As editor of Evidence Based Nursing I, perhaps unsurprisingly, believe it is important that nurses use the best available evidence when making health care decisions. I also believe politicians should do the same when deciding on health care policy. When Jeremy Hunt took over from Andrew Lansley as the English Secretary for Health last September I hoped we would have someone in post who would both listen to what nurses were saying and make evidence-based decisions. However, this appears not to have happened.

A prime example of where evidence does not seem to be taken into account by politicians is their refusal to set minimum staffing levels for registered nurses in England. Over the last month there has been a lot of press coverage relating to current staffing levels. In April the Royal College of Nursing (RCN) announced that nine out of ten nurses in Scotland believe staffing levels are not always adequate to provide safe patient care (see: http://bit.ly/17Z5WMT).  Over a quarter (27%) of nurses in Scotland think staffing levels are rarely or never safe. Last weekend the Safe Staffing Alliance reported the results of a survey of just under 3,000 nurses at 31 English hospitals, which found that hospital wards regularly (at least 40% of the time) have one registered nurse caring for eight patients (see: http://bbc.in/14e2R9x).  A poll carried out with 2,000 nurses for the Sunday Mirror and the Nursing Standard, also published last weekend, found that 40% of nurses said there were not enough staff to provide a safe level of care on their last shift (see: http://bit.ly/YByJUJ). This survey also found that more than three-quarters of nurses believe a scandal similar to that at Mid Staffordshire Hospital could happen again.

Something appears to have gone dreadfully wrong in relation to nurse staffing levels in the UK. When I met a friend for a drink the other week we had to wait a long time to be served and the level of service was poor because there was only one member of staff on duty. Given the reduction in the nursing workforce it is hardly surprising then that the quality of care is falling. Indeed, there is increasing research evidence demonstrating the link between registered nurse staffing levels and the quality of care (e.g. Aiken et al. 2012).

One of the lessons of the Mid-Staffordshire Hospital disaster that Jeremy Hunt appears to have missed is the tendency of hospital managers to focus on nationally set targets such as the 4-hour wait in emergency departments to the detriment of other issues for which no such targets exist. The nursing workforce at Mid-Staffordshire Hospital had reached dangerously low levels as managers aimed to meet the financial targets required to achieve Foundation Trust status. If national minimum staffing levels had been in place and been audited at this time it is likely that different decisions may have been made in what had become a financial driven organisation. Despite this Jeremy Hunt and his ministers are still refusing to consider national staffing standards, repeatedly saying this is an issue that should be managed locally.

It is not that nurses don’t care but that all to often they are caring for too many patients. At RCN Congress last month exactly how much nurses do care was illustrated by a poem written by a nursing student in response to the battering the nursing profession was receiving in the press. This can be seen at: http://www.youtube.com/watch?v=XOCda6OiYpg

So my message to Jeremy Hunt is to stop blaming nurses and nurse education for the ills of the profession and take note of the evidence. Instead of coming up with unworkable schemes such as all prospective nursing students undertaking a year as a health care assistant prior to starting their training take note of the real messages of the Francis report and set national standards for nurse staffing. You can find a summary of the evidence relating to minimum staffing levels at: http://bit.ly/128aMDn. However, if you continue to ignore the evidence in this context and do nothing about minimum staffing I believe we will see more Mid Staffs-like disasters.

Alison Twycross

References:

Aiken, L.H., Cimiotti, J.P.. Sloane, D.M., Smith, H.L., Flynn, L. and Neff, D.F. (2012) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Journal of Nursing Administration, 42(10 Suppl): S10-S16.

One often hears the anecdotes  about abuse of nurses from patients, families, co-workers and employers.  A recent study sought to determine the experience of nurses and midwives with aggressive behaviour and bullying. Of the 1495 returned questionnaires over half of the participants (52%) experienced some form of workplace aggression. Thirty-six percent experienced violence mostly from patients or their visitors/relatives and 32% experienced bullying mostly from colleagues or from their managers/supervisors.  Organizational response is thought to play a role.  The research article is the foundation for the EBN Twitter Journal Club discussion.

Some questions to consider:

1. What do you think are some of the drawbacks of the questionnaire that was used?
2. Workplace aggression and workplace bullying.  Do you think the two issues should be researched separately?  Why, or why not?
3. What role do you think bystanders of WO or WB play in solving these problems?

Farrell GA, Shafiei T. Workplace aggression, including bullying in nursing and midwifery: a descriptive survey (the SWAB study). Int J Nurs Stud 2012;49:1423–31

Full Article Online  http://bit.ly/11vmIEi

Commentary available at:  http://bit.ly/10F071F

The discussion will take place Wednesday, May 15 (14.00 UK time) to Friday, May 17 (16.00 Eastern Canadian time), 2013.  Be sure to tweet your messages and include #ebnjc to be part of the discussion.

NOTE:  The EBN Journal Club will be moving to a new format in May.  Stay tuned for details!

Each year, the International Council of Nurses celebrates International Nurses Day on May 12^th, the birth date of Florence Nightingale. I read that there was a lobby to change the date since it was felt that Florence Nightingale no longer represented ‘modern’ nursing. Although she lived in an era that included very few rights for women, she had an impact on women’s lives, health and nursing that is felt to this day. Some of her achievements were the use of statistics to demonstrate the detrimental effects of poor sanitation on health and mortality in the Crimean War and with soldiers in India. Subsequent sanitation reforms reduced mortality.  She was credited with social reforms that improved health care and she laid the foundations for the first secular nursing school in the world.

Almost two hundred years after her birth, one wonders what Florence Nightingale would think of modern nursing. Standards for nursing care are reflected in regulation in most countries and schools of nursing promote evidence based practice.  With very few exceptions, nurses work in every part of every health care system.  In 2008 I attended the International Nurse Practitioner/Advanced Practice Nursing conference in Toronto, Canada with speaker Steven Lewis. He spearheads the Steven Lewis Foundation, an NGO that supports AIDS and HIV grassroots organizations in Africa. He said with emotion, that if it wasn’t for nurses, there would be no health care in the places he had been to in Africa.  So, why is it, with high standards of education, a commitment to evidence based practice and tremendous responsibilities in nursing roles across the globe, do nurses continue to have to fight for recognition and respect?

We’re a profession under stress and under attack. A recent survey of 4500 nurses from across Canada demonstrated that 40% were experiencing burnout and 25% would not recommend the hospital where they worked http://bit.ly/10H0nhn. Job stress is extreme in nursing with many repercussions to health care.  Across the ocean in the UK, the answer to the outcomes of stressful working conditions for nurses is to create new entry to practice requirements such as a year as a support worker to boost compassion of those that then seek nursing licensure http://bit.ly/11jGLW5.

Getting back to Florence Nightingale.  The clear message from her biography is not the specific accomplishments, although there were many.  The message is her tireless work to create positive change.  If she were here today, I think she’d do the same and, as International Nurses Day approaches, this is the message for all of us.

Roberta Heale

A meeting of the Evidence Based Nursing (EBN) Editorial Board took place on the 26th April in London. The meeting was attended by Claire Weinberg, Catherine Lucas, Claire Bower and Allison Lang from BMJ and the Editorial team including myself,  Alison Twycross and Joanna Smith from the UK, Roberta Heale and Dorothy Forbes from Canada  and Allison Shorten from the USA.

One key topic discussed was the use of technology to support engagement with EBN. As you may know the EBN Twitter Club runs 2 weekly with information regarding the club available via the EBN Blog. It was decided that Twitter may not be the best medium within which to run the Journal Club due to difficulties sharing rich and detailed information about a research article, its methodology and its potential impact on practice. Changes that we agreed are to firstly run the Journal Club monthly, to name it the EBN Journal Club, to link it to a theme and to a monthly podcast. It will run via the blog and possibly Facebook. We would very much welcome your comments on how best run an online Journal Club so please do contact us if you have any ideas or questions.

Face to face journal clubs have been successful as a place where knowledge can be shared and research findings discussed in relation to best clinical practice. This aside attendance at these meetings is not always satisfactory limiting the success and sustainability of journal clubs. Online journal clubs provide the opportunity for asynchronous discussion and members are able to take part in evidence-based discussion when it suits them and in the place where they live or work – See http://www.ncbi.nlm.nih.gov/pubmed/20216996

The Cochrane Students Journal club is interesting – see  http://csjconline.blogspot.co.uk/p/rules-and-regulations.html Each month a clinical scenario is presented. Students must then search the Cochrane library for a Systematic review that will answer specific questions and post the citation of the review. Later in the month a suitable search strategy and its result is presented and students must read the review and write a summary of how it applies in practice. Finally a critical appraisal of the review by an expert will be posted online. Members who are active on the Journal Club and send in relevant appraisals are awarded certificates. This seems like a lot of work but ultimately there is a reward for students which may be the way forward for other Journal clubs such as EBN – what do you think?

EBN Twitter Club #ebnjc – Session 8

The incidence of Sudden Infant Death Syndrome (SIDS), the sudden death of an infant that is not predicted by medical history and remains unexplained after autopsy, has reduced since the world wide ‘back to sleep’ initiative implemented during the early 1990’s.  While it has been established that placing infants supine for sleep significantly decreases the risk of sudden infant death, theories explaining the physiological reasons the supine sleep position remain speculative.  Sleep position does not appear to influence the risk of extreme cardiorespiratory events in vulnerable infants.

Questions to consider:

1. Sleep position does not appear to influence the risk of extreme cardiorespiratory events in infants, yet the study recommends continued advocating of supine sleeping position, why is this?
2. What do you think are the limitations to this case-control study?
3. Why is it difficult to find explanations for the physiological reasons for SIDS?

Article for discussion:

Lister G, Rybin DV, Colton T, et al. (2012) Collaborative Home Infant Monitoring Evaluation

(CHIME) Study Group. Relationship between sleep position and risk of extreme cardio respiratory events. J Pediatr;161:22-5. http://bit.ly/11pPdy3

EBN Commentary at: http://bit.ly/ZRMkVl

The discussion will take place Wednesday, May 1 (14.00 UK time) to Friday, May 3 (16.00 Eastern Canadian time), 2013.  Be sure to tweet your messages and include #ebnjc to be part of the discussion.

We are updating our Journal Club Format.  STAY TUNED FOR MORE INFORMATION!!

In my last blog on the 19^th February 13 I described how my diagnosed sciatica led to an MRI and consequently the identification of a substantial prolapsed disc at L5-S1.At the time I was awaiting a surgical appointment with a view to possible lumbar discectomy but I was aware of the controversy surrounding the efficacy of the procedure relative to nonoperative care (1). Ultimately I met the neurosurgeon. A full examination and history was taken. I was still very uncomfortable and managing my pain with anti-inflammatory medications but was given the good news that things should continue to improve without any intervention!! I was delighted and have come on in leaps and bounds since that consultation. The neurosurgeon agreed that physio would probably aid my recovery but he thought I should avoid chiropractors in this early stage of recovery in case any problem was made worse. Interestingly I was warned that Cauda equina syndrome could still be a potential problem. This is a serious neurologic condition with acute loss of function of the lumbar plexus and nerve roots of the spinal canal below the termination (conus medullaris) of the spinal cord. That worried me slightly but since that day I have continued to recover, returned to work and am feeling much improved.

Having suffered this serious health concern I am now aware of the effect it has had not just on my back and sciatic nerve but also the rest of my body. Yes, the prolapsed disc originated in the back and caused severe sciatic pain but the impact felt elsewhere should also be noted. I immediately lost weight as I stopped eating. I was in too much pain to think about food. I could only lie flat so eating was also very uncomfortable and impractical. I was in constant pain at times and found it difficult to converse with well meaning visitors and my family. My three young boys helped as much they could (my 12 year old now understands the importance of a dark and white wash!) but they worried as did those who came to visit and help. I looked grey and very unwell and my quality of life deteriorated. It will take time to get back to full recovery and I know I am impatient but must take things slowly or am at risk of further damage. As I suffered my family suffered. Illness is hard for the person who is ill but can have a huge impact on those around who watch the suffering and feel helpless. Luckily my illness has been short lived but it has given me time to accept some of my limitations and to think about the impact illness has on family carers. My needs were well assessed and addressed and the needs of those caring for me were touched upon. I am sure the burden of caring for me in some way reduced their quality of life whilst I was sick. It was short term but for others may be much more of an adjustment. There is an excellent resource online titled: A guide to assessments of carers’ needs which identifies who a carer is and the entitlement to an assessment (2) which I would recommend.

(1)  1. Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial: A Randomized Trial” JAMA 296(20):2441-2450, 2006.http://jama.jamanetwork.com/articleReports.aspx?doi=10.1001/jama.296.20.2441&isRedirect=True&journalId=67

(2)  A guide to assessments of carers’ needs (2012) http://www.wiltshire.gov.uk/a-guide-to-assessment-of-carers-needs.pdf (accessed 23.4.13)

I am not a paediatric nurse but as a parent I sometimes have opportunities to admire the skill of paediatric nurses who make a difference in the lives of children and their families, by putting young patients at the centre of decisions about their healthcare.  It was during a hospital visit with a family member a few weeks ago that I started to think about what it means to share decisions with patients and how important even the small decisions can be.  During the visit I was observing a nurse who was working in the “infusion room” within a large Children’s Hospital, and I witnessed the ease with which a decision was seamlessly shared between a teenage patient and the nurse regarding the “routine” task of inserting an intravenous (IV) cannula.   

As we all know, having an IV inserted for an infusion can strike fear into the hearts of adults, so developing the skills to help children cope and even adapt to this experience is no small achievement. On this day, a nurse approached an anxious teenage boy to insert an IV cannula for an  infusion which was to run over the next few hours. In all honesty, I was expecting the nurse to inform him about what she was about to do and to go ahead and do it. I expected competent practice based on evidence about safe IV cannula insertion. I did not expect that this routine procedure would be either positive or empowering and expected him just to be relieved when it was over. However, on this occasion the nurse invited her patient to guide her practice and to share  perspectives about what was best for him.  In the space of 60 seconds, the nurse invited her new patient to discuss his preferences for pain relief,  describe his previous experience of IVs, explain what he felt helped reduce anxiety and discomfort during the procedure, and to guide her about when he was ready for the procedure to start. In that 60 seconds the nurse gained his trust and the patient shared some control over what was happening to him.

What I was reminded of in that short encounter was that nurses who creatively use strategies to put patients in the centre of care achieve so much more than the completion of a task. They turn everyday care into positive and empowering experiences for patients and families.  This nurse demonstrated that taking a little extra time to share decisions with young patients can empower them and may even prepare them to cope with much bigger health decisions in the future. Giving young patients a voice about the little things may help them find their voice when the stakes are even higher.

The phrase “no decision about me without me” ¹ can be played out at all levels of decision making from the simple to the complex.  No matter how small the decision or how routine the procedure, nurses can create opportunities for patients  to be in the centre of the decision making process.

One final thought – perhaps there is no such thing as “routine” care when there is genuine patient-centered care.

Reference:

1. Department of Health Equity and Excellence: Liberating the NHS White Paper Cm788. 2010 July 10 https://www.gov.uk/government/publications/government-response-to-the-consultation-on-proposals-for-greater-patient-involvement-and-more-choice

Allison Shorten RN RM PhD

Yale University School of Nursing

The morbidity and mortality associated with cardiac surgery is commonly a consequence of pulmonary complications.  Improving lung function may reduce postoperative pulmonary complications.  While the benefit of postoperative physical therapy interventions is fairly well documented, there is a paucity of evidence in relation to the impact of preoperative physical therapy on postoperative pulmonary complications and reduce hospital stays after cardiac surgery. Identifying patients who have a higher risk of developing postoperative pulmonary complications and improving lung function preoperatively has potential to reduce post operative complications.

Questions to consider:

1. How realistic do you think it is to increase the physical fitness of patients requiring cardiac surgery preoperatively?
2. What precautions would be necessary when implementing physical fitness programmes for patients requiring cardiac surgery?
3. What are the advantages of undertaking systematic reviews in areas where there is limited evidence?
4. What are the limitations of undertaking systematic reviews when there only a few studies are included and included studies are based on small samples?

Article for discussion:

Hulzebos EH, Smit Y, Helders PP, et al. (2012) Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev;11:CD010118

EBN Commentary at: http://bit.ly/ZWKUri

Abstract of Article at: http://bit.ly/17CgC4M

The discussion will take place Wednesday, April 17 (14.00 UK time) to Friday, April 19 (16.00 Eastern Canadian time), 2013.  Be sure to tweet your messages and include #ebnjc to be part of the discussion.

For someone my age, learning to communicate via a blog or tweeting is a steep curve. My five-year old granddaughter is more adept at downloading apps and searching the internet than I. Besides age, I’m also discovering other important factors that influence knowledge exchange through my research in northern Canada.  The context of a health care work setting is widely considered to be an important influence on the use of best available evidence in practice (Dopson, FitzGerald, Ferlie, Gabbay, & Locock, 2002; Wallin, Estabrooks, Midodzi, & Cummings, 2006). The Promoting Action on Research Implementation in Health Services (PARIHS) framework describes context as including culture (Kitson et al., 1998; McCormack et al., 2002; Rycroft-Malone et al., 2002), leadership (McCormack et al., 2002), evaluation (Kitson et al., 1998), and resources (Rycroft-Malone et al., 2004) as important domains of the work setting that facilitate the use of research evidence in practice. Culture is defined as the forces at work, which give the physical environment a character and feel (Kitson et al., 1998; Rycroft-Malone et al., 2002) and encompasses the prevailing beliefs and values, as well as consistency in these values and a receptivity to change among home care providers (McCormack et al., 2002). Leadership is defined as the “nature of human relationships” (McCormack et al., 2002, p. 98) with strong leadership giving rise to clear roles, effective teamwork and organizational structures, and encouraging involvement in decision making and learning. Evaluation is described as feedback mechanisms (individual and system level), sources, and methods for evaluation (Kitson et al., 1998) and is recommended to occur routinely. Lastly, Rycroft-Malone and colleagues (2004) identified time, equipment, and clinical skills as resources needed to implement research findings. Nurses working in health care settings with a supportive and collaborative culture, strong leadership, and positive evaluation or performance feedback are significantly more likely to report more research utilization, more staff development, and lower rates of patient and staff adverse events than do nurses working in settings where these dimensions of the context are lacking (Cummings, Estabrooks, Midodzi, Wallin & Hayduk, 2007).

My research team and I are discovering that within home care centres in northern Canada, most home care providers positively agree that there is strong leadership, a positive culture (the way things are done in their home care centres), and connections among health care providers within their centres. These dimensions are fundamental to establishing a vibrant workplace where employees actively seek out ways to develop and use their skills, knowledge, and abilities to provide evidence-based quality care. When health care providers collaborate, “the sum becomes greater than the parts, teams and the organization develop capabilities for performance, innovation, and creativity that far surpass what individual members bring to their jobs” (Lowe, 2010, p. 2).  However, innovative strategies are needed that promote collaboration between health care providers who are working with the same clients but from different organizations. Formal linkages that connect rural health care providers with specialists in urban settings will also enhance evidence-based practice in rural home care centres. How data is currently being used to evaluate group/team performance and to achieve outcomes also needs to be further examined as there appears to be a wide range of use of data for evaluation purposes. In addition, for home care providers to apply their capabilities to the fullest, resources such as staff, time, space, and information technology that enable them to collaborate, access, adapt, and apply the best available evidence in their practice are needed. Are there opportunities within your healthcare setting to change the context to promote the exchange of best available evidence?

Cummings, G.G., Estabrooks, C.A., Midodzi, W., Wallin, L., & Hayduk, L. (2007). Influence of organizational characteristics and context on research utilization. Nursing Research, 56(4, Suppl 1), S24-S29.

Dopson, S., FitzGerald, L., Ferlie, E., Gabbay, J., Locock, L. (2002). No magic targets! Changing clinical practice to become more evidence based. Health Care Management Review, 27(3), 35-47.

Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence-based practice: A conceptual framework. Quality and Safety in Health Care, 7(3), 149-158.

Lowe, G. (2010). Creating healthy and sustainable health care organizations. Retrieved from http://www.grahamlowe.ca/documents/259/Lowe%20Qmentum%20Q%20Dec2010.pdf

McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J., Titchen, A., & Seers, K. (2002). Getting evidence into practice: The meaning of ‘context’. Journal of Advanced Nursing, 38(1), 94-104.

Rycroft-Malone, J., Harvey, G., Seers, K., Kitson, A., McCormack, B., & Titchen, A. (2004). An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13(8), 913-924.

Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., … Estabrooks, C. (2002). Ingredients for change: Revisiting a conceptual framework. Quality and Safety in Health Care, 11(2), 174-180.

Wallin L., Estabrooks C.A., Midodzi W.K., & Cummings G.G. (2006): Development and validation of a derived measure of research utilization by nurses. Nursing Research, 55(3), 149-160.

Dorothy Forbes

Some reflections from Suzanne Watts, this year’s Marjorie Simpson New Researcher

Alison Twycross (Editor of Evidence Based Nursing) presents Suzanne Watts with her certificate at the RCN’s International Nursing Research Conference

Award winner

I suspect that the 2013 RCN International Research Conference will be remembered by the delegates for two things. The first being the breadth and scope of the outstanding presentations and the second the weather.  For some of the delegates the blizzard conditions on the final day may possibly have overshadowed the presentations and other activities, as flights were cancelled, airports and roads closed and anxieties raised about return journeys home.  However, for many of us inside the conference hall, it was only the occasional flicker of lights throughout the day that reminded us of the blizzard conditions blowing outside.

Over the three days, the conference programme was packed with themed concurrent sessions, keynote presentations, symposium and posters. The breadth of presentations was impressive, providing a diverse programme to meet the interests of nurse researchers, practitioners and educators.  As always there was never quite enough time for questions and discussion after the many excellent, thought provoking presentations.  Thankfully, session chairs kept to time providing opportunities for questions from the floor before a quick dash to the next presentation. It is impossible to begin to describe the range of presentations, however they can be downloaded to view from the conference website (together with the comprehensive Book of Abstracts).

http://www.rcn.org.uk/development/researchanddevelopment/rs/2013_-_annual_conference

This was a truly international conference with presenters from as far afield as Iceland, Australia, USA and South Africa.  In an inspirational plenary address to the conference Professor Wendy Chaboyer described how she nurtured, developed and established the Nursing Centre for Research Excellence at Griffith University, Australia, by demonstrating the contribution of high quality nursing research to the evidence base of health care.

A series of fringe meetings were organised for delegates who were PhD students and supervisors. These meetings were well attended and provided insights into a range of issues.  A mock up viva examination offered helpful hints and some reassurance about the process for those nearing the end of their studies.  A Q&A session provided the opportunity to quiz experienced academics about the PhD process from registration to examination. One of the most enjoyable parts of these events was to meet other PhD students, at different stages of their studies, to share stories and experiences.  These fringe meetings are an excellent way to support and encourage novice researchers. However, talking with other delegates it would seem that there is a need for workshops for those who are thinking about embarking on a PhD and who require advice about the early stages of the process.  In particular for nurses who who may not have strong links with academic departments.

On the second evening of the conference a drinks reception was hosted by the University of Ulster and the Belfast Visitor Bureau. Coaches picked up delegates from the conference venue for a city tour en route to a drinks reception held at Stormont parliament buildings. Despite the bitter cold wind outside, there was a warm welcome at the reception with drinks, delicious nibbles and entertaining speeches.

I was fortunate to receive the RCN 2013 Research Society Marjorie Simpson New Researcher Award. The award is in recognition of the work of Marjorie Simpson who was instrumental in developing and promoting nurse research in the UK in the 1960’s and 1970’s. Her legacy is apparent at this conference in the quality and quantity of international nursing research.  I would like to take this opportunity to thank Evidence Based Nursing who sponsored the award covering the cost of my conference registration fees, accommodation and a contribution of £100 towards costs of travelling.

This was my first RCN International Research Conference and I was not disappointed. I am now looking forward to attending the 2014 conference in Glasgow where, hopefully, the weather will be more Spring like.

Suzanne Watts, PhD Student, Oxford Brookes University