You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

‘Our National Shame’ Older people and loneliness ‘ by Nova Corcoran, University of South Wales, (@NovaCorks); Calvin Moorley London South Bank University (@CalvinMoorley)

28 Sep, 14 | by Calvin Moorley, Associate Editor

The Rt Hon Jeremy Hunt MP in a speech in 2013 referred to loneliness in the UK as ‘our national shame’ highlighting the millions of people who are part of the ‘boarder problem of loneliness that in our busy lives we have utterly failed to confront’ (DOH/Hunt 2013). Loneliness is not just something we feel when we don’t have anyone to talk to, but a state of isolation, depression or abandonment, MIND (2014) call the feeling of loneliness ‘not feeling part of the world’.

Loneliness is not a constant state and recent research suggests that while there is an increase in loneliness with age, older people move in and out of frequent loneliness over time (Dahlberg et al. 2014). Loneliness can affect older men and women differently as for each group there are different predictors and outcomes for loneliness. It may also be difficult to both recognize and admit to feelings of loneliness by the older person who is affected.

Older people are particularly vulnerable to loneliness through a mixture of circumstances including loss of family and friends, lack of mobility, no access to private transport, living alone, increasing disabilities and low levels of income and geographical location for example see Moorley & Corcoran 2014 editorial on older people living in inner cities. Loneliness and social isolation has a negative impact on health and well-being and numerous studies have examined the link between health and loneliness. This includes early admission to residential or nursing care, poorer function in daily activities (DOH/Hunt 2013) and specific poor mental health outcomes such as depression, low life satisfaction and low resilience (Zebhauser et al. 2014).

As with most public health interventions to tackle complex health problems there needs to be a focus at micro and macro levels and thus both individual and community responses to loneliness need consideration. A multi-sectorial response is also important that includes not just health professions but organizations, groups or charities that operate within the community.

A systematic review in 2011 noted that interventions to address loneliness that offer social activity and/or support within a group format, along with interventions in which older people are active participants were found to be the most effective in reducing loneliness (Dickens et al. 2011). Strategies to reduce loneliness may also have an impact on other health domains such as mental health or physical health. For example, programs that use social support to reduce loneliness can reduce rates of depression (Liu et al. 2014).

Other interventions that have shown promise in reducing loneliness include mentoring and befriending schemes (Dury 2014) and social network maintenance and enhancement (Cohen-Mansfield & Perach 2014). The SCIE has produced guidance on reducing isolation and loneliness and they note community befriending schemes and community navigator schemes* are successful (Windle et al.2011). One campaign group that aims to reduce loneliness is ‘the campaign to end loneliness’ which supports organizations who want to tackle loneliness. They also have a comprehensive tool kit and a ‘loneliness harms health’ kit you can download for free (see references).

Environmental barriers can increase loneliness. Rantakokko et al (2014) note that barriers that increase loneliness including weather, hills, distances to services, and difficulties in walking more than 2km. Wider environmental modifications can reduce loneliness so although we cannot change the weather or move hills, we can situate services within local communities and provide groups and club activities or informal meeting spaces in easily accessible venues.

One area that has received attention is the use of the internet and social media, although there are no systematic reviews that examine this area. Generally research is mixed suggesting technology can both reduce and increase loneliness and isolation depending on how it is used. For example Sum et al (2008) found that if the internet was used as a communication tool then there were lower levels of social loneliness, but use of the internet to find new people was associated with higher levels of emotional loneliness.

In summary, older people are at risk of increased loneliness, and with budget cuts in both health and community services the risks around loneliness and isolation may increase. Join the evidence based nursing debate on Wednesday 1st Oct 2014 at 8.00 to consider what health professionals can do to address the challenge of reducing loneliness in older people.

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 on 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

*Sometimes called Wayfinder initiatives they use community workers in the local community (i.e. a library or pharmacy) who signpost people to local services i.e. clubs and groups.


Campaign to End Loneliness available at the tool kit is available at

Dahlberg L, Andersson L, McKee KJ & Lennartsson C (2014) Predictors of loneliness among older women and men in Sweden: A national longitudinal study Aging and Mental Health Aug 15 1-9 [pub]

Dickens AP, Richards SH, Greaves CJ, Campbell JL (2011) Interventions targeting social isolation in older people: A systematic review BMC Public Health 11: 647

DOH/Hunt (2013) the forgotten million available at

Dury R (2014) Social Isolation and loneliness in the elderly: An exploration of some of the issues British Journal of Community Nursing 19 (3) 125-8

Liu L, Gou Z, Zuo J (2014) Social support mediates loneliness and depression in elderly people Journal of Health Psychology Jun 11 [E pub ahead of print]

MIND (2014) Loneliness available at

Moorley, C. R. and Corcoran, N. T. (2014), Editorial: Defining, profiling and locating older people: an inner city Afro-Caribbean experience. Journal of Clinical Nursing, 23: 2083–2085. doi: 10.1111/jocn.12487 Avaiable at

Rantakokko M, Iwarsson S, Vahaluoto S, Portegijs E, Vilianen A, & Rantanen (2014) Perceived Environmental barriers to outdoor mobility and feelings of loneliness among community-dwelling older people J Gerontology A Bio Sci Med Sci 26 [epub ahead of print]

Windle et al (2011) SCIE Research briefing 39: Preventing loneliness and social isolation: interventions and outcomes available at

Zebauser A, Hofmann XL, Baumert J, Hafner S, Lacruz ME et al (2014) How much does it hurt to be lonely? Mental health and physical differences between older men and women in the KORA-Age study. International Journal of Geriatric psychiatry 29 (3) 245-52


Patients need help to navigate the maze of healthcare

22 Sep, 14 | by ashorten

Each time I enter the healthcare system from the other side (that is the side of the patient or family member) I am reminded how vulnerable patients and families are when there is no one advocating for them. I am reminded of how important good communication is between patients and care providers, and how critical the flow of information is for patients and families when they are facing serious challenges to their health and life. When patients get lost in the system without a guide it is a perilous and potentially deadly place to be. Over the last few weeks I have heard a number of stories from family and friends about a variety of personal encounters with the healthcare system and have been alarmed by the themes of “being in limbo”, “pushing for answers” and “going into battle” with the system to get appropriate, timely and effective care.

Why do patients need such protection from the system designed to help and heal them?

When the system becomes more complex and highly specialized, healthcare can become fragmented.  Patients are so often sent off on journeys to find answers to their health problems on their own. Patients have a somewhat naïve faith that all team members are talking to each other and working together to solve their health problem in an individual and personal way. Patients believe that someone is actually putting the pieces of information together for them and managing their journey from illness to health. When high quality healthcare is being delivered this is actually true and their faith is rewarded. Unfortunately, in many cases, it is the patient themselves or their family that is left with the responsibility to co-ordinate care, from scheduling diagnostic tests, arranging visits to specialists and even managing treatments. Without inside knowledge and strategic alliances, patients can get lost in the system, waiting days, weeks or even months for specialist appointments, testing appointments, test results, diagnoses and treatment plans. Sometimes such a significant amount of time is lost in this process that opportunities for recovery are missed. It is incredibly time consuming to engage with the healthcare system and patients can easily give up on seeking care or find they are not equipped to advocate effectively for themselves and powerlessly accept the long wait for advice or care.

My nursing colleagues often take on the role of informed advocate for their own friends and family in these situations and many have shared stories of correcting a misdiagnosis and standing their ground to get critical tests, information and answers when they have slipped into the void or seem stuck on the medical merry-go-round. In fact my own family has an open offer for me to appear at their bedside or doctor’s office at any time of day or night if they need someone to be their healthcare navigator in times of illness or injury. I help them find the right words, know the buttons to push, help gather the best evidence about the most effective treatment and even go into battle with them if they need a second opinion.

What if patients don’t have nurses in their personal network or informed advocates by their side?

Patients can engage a professional patient advocate whose role it is to give the patient a voice in their care. Professional patient advocates are available in many hospitals and have a strong commitment to patient safety and well-being. But what about nurses? Patient advocacy is supposed to be part of the nursing DNA. It is stated in our code of ethics1 and underpins our discipline. Sadly nurses sometimes miss opportunities to advocate for patients. Perhaps nurses become so accustomed to the healthcare environment that they do not see things through the eyes of patients and families and miss the cues that they need to advocate. Strategies are needed to support all members of the healthcare team to identify when patients are floundering, in order to create a truly patient centered and coordinated approach to care.

A recent article by Pamela Greenhouse entitled “Shaping the next generation of health providers” outlines the challenges in changing the culture of healthcare to be truly patient centered. She speaks of the importance of providers being able to see the healthcare experience through the eyes of patients and families. Greenhouse explains how students in nursing, medicine and health policy can be used as “shadowers” of healthcare.  Greenhouse believes that having students shadow the care experience in every segment of the journey sets them up to see healthcare through the eyes of patients and families as well as providing the organization with vital information about the flow of care from the receiving end. One “shadower” reflects on this:

Shadowing has allowed us to view health care not from the typical care giver’s perspective as we are used to, but from the patient and family’s perspective. Being able to Shadow the caregiving experience from both the caregiver and the patient perspective is a unique dichotomy that we are privileged to have experienced. We Shadowed patients through a wide array of care experiences, including orthopedic surgery, internal medicine, transplant surgery, and obstetrics. Each care experience provided us with unique insights into not only these medical specialties but the processes by which care is delivered.”

This is just one way of addressing the challenges of providing patient centered care. Another example can be found in the various “Mhealth” or mobile technology innovations and phone apps, which are also poised to put the patient in the center and better connect patients with providers as they navigate the system. It is the hope that these new tools will keep patients in the loop and enable more timely communication, more effective treatment plans and ultimately better health outcomes. However  it is early days and we are still gathering the evidence about the best ways to use health information technology to engage patients and build communication bridges for safe and effective care.

For many patients there is no real substitute for the personal approach and nurses are often best placed to connect with patients and support their journey from illness to wellness. So, be alert to patients who are lost or wandering in the system. You have the skills to recognize when help is needed and to guide patients back onto the path to better healthcare experiences.

Allison Shorten RN RM PhD

Yale School of Nursing


  1. International Council of Nurses (2012) The ICN Code of Ethics for Nurses (accessed September 22nd 2014)
  2. Greenhouse P. (2014) Shaping the Next Generation of Healthcare Providers. (accessed September 22nd 2014)

Raising concerns ‘speaking up’ a student nurse perspective by Andrew Catherall Twitter @AndrewCatherall

14 Sep, 14 | by Calvin Moorley, Associate Editor

It is really tough being a student nurse, I am sure that goes without saying most of you reading will either be student nurses or have at least been in the recent past but I think as we spend more time in the clinical or work environment the more we forget the anxiety of the first time we stepped into our first placements. For me having come into adult nursing with no prior care experience it felt like stepping into an entirely different world. I was fortunate enough to have an excellent first experience working on a great ward with very supportive mentors and colleagues, but some of my friends were far less fortunate. The topic for this blog is what happens when student nurses feel that their experience were bad enough to speak out.

The Nursing and Midwifery Council (2013) clearly states that raising concerns is a part of our code of conduct and that speaking out is a fundamental part of protecting our patient’s wellbeing. This being said I don’t believe speaking out to be an easy task. I believe to do it requires intense personal courage and self-confidence. As such supporting those who want to raise concerns is essential. But to understand how we can support people we need to understand what stops people from raising concerns.

I am currently involved in a research project that aims to examine the factors that prevent students from raising concerns, this idea came out of conversations I had with my student nurse peers who had poor experiences on placement and wanted to speak out about a variety of issues but choose not to. I don’t have any answers yet to what it is that holds students back from speaking out so it is difficult to say what we can really do to improve people’s experience and to support students but speaking as a student I think the number one recommendation would be to provide better education about safeguarding and incorporate raising concerns into our safeguarding training. Ensuring that students who do raise concerns have the option to move to another placement area or have their anonymity protected are also good ways of supporting students. These options though are only relevant once a student has already come forward; the real battle is about making the environment safe for anyone who may wish to raise a concern.

Fear of the repercussions of ‘speaking up’ is a major factor that prevents anyone from coming forward self-preservation is one of the most powerful human instincts and it is easy to see why someone may think twice before raising a concern(s). So far I have tried to avoid the phrase ‘whistleblowing’ I don’t like the phrase because I feel it stigmatises speaking out and raising concerns. Whistleblowing doesn’t do justice to how important raising concerns is to the delivery of safe care. Front line staff feeding back their concerns to their seniors and using feedback to improve care, whether this is through identifying inadequate staffing levels or pointing out that a colleague’s behaviour is below what is expected of the profession.

So to wrap up it is really easy to underestimate the value of raising concern or to see it as an unsavoury activity but it forms a key part of service improvement and safeguarding. I feel that supporting students in raising concerns is really important both for improving the students experience on placement and for the benefit of our patients. Thank you for reading see you over on Twitter this Wednesday 17th September for #EBNJC 2000-2100.

Andrew Catherall is 2nd year student nurse (Adult) at London South Bank University he can be found on Twitter on @AndrewCatherall

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 on 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


Nursing and Midwifery Counicl (2013) Raising Concerns: Guidance for Nurses and Midwives. London. NMC

Roberta’s Rant By Roberta Heale Associate Editor EBN, @robertaheale

7 Sep, 14 | by rheale

A tv personality in Canada, Rick Mercer, is well known for his ‘rant’. Every week he’s filmed walking around outside in back lanes where he expresses his frustration about a variety of issues. Here’s his rant about people who don’t get the flu shot:

I want to rant. I work at a community health centre once per week where I routinely care for patients with diabetes. Despite ongoing education about diet and exercise, most continue to gain weight and most are obese or morbidly obese. Very few are in target range for glucose or cholesterol, yet, the many also choose to stop their cholesterol medication (usually because of what they read on the internet). There is a great deal of confusion about appropriate lifestyle changes. All of this, and the clinic follows evidence based guidelines for diabetes education and management.

Knowing that confusion about diabetes care is not a unique to a few individuals, I can’t help but wonder what are we, as health care professionals, going to do? Looking at counseling for diet alone, it seems as if education about weight loss and healthy diets is like fighting a tsunami with a bucket. Obesity is rampant and growing (pardon the pun). People don’t appear to understand even very basic concepts, so how can we expect them to understand food labels, carbs, fat content, portion size, calories etc?

A research report released last week was splashed all over the news….every diet works    The issue is ‘for how long’???? The numbers show that people are not able to maintain changes in diet and exercise. The only successes appear to come from those who have received gastric bypass surgery. Has is come to this? Is the only way a patient can lose enough weight to get back into a healthy range through surgery?

We know a lot about disease processes such as diabetes, but we still know very little about what it takes for patients to make meaningful lifestyle changes. Until we know more, I’m going to give all of my patients a prescription for the following: Only eat ‘real’ food…fresh fruit and vegetables, lean meats, whole grains, nothing from boxes, nothing with added sugar or salt. No portion of meat, grains bigger than a closed fist. You can have a small sweet treat twice per week IF it’s made from scratch at home. Brisk walk for 20 minutes before each meal. Return to Clinic in 3 months for a review of progress. The hardest part will be to implement it myself.

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

Analysis and discussion of developments in Evidence-Based Nursing

Evidence-Based Nursing blog

Analysis and discussion of developments in Evidence-Based Nursing. Visit site

Latest from EBN

Latest from EBN