quantitative findings (Moorley, 2012) a researcher can use the technique following a thread O’Cathain et al. 2008. For example in my work I found that African Caribbean women reported higher abilities to perform of activity of daily living compared to their other ethnic counterparts in my quantitative data analysis (Moorley et al. 2014). I followed this up in interview questioning to understand the lived experience of this group which was different from what they reported to the health practitioner. Here qualitative research helped me to understand why African Caribbean women over reported their abilities and I was able to make recommendations to the stroke rehabilitation team based on the qualitative findings.

Can qualitative research help us understand maternal health?

Millennium Development Goal (MDGs number 5) states

“In recent years, there has been increased recognition that reducing maternal mortality is not just an issue of development, but also an issue of human rights”. (United Nations Populations Fund, 2010).

What is known about maternal death?

Maternal deathis the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (World Health Organisation, 2014).

Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia (World Health Organisation, 2014). Sub-Saharan Africa still had high maternal morbidity and mortality rates (Rogo et al., 2006; Alvarez et al., 2009).

What contributes to maternal deaths?

According to the WHO (2014) maternal mortality occur due to the following reasons:

  • Poor access health
  • Severe bleeding (mostly bleeding after childbirth)
  • Infections (usually after childbirth)
  • High blood pressure during pregnancy (pre-eclampsia and eclampsia)
  • Complications from delivery
  • Unsafe abortion.

Maternal mortality ratio in developing regions continues to be 14 times higher than in the developed regions (United Nations, undated).

How can Qualitative research help us to understand maternal health and mortality?

Qualitative research may help to explain the experience of bereaved families before and after the death of a mother, daughter, child or both.

For instance, it is useful to find out how a mother-in-law, husband and children felt after the death of a wife and mother or what practices may have led to the death and explore these. What does a community, bereaved family and, looked after children think is the reason for maternal deaths? What is their experience of maternal mortality and to what extent does cultural practices contribute to maternal health and mortality?

The role of qualitative research in delivering primary care services

There is role for using qualitative research that can help in delivering primary and public health care services, firstly qualitative research can help to contextualise quantitative finding and strengthen a study. By undertaking qualitative research we can understand why individuals do not adhere to medications regimens and attribute causes other than pathophysiological for disease (Moorley, 2012). By using qualitative research health practitioners can understand why patients take certain actions, qualitative research opens up a space for discussion with service provider and user, which can ultimately lead to benefits for both groups. Using a qualitative approach such as case study or phenomenological research can help to answer some of the questions we posed in this blog (pertaining to our research), which can in turn be used to deliver primary care services that will contribute to reducing maternal mortality , improved stroke aftercare and better access of public health services.

Questions for the #EBNJC

1. Can you think of a time when qualitative research would have helped you to do your job better?

2. How can we ensure we embed qualitative methods in health research?

3. What benefits can qualitative research bring to primary care delivery?

4. How can qualitative research help in delivering the wider public health agenda and meet needs of local communities?

5. Can we reduce maternal mortality through qualitative research findings?

The next EBN Twitter Journal Chat #EBNJC will take place on Wednesday 9th July 2014 8-9 pm (UK time) and focus how can qualitative research help us to deliver primary care services.

Participating in the EBN Twitter Journal Chat

1 To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

2 You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
3 NB not including #ebnjc means people following the chat won’t be able to see your contribution.


Alvarez, L. J., Gil, R., Hernández, V., and Gil, A, (2009) ‘Factors associated with maternal mortality in Sub-Saharan Africa: an ecological study’, BMC Public Health, 9, pp. 462-469, Academic Search Complete: EBSCOhost. Available at: [Accessed: 3 July 2014].

Moorley, C. 2012 Life after stroke: Personal, Social and Cultural Factors – An Inner City Afro-Caribbean Experience. PhD Thesis University of East London.

Moorley C, Tunariu., A, Cahill., S, Scott O. (20140 Impact of stroke, a functional, psychosocial report of an inner city multiracial population Journal of Primary Care 24(4) 26-34

Partnership for Maternal, New born and Child Health (2011) Commission on information and accountability for women’s and Children’s Health [Online]. Available at: WHO. [Accessed: 5 July 2014].

Rogo, K. O., Oucho, J. and Mwalali, P. (2006) Maternal Mortality. In: Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd edition. Washington (DC): World Bank; 2006. Chapter 16. Available at: [Accessed: 4 July 2014].

Robson., C. 2011 Real World Reserch London Sage

Sofaer., S. Qualitative research methods. Int J Qual Health Care 2002;14:329–36.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357.

United Nations (undated) Goal 5: improve maternal health [Online]. Available at: UN. [Accessed: 4 July 2014].

United Nations Populations Fund (2010) Reducing maternal mortality the contribution of the right to the highest attainable standard of health [Online]. Available at: [Accessed: 5 July 2014].

World Health Organisation (2014) Maternal mortality [Online]. Available at: WHO. [Accessed: 5/7/2014].



Outcome measurement and valuation – what is it and why do we need it?

30 Jun, 14 | by hnoble

Last week I spent a couple of days in York, England exploring outcome measurement and valuation for Health Technology Assessment with academics from the Centre for Health Economics at the University of York. People attended from across the world and I sat beside colleagues from many countries including India, Ghana, Switzerland, Greece, Denmark, Spain and Germany. The world cup took on new significance!

Health outcomes involve changes in health status – changes in health of an individual or population, attributable to an intervention. Sometimes the population or group is defined because different outcomes are expected for diverse people and conditions. Measurement of health outcomes involves carrying out different measurements including, measurement of health status before the intervention, measurement of the intervention, and measurement after to try and relate the change to the intervention.

Health Technology Assessment (HTA) in its simplest form is about determining whether or not health services are safe and effective. The primary goals are to improve safety of healthcare; make decisions on treatment more consistent; ensure cost-effective treatments are utilized and to share information to assist with decision making (see Within HTA we try to determine if the benefit gained from the new treatment is greater than the benefit forgone through displacement.

Outcome measurement for decision making has an important role in patient reported outcomes. Firstly we design health care interventions around basic science and anticipated clinical effects. We then need to understand the clinical impact – such things as cancer progression or clinical interpretation. Finally, we need to understand the impact on patients. We can do this by measuring such things as subjective well-being or function e.g we could measure changes in quality of life in patients with end stage kidney disease, before and after and intervention, by using the Kidney Disease Quality of Life Questionnaire.

The building blocks of outcome measurement include:
Measurement – What is the impact of the disease? What is the impact of the interventions?
Individual preferences – Trading off length of life for quality of life; what weight is given to different aspects of health
Societal preferences – Relevant to disease or other characteristics

If an intervention is to be introduced there are different methods for valuing health and often it is quality of life that is measured. Health related quality of life is a patient’s subjective perception and not determined by a clinician. It is multidimensional and includes physical function, psychological health and social wellbeing. It can be measured using a variety of tools. Disease specific questionnaires can be used e.g. the Chronic Heart Failure Questionnaire; or generic health related quality of life tools which are non-preference based can be used such as the SF-36. Finally preference based tools such as the EQ-5D -5L can be used. The EQ-5D -5L is a very useful measure and recommended by the National Institute for Clinical Excellence as it allows for an economic evaluation where health benefits are expressed in terms of Quality Adjusted Life Years (QALYs). (See

So why is it important that we measure health outcomes? Measuring health outcomes allows us to make decisions about how to best care for our patients and outcome measures help us predict the patients who might benefit most from a particular intervention. It helps us identify any improvement after an intervention is provided. The effective use of outcome measures is an important aspect of clinical care and deciding which outcomes are relevant to a patient group and selecting appropriate measures of those outcomes requires an understanding of the clinical situation, as well as an understanding of the measurement properties of the outcome measures. Outcome measures can be important tools for guiding clinical decision making. However, to function well these tools must be used with skill and understanding.

So if this blog has sparked your interest and you want to know more about Outcome measurement and valuation have a look at the York Expert Workshops at

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