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Should mismanaged pain be considered an adverse event?

15 Mar, 15 | by atwycross


This week’s EBN Twitter Chat on Wednesday 18th March between 8-9 pm (UK time) will focus on whether mismanaged (undertreated) pain should be considered an adverse event. The Twitter Chat will be hosted by Dr Alison Twycross (@alitwy) who is editor of EBN and has also done lots of work in the area of paediatric pain management. This Blog provides some context for the Chat. The examples given relate to paediatric pain but the principles apply to pain in patients of all ages.

Participating in the Twitter Chat

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, You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending 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.

Mismanaged pain as an adverse event

An adverse event has been defined as:

An injury related to medical management, in contrast to complications of disease. Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable.”[1]

The idea of mismanaged (undertreated) pain being treated as an adverse event was first raised around five years ago [2]. Chorney et al. argue that medically caused pain (post-operative and procedural) is health care professionals’ dirty little secret.

If we consider the case of paediatric procedural and post-operative pain management practices the knowledge to guide practice is readily available [3] but many children continue to experience moderate to severe unrelieved pain during hospitalization [4, 5]. However, at the moment if health care professionals do not manage patients’ pain adequately there is no come back on them. In addition there appears to be a general acceptance among professionals and patients that just because a person is in hospital for surgery or a procedure that they can expect to be in moderate to severe pain for at least some of the time with little acknowledgment of the consequences of unrelieved pain (see below).

Mismanaged (undertreated) acute pain following surgery or procedures fits the definition of an adverse event for several reasons. First, this pain is a direct result of medical management. Pain in hospital results from a range of procedures, for example, venepunctures, chest tubes, and surgery. Without adequate treatment, the pain from these procedures is often severe and above the threshold which parents and children find acceptable [6, 7], with 33-82% of children experiencing moderate to severe pain during hospitalization [8, 9]. Second, pain can have detrimental consequences for children. Early experiences with pain, have been associated with a range of adverse behavioural and physiological consequences [10, 11]. Regardless of age, pain and associated tissue injury cause a cascade of hormonal, neuro-chemical, and electro-physiological responses that impact on physical outcomes such as wound healing, cardiac ischemia, and immobilization [12]. Mismanaged acute pain can also lead to chronic post-operative pain in adults [13] and children [14],

The definition of an adverse event provided earlier makes it clear that failure to diagnose or treat should be considered an adverse event [1]. Given this, it could be argued that the following should be considered adverse events:

  • Not assessing or reassessing pain
  • Not administering or prescribing sufficient analgesic drugs post-operatively or prior to a painful procedure
  • Not using non-drug methods to help manage post-operative or procedural pain

There will be other examples you will be able to come up. Attempts have been made to identify adverse event indicators for paediatric post-operative and procedural pain [15] but these have proved difficult to implement in practice.

During the Twitter Chat we will discuss, among other things:

  1. Whether mismanaged pain should be treated as an adverse event.
  2. Whether treating mismanaged pain as an adverse event would help change practices and reduce the amount of pain patients experience.
  3. What pain-related events should be considered adverse events.
  4. Would having to invoke a hospital’s adverse event procedure if a patient experienced mismanaged pain encourage health care professionals to manage pain more effectively?
  5. When does acute pain become mismanaged/undertreated? Can we identify a point on a scale of 0-10?

Alison Twycross

Head of Department for Children’s Nursing and Reader in Children’s Pain Management

Department of Children’s Nursing, School of Health and Social Care

London South Bank University


  1. World Health Organisation, WHO Draft Guidelines for Adverse Event Reporting and Learning Systems: From Information to Action. 2005, WHO: Geneva.
  2. Chorney, J.M., P.J. McGrath, and G.A. Finley, Pain as the neglected adverse event. Canadian Medical Association Journal, 2010. 182(7): p. 732.
  3. Association of Paediatric Anaesthetists, Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Pediatric Anesthesia, 2012. 22(S1): p. 1-79.
  4. Birnie, K.A., et al., Hospitalized children continue to report undertreated and preventable pain. Pain Research and Management, 2014. 19(4): p. 198-204.
  5. Twycross, A. and G.A. Finley, Children’s and parents’ perceptions of postoperative pain management: A mixed methods study. Journal of Clinical Nursing, 2013. 22(21-22): p. 3095–3108.
  6. Gauthier, J.C., G.A. Finley, and P.J. McGrath, Children’s self-report of postoperative pain intensity and treatment: threshold: determining the adequacy of medication. Clinical Journal of Pain, 1998. 14(2): p. 116-120.
  7. Birnie, K.A., C.T. Chambers, and P.J. McGrath, When does pain matter? acknowledging the subjectivity of clinical signficance. Pain, 2012. 153(12): p. 2311-2314.
  8. Stevens, B.J., et al., Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain, 2012. 13(9): p. 857-865.
  9. Twycross, A. and S. Collis, How Well Is Acute Pain In Children Managed? A Snapshot In One English Hospital. Pain Management Nursing, 2013. 14(4): p. e204-e215.
  10. Taddio, A. and J. Katz, The effects of early pain experience in neonates on pain responses in infancy and childhood. Pediatric Drugs, 2005. 7(4): p. 245-257.
  11. Anand, K.J.S., et al., Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Archives of Pediatric Adolescent Medicine, 1999. 153(4): p. 331-338.
  12. Carr, D.B. and L.C. Goudas, . Acute pain. LANCET, 1999: p. 2051-2058.
  13. Kehlet , H., T.S. Jensen, and C.J. Woolf, Persistent postsurgical pain: risk factors and prevention. Lancet, 2006. 367: p. 1618-1625.
  14. Fortier, M.A., et al., Acute to chronic postoperative pain in children: Preliminary findings. Journal of Pediatric Surgery, 2011. 46(9): p. 1700-1705.
  15. Twycross, A., et al., A Delphi Study to Identify Adverse Event Indicators for Pediatric Post-operative and Procedural Pain. Pain Research and Management, 2013. 18(5): p. e68-e74.

Nursing: Still a Great Career

9 Mar, 15 | by rheale

By Roberta Heale,  EBN Associate Editor @robertaheale @EBNursingBMJ

I knew I was scheduled to post the blog this week, but I struggled with what to write.  I scanned EBNursing website and Twitter account @EBNursingBMJ as well as other nursing related stories and research articles.  There were so many potential topics that soon my head was spinning.  Then it occurred to me that this is the story: Nursing’s diversity and the amazing career opportunities.

A few decades ago, when I was contemplating what to do with my life, I started to focus on nursing.  My Mom is a nurse and to my teenage sensibilities her job seemed to be really tough, but also really interesting and a little disgusting.  However, I realized that her work gave her fulfillment.  At the same time, she could support herself financially if need be.  She moved from a medical nursing floor, to a long-term care facility to management.  I figured that if I went into nursing, I could work anywhere in the world, in hospital or community, in management, research, education or more.  So, with the protests of my friends and some of my teachers ringing in my ears, I applied to take a BScN program.  That was 31 years ago and, you know what?  I was right.

Soon after I graduated from my undergrad degree, I started work on a medical floor in a hospital in downtown Toronto, Canada.  It was one of the most difficult positions I’ve ever had. The physical care was difficult (heavy lifting, etc), the patients complex and HIV/AIDs was still new on the healthcare map.  Usual care was complicated by a bit of fear, mixed with compassion and helplessness for many of the patients. In comparison, I have a friend who had graduated the same year as me with a BA and her first job was in a back office of a government building.   I met her to go for lunch one day and found her asleep at her desk.  She told me that she couldn’t believe how boring her job was.  In all my years in nursing ‘boring’ has never been a word I’ve used to describe my work.

We hear so many negative things about nursing; long hours, stress, lack of recognition and appropriate remuneration.  Unfortunately, these situations continue to exist in most countries.  However, nursing remains an incredibly dynamic, flexible and exciting profession with so many opportunities, it’s mind boggling. I would happily encourage anyone to become a nurse.   If you think I’m wrong, just Google ‘nursing jobs’ and see what you find. Maybe the next step in my career will be the nurse on a cruise ship!

Is it time to change our approach to end of life education in undergraduate nursing?

2 Mar, 15 | by hnoble

This week’s EBN twitter chat on Wednesday 4th March between 8-9 pm (UK time) will focus on end of life education in undergraduate nursing. This week’s Blog has been written by Dr Claire Lewis from Queens University Belfast and provides some areas to think about ahead of the Twitter Chat. 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.

Providing care to patients who are at end of life and their families is a known area of concern for undergraduate nursing students. Many have reported feelings of anxiety and emotional distress when faced with the experience of providing care to a dying patient (See Cooper and Barnett, 2005).

Despite these concerns, end of life care has traditionally been poorly delivered within undergraduate nursing curricula. Evidence suggests that nursing students and newly qualified nurses feel inadequately prepared to provide quality care to patients at end of life and support to their families (Cavaye and Watts, 2010). Many report concerns about knowing what to say to patients and their relatives; concerns about their own fears and reaction to death; and practical issues such as symptom management and care of the body after death.

Anecdotally, I know my own undergraduate nursing students share these concerns. On many occasions the subject of death and dying has been raised in class discussions and they are eager to ask questions about my own clinical experience of caring for people at end of life. We dedicate a substantial amount of our overall teaching hours towards end of life care, and the teaching format follows the traditional model of large group lectures followed by a small group tutorial sessions. However, it has been suggested in a review by Gillan et al (2014) that traditional didactic teaching formats such as large group lectures are not best suited to teaching end of life care as they do not provide an opportunity for students to reflect on their own experiences and concerns. Rather, students should be exposed to end of life care teaching methods which promote active and experiential learning. In short, more innovative ways of teaching. Innovative approaches to end of life education have included the use of cinemeducation (the use of film in teaching); storyboarding (narrative story telling); hospice volunteer programmes; problem based learning through case studies; and the use of high fidelity simulation.

My own recent area of interest and research is the use of high fidelity simulation to teach end of life care. It is generally accepted that increased exposure to patients receiving end of life care will improve students’ competence and confidence in delivering care to this patient group. However, many students may have limited opportunities in the course of their clinical placements to gain such experience. High fidelity patient simulation uses computerised manikins to simulate real life clinical scenarios. It has been demonstrated to provide experiences and educational outcomes comparable to that of clinical placement

High fidelity simulation allows students to develop their practice skills and improve their critical thinking and decision making in a safe and non-threatening environment. From the limited evidence available, end of life care simulation has been proposed as a viable teaching method given its positive impact on knowledge acquisition, communication skills, student satisfaction and level of engagement in learning. We plan to test this in our own School this year as an alternative method of delivering end of care education for both undergraduate nursing students and medical students.

As nurse educators it is imperative that we prepare students adequately for the delivery of end of life care given a negative first experience with death can impact greatly on a nursing student’s future practice (Terry and Carroll, 2008). Not only will this warrant confidence in their ability but it will also ensure patients and their families are afforded the highest standard of care at this highly emotive and sensitive time. After all, we only get one chance to get it right.

Questions to consider:

  • How can we adequately prepare students for their first experience of death?
  • How is end of life care best taught to undergraduate nursing students?
  • Are teaching methods such as simulation appropriate to deliver end of life education?


  • Cavaye, J. and Watts, J.H. (2010) End of life education in the pre-registration nursing curriculum. Journal of Research in Nursing, 17(4), p.317-326.
  • Cooper, J. and Barnett, M. (2005) Aspects of caring for dying patients which cause anxiety to first year nursing students. International Journal of Palliative Nursing, 11(8), p.423-430.
  • Gillan, P., van der Riet, P., Jeong, S. (2014) End of life care education, past and present: a review of the literature. Nurse Education Today, 34(3), p331-342.
  • Terry, L.M., Carroll, J. (2008) Dealing with death: first encounters for first year nursing students. British Journal of Nursing, 17(12), p.760-765


The Freedom to Speak Up review – whistleblowing post Mid Staffordshire

23 Feb, 15 | by hnoble

Extreme poor standards of care exposed at Mid Staffordshire NHS Foundation Trust in England made national headlines in 2009 and horrified the public and NHS staff alike. A report led by Robert Francis QC, a barrister with extensive experience of clinical negligence claims exposed appalling treatment of patients and high mortality rates at the hospital trust. The public inquiry heard recurrent themes of patients left lying in their excrement or vomit, call bells unanswered, food and drink which couldn’t be reached and incidents such as falls hidden from relatives. Many patients and their relatives reported being treated callously and with insensitivity by nursing staff.

It became apparent from Sir Francis’ report that although we proclaim openness and honesty in the National Health System (NHS) in the UK there still remains a problem when it comes to staff speaking out when wrong doing takes place – in other words ‘whistleblowing’.

‘Whistleblowing’ is when an employee reports suspected wrongdoing in their workplace and is concerned with making a disclosure which is in the interest of the public. The employee might notice something illegal, a person acting dangerously at work or someone neglecting their role. There may be a risk to someone’s health or safety, environmental damage, law breaking and illegal activity or the covering up of some wrong doing. Of the recommendations, arising from the public inquiry into Mid Staffordshire NHS Foundation Trust, a key area with most attention was encouraging staff to raise concerns or whistleblow. All of us are very aware of the catastrophic effects that might arise if concerns are not identified and acted upon. Whistleblowers continue to face problems if they speak out in the health service even though there has been a concerted effort to create an open and honest culture where whistleblowing is viewed positively. That said whistleblowers continue to face problems if they speak out in the health service even though there has been a concerted effort to create an open and honest culture where whistleblowing is viewed positively. See

Since Sir Francis’ report The Freedom to Speak Up review also led by Sir Robert Francis QC, was published on 11 February 2015 which explored the raising concerns culture in the NHS. Worryingly, as mentioned, there continues to be a problem and staff continue to feel intimidated and unable to speak out. If staff don’t speak out patient care may remain sub-standard. A Tweet just yesterday on Twitter from the Patients Association@PatientsAssoc reported:

Themes from our Helpline: ‘Patients want to be treated humanely, with compassion and listened to':

The Freedom to Speak Up review makes a number of key recommendations under five overarching themes with actions for NHS organisations and professional and system regulators to help foster a culture of safety and learning in which all staff feel safe to raise a concern. It recognizes that since reporting on the failings at Mid Staffordshire, some progress has been made in the NHS but there is still much to be done if we are to continue building a culture of improvement and learning. Since the Freedom to Speak Up review the Secretary of State has committed to write to every NHS trust chair to buttress the importance of staff feeling safe to discuss concerns openly in teams, and for appropriate actions to be taken. Each organisation is to appoint a local guardian with direct reporting line to the chief executive, who staff can approach to raise concerns. There is also a national Whistleblowing Helpline which provides advice for staff on raising concerns. It is also available to employers for advice on policy and governance arrangements. Tel: 08000 724 725 or email

Protecting patients and staff from harm and ensuring dignity of care requires an open and transparent culture at all levels of the system, but getting it right is no easy task.

Other useful websites include: which offers guidance for employers signposting them to guidance, policy and legislative drivers realted to whistleblowing which offers guidance for staff about raising conerns Sir Robert Francis review of whistleblowing processes and the latest information about the ‘Freedom to Speak Up’ review tools and resources - free downloadable communication tools and frequently asked questions.




Using health promotion theory with patients

16 Feb, 15 | by josmith

Nova Corcoran, University of South Wales will be leading this week’s ENB twitter chat on Wednesday the 18th of February between 8-9pm focusing on ‘5 Quick ways to use health promotion theory with patients’. 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.

5 Quick ways to use health promotion theory with patients by Nova Corcoran

Many nurses view health promotion theory as something they vaguely remember from university and very few would claim to use health promotion theory in practice. Here’s the good news – you don’t need to remember a whole theory to use theory? There are many common elements in health promotion theories that can be incorporated in day to day practice. Here are five quick ways to use health promotion theory with patients.

Promote the benefits of change –not just the health benefits

We tend to focus on changing behaviour being ‘good for you’ but often patients find it difficult to quantify health benefits that are twenty years or more down the line. Benefits are recognized in a number of theoretical models and tangible benefits can include saving money, losing weight, not smelling of smoke or making new friends. Use resources to help you promote the short term benefits, for example websites that calculate how much money you save by quitting smoking (refer to resources list).

Promote patient behavioural control

A feature of a number of health promotion models is the role of self-efficacy or behavioural control. This is the patients’ perception of their own ability to be able to achieve something. Patients with low self-efficacy are much less likely to change. Be positive with your patients; tell them they can achieve their goal. Focus on small goals for example swapping instead of stopping. Change4life has good ideas for nutrition smart swaps (refer to resources below). Equally swaps could be in other lifestyle areas for example alcohol by swapping higher to lower strength beers.

Identify barriers to change

Numerous theoretical models acknowledge that barriers stop many behaviour change efforts. Ask patients what they think will stop them achieving a behavior, for example quitting smoking and how they plan to overcome this barrier. For example barriers to quitting smoking include peer pressure from friends, habit and cravings. If the response can be planned relapse is less likely. You might suggest a distractor app for iPhone/android phones such as the Filter Distractor app (refer to resources below) or Nicotine Replacement Therapy (NRT).

Recognize the wider environment

The environment is an important element of behaviour change. Safety, traffic and aesthetics can discourage exercise outdoors and unfriendliness, unfamiliarity and embarrassment can discourage exercise indoors. If you wanted to encourage a patient to exercise more then you need to be able to signpost them to friendly, safe spaces. Become familiar with your local area; which physical activity groups are easy to access? Does your leisure centre run special classes for teenagers or older people? and which green spaces are safe?

Tailor information to the patient

If you work with children you probably communicate health information use simple words or pictures. The same tailoring ethos should also apply to other patients; for example providing information in a different language or large print. Recognize that patients are at different stages of change. For example does your patient have all the information they need? Are they very knowledgeable? Have they tried to change before? What is stopping them from changing? Being a good signposter can help you tailor information. If a patient wanted support to change a behaviour i.e. diet some patients would prefer a group, some would prefer a website and others might just want to do it by themselves. Ask the patient what they would prefer and signpost accordingly.

You do not need to be an expert in health promotion theory to do any of these five things – just think small changes, short term goals and know the assets in your local area that will support your patient when they are back at home.

Can you think of any more quick ways to include theory in practice?


Change4life (2014) Smart Swaps available at

NHS (2014) Smokefree calculate the cost available at

Filter (2014) Distractor app available at

A useful online resource for nursing theories is available at


Addition information on theoretical models can be found in Corcoran N (2013) Health Communication; strategies for health promotion, Sage, London.

A good overview of different theories for nurses in behaviour change can be found in is Davies N (2011) Healthier Lifestyles: behaviour change. Nursing Times 107 23 20-23 available at

Acupuncture and My Search for Chronic Pain Treatments

8 Feb, 15 | by rheale

by @RobertaHeale, Associate Editor, EBN

What I like about being a nurse practitioner is the ability to provide wholistic care to patients including assessment, diagnosis and treatment.  It brings me great professional satisfaction to not only monitor my patient’s response to treatment of chronic conditions, but also to educate them about their condition and implement preventative care measures.  However, one area of care falls short; the management of chronic pain.

Chronic pain issues, at various degrees, represent a large percentage of the reason for patient appointments.  Chronic pain is often combined with other issues:  osteopororis and chronic pain; cardiac disease and chronic pain; diabetes and chronic pain…the list goes on.  I’ve been frustrated and concerned that the predominant treatment of chronic pain in my repertoire of options is medication.  Pharmaceuticals may take the pain away, but only for a short time and they are fraught with problems:  side effects (some deadly), addiction, cost and more.  Besides, pills don’t treat the problem, only the symptom.  In addition, in Canada, physiotherapy, massage, chiropractic etc, are not included in health coverage.  Most of the patients I see do not have additional health benefits to cover these treatment options and can’t afford to pay for it themselves.

I happened to work with a nurse practitioner who practices acupuncture.  What a revelation! I didn’t know much about acupuncture, but over time, her successes in treating patients with chronic pain took me down a path of discovery.

Classical acupuncture has been documented in China for thousands of years. The earliest work about acupuncture, the Nei Jing, was compiled around 305-204 BC and contained everything that was known about acupuncture to that point.   Since that time, acupuncture has remained an important part of Chinese medicine.  See this site for more information about the history of acupuncture:

Western medicine has been slow to embrace acupuncture.  However, there has been increasing interest and implementation of acupuncture since the 1970’s.  More and more scientific evidence has accumulated that supports the effectiveness of acupuncture in the treatment of chronic pain, as well as a number of other conditions1. Check this out

Nurses in Ontario, my home province, along with all other regulated healthcare providers, are eligible to include acupuncture in their practice.  It goes without saying that this is after receiving training from an accredited education program.  So, that’s what I’m doing.  I started an entry level acupuncture course.  I’ll complete the online portion and then participate in an intensive onsite seminar over a number of days where I’ll poke other students with extremely fine needles and, hopefully, get them in the right place.  At this point, I’ll be allowed to implement basic acupuncture with my patients.  A few of my patients are aware that I’m taking this program…they’re just as frustrated as I am with the scant options for chronic pain and are waiting for me to finish my program.  Actually, all but one person I know, has volunteered to let me practice on them.

So, this is a blog without an ending…yet.   I’ll write a follow up in the Spring and let you know about my experiences in implementing acupuncture into my practice.   Stay tuned!

1. Wang, S., Kain, Z. N. & White, P. (2008). Acupuncture analgesia:  1.  The Scientific basis.  International Anesthesia Research Society, 106(2), 602-610.

Should we expect nurses to be role models for healthy living?

1 Feb, 15 | by atwycross

This week’s EBN twitter chat on Wednesday 4th February between 8-9 pm (UK time) will focus on whether we should expect nurses to be role models for healthy living. This links very nicely with last week’s Blog “Loosing the fight against obesity”. This week’s Blog has been written by Professor Jane Wills from London South Bank University and provides some areas to think about ahead of the Twitter Chat. The Twitter Chat will be hosted by PhD student Muireann Kelly (@muireanntweets), also from London South Bank University, who is looking at the subject of nurses as role models for her doctoral studies. 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.

NHS chief executive Simon Stevens has claimed that obesity in the UK is a “slow motion car crash” that could be financially disastrous for the health service. The NHS is now spending more on bariatric surgery for obesity for example, than on the national rollout of the intensive lifestyle intervention programmes. The health service has to “get its own act together” on obesity by helping staff to lose weight. Stevens claims that more than half of the NHS’s 1.3 million staff are overweight or obese.

Whilst the source of the figure is not known, the latest Health Survey for England states that a quarter of adults are obese (24% of men and 26% of women), while 65% of men and 58% of women are overweight or obese. So these figures on the health care workforce reflect those of the general population and nurses are not that different. Weight-related problems are strongly related to economic factors, but so too is the difficult task of rectifying them. For nurses, long hours, shift work, low pay and the work itself of caring for others all make addressing personal health a challenge.

Why does it matter if nurses don’t lead particularly healthy lifestyles themselves? The argument being put forward is that nurses and midwives are credible sources of advice and support to patients about how to improve their own and their family’s health. ‘Making Every Contact Count’ (MECC) is the initiative to train nurses and midwives to find out what motivates people and to work out with them what are the best steps they personally can take to improve their own health. Yet this kind of health promotion is rare to observe in practice. Why? Maybe nurses and midwives think it would not be welcome or may damage a good relationship between the health care professional and patient.

Question: Why do you think there is a reluctance to take health improvement opportunities to talk to patients about their lifestyle?

The national press responded to Stephens’ speech with headlines such as “Weight’s up doc . Fat medics told to slim by NHS chief” (Sun newspaper) and there followed a blaming discourse that, irrespective of the health system’s failure to enable better health, somehow nurses “ought to know better”.

Question: Should nurses and midwives adopt healthy lifestyles themselves so they can act as role models?

Both government policy and professional nursing bodies have shown that they are concerned about nurses’ lifestyles and about nurses being healthy role models. The recent Five Year Forward View called on all healthcare workers to “stay healthy, and serve as health ambassadors in their local communities” (p.11), and the NMC have included role modelling health-promoting behaviour as a competency for all nurses.

The argument being put forward for nurses to ‘practise what they preach’ is multifaceted. Last week, Jane Cummings said staff might find it hard to give advice until they themselves start to make some changes in their own lifestyles. Patients may be less likely to follow the health advice of nurses who do not personally engage in the behaviours they are seen to promote. An Ipsos Mori survey found that 37% of the public would not accept health advice from a healthcare professional who appeared to have an unhealthy lifestyle (

Furthermore, unhealthy nurses may have higher sickness absence rates and lower productivity, which place an avoidable strain upon NHS resources. This may also impact on the quality of care and patient safety.

There is a counter-argument that nurses are only human, and that they should be free to make individual choices about their lifestyles. Nursing is a stressful job which can encroach into an individual’s personal life. The constraints of the job can sometimes make it more difficult for nurses to choose a healthy option. A focus of the Five Year Forward View plan is highlighting the health system’s role in promoting healthy lifestyle change. The plan includes moves to reduce the sale of high-sugar and high-fat products on hospital premises, and all hospital trusts should offer healthy food for their staff 24 hours a day. At present only a quarter of hospitals offer healthy food to night staff, which means they have to rely on vending machines and microwave meals. Trusts will also be told to encourage staff to join work-based weight-watching and exercise schemes via sponsored membership of local leisure centres and gyms.

There is a widespread view that patients are more likely to listen and heed the advice and support given by someone like themselves. A nurse who is overweight or a smoker may be better able to empathise with patients faced with making lifestyle changes. Is nursing more about giving health promotion advice and information with confidence and experience than trying to be an exemplar of healthy living? The views of nurses themselves are not well-researched, and so little is known about how nurses themselves feel about being role models for healthy lifestyles.

Question: What do you think? Is it reasonable to expect nurses to be role models for healthy living?




Losing the Fight Against Obesity

26 Jan, 15 | by rheale

By Roberta Heale  @robertaheale

Look to any blog, news or health website and you’ll find a story about the world obesity epidemic almost every day from every angle: Financial obesity programs health & & from the fashion and beauty industry etc. etc. etc.  Despite the news, the world is getting fatter and fatter and fatter.  The World Health Organization indicates

·  worldwide obesity has more than doubled since 1980.

·  In 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 600 million were obese.

·   39% of adults aged 18 years and over were overweight in 2014, and 13% were obese.

·   Most of the world’s population live in countries where overweight and obesity kills more people than underweight.

·   42 million children under the age of 5 were overweight or obese in 2013.


Most importantly, obesity is preventable.  Think about it.  What other epidemic has affected so many people?

As with all epidemics, nurses are on the front line in the fight against obesity.  Health care education and programs are important steps.  However we aren’t winning this war. Albert Einstein, is credited with saying “The definition of insanity is doing the same thing over and over again, but expecting different results.”  Given this, maybe we need to change our approach.

I just watched the movie The Imitation Game. It portrays the important work of another genius, Alan Turing, who refused to waste his time on the traditional code breaking techniques that were not making any headway in breaking the German code system used in WWll.  Instead he designed the first computer, which cracked the codes that were previously unsolvable.  Maybe we need to change our approach and think in an innovative and strategic manner with the ‘big picture’ in sight.

Advocacy and leadership are among the list of nursing competencies and nurses have been involved in many campaigns for health public policy.  There has been success in reducing smoking rates through strategic policies in some jurisdictions. Perhaps increasing our efforts in advocating for meaningful health policy changes will make a difference in the fight against rising obesity rates.  Success has already been achieved in my province through the implementation of policy removing vending machines with fat-promoting food from high schools.  It’s just a small start, but worth a try in the war against the obesity epidemic.

Non-Pharmacological Approaches for Alleviating Distress in Dementia Care

19 Jan, 15 | by josmith

Gary Mitchell, Dementia Care Advisor and Joanne Agnelli, Dementia Services Quality Manager for Four Seasons Health Care,  will be leading the next ENB TWITTER chat on Wednesday 21st January 8-9pm UK time, and will focus on non-pharmacological approaches for alleviating distress in dementia care. In order 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 an account contributing is straightforward; you can follow the discussion by searching for links to #ebnjc @EBNursingBMJ, or better still, create a tweet (tweets are text messages limited to 140 characters) to ENB the journal @EBNursingBMJ and add #ebnjc (the EBN chat hashtag) at the end of your tweet, this allows everyone taking part to view your tweets.

Estimates suggest that feelings of distress occurs in almost 80% of people living with dementia (James et al, 2008). Traditionally the management of distress was through the use pharmacological intervention, like Risperidone, Olanzapine, Quetiapine (Sink et al, 2005). While the use of these medications may be appropriate for some people living with dementia, the use of non-pharmacological approaches as a means to reduce distress is recommended because they can be more dignified and are in keeping with the ethos of person-centred care, and are more cost-effective when compared to the prescription and administration of medications (NICE, 2011). The approaches of reminiscence, reality orientation, validation, music therapy, horticultural therapy, doll therapy and pet therapy have proved popular techniques when considering non-pharmacological approaches for alleviation of distress in dementia care.

Reminiscence Therapy – focuses on assisting the person living with dementia to relive positive past experiences of their life and may be related to their family life, their wedding, the places they used to visit or the activities they used to carry out at work.

Reality Orientation – is about re-orientating the person living with dementia to their current environment. Orientation can be achieved directly through open communication between healthcare professionals and people living with dementia. In addition aids such as clocks, calendars, specialist dementia signage and personalisation of living spaces can also aid in assisting people living with dementia to recognise their surroundings.

Validation Therapy – centres on the idea of acceptance of another person’s reality. The clinical manifestations of dementia mean that sometimes people living with the condition may feel they are in another time or place. When healthcare professionals fail to validate a person’s feelings or reality this can intensify the level of distress a person is experiencing.

Music Therapy – is categorised as a sensory therapy which has generated positive results in relation to enhancement of wellbeing and alleviation of distress in dementia care. The personalisation of music therapy is an important element to consider so as to ensure that the person living with dementia actually finds the music, either being played or being listened to, as therapeutic.

Horticultural Therapy – or garden therapy has been emerging as a popular therapy in recent years. Horticultural therapy can be directed by healthcare professionals in a garden area and activities may be guided, for example the potting of plants, the sewing of seeds or the feeding of birds.

Doll Therapy – arguably the most contentious non-pharmacological approach on offer, doll therapy is often unstructured and engagement with the doll could be any number of things to include: talking to the doll, cuddling the doll, dressing the doll, playing with the doll or feeding the doll Benefits to doll therapy include: greater levels of wellbeing through improvement in communication, maintaining a safe environment and personal care. It should be noted that while there are a plethora of benefits associated with doll therapy, there are number of things that healthcare professionals need to consider in relation to doll therapy, the most of important of these is arguably ethical conduct as some critics of doll therapy believe it to be infantile, in that people living with dementia are encouraged to play with dolls like children.

Pet Therapy – is a popular but sometimes difficult intervention to source given the practicalities. Pet therapy or animal assisted therapy has shown positive results in people living with dementia who are fond of animals. The most popular animal used in this intervention is a dog.

Personalisation – Arguably the most important factor in all of these approaches is personalisation. These approaches to care are enhanced through life-history work (i.e. when a healthcare professional has taken the time to get to know the person living with dementia and understands their personality). The final point to note is that note that these approaches are important, not only in reducing episodes of distress, but actually enhancing the wellbeing of people living with dementia.

Possible Questions for Consideration:

What other examples of non-pharmacological approaches have benefited people living with dementia?

What is the difference between validating someone’s reality and telling lies in dementia care?

What is actually needed to utilise garden therapy effectively?

What are the ethical issues associated with doll therapy?

When the approaches described do not reduce distress is it always appropriate to seek anti-psychotic medication?

Is there a difference between distress and challenging behaviour?


James I, Mackenzie L, Pakrasi S et al (2008a) ‘Non-pharmacological treatments of challenging behaviour’. Nursing Residential Care 10, (5), pp. 228-32

National Institute for Clinical Excellence (2011) A NICE–SCIE Guideline on supporting people with dementia and their carers in health and social care. National Clinical Practice Guideline Number 42. HMSO: London

Sink, K., Holden, F. and Yaffe, K. (2005) ‘Pharmacological treatment of neuropsyciatirc symptoms of dementia: A review of the evidence’, Journal of American Medical Association, 293, (5), pp. 596-608.

Building communication bridges with information technology: Looking back as we leap forward.

12 Jan, 15 | by ashorten

It is now almost two years since I wrote a blog on the introduction of the electronic medical record (EMR) in our local health service.1 It was the day before the new EMR system went ‘live’ and clinicians were nervous about how it would affect their daily lives and, most importantly, communication with patients and families. At the time one of the doctors shared with me that he had real concerns about giving patients adequate ‘face to face’ time while simultaneously meeting the needs of the new computer record keeping system. It was clear to all that it would take extra time to provide and document care with the new system and there was going to be a steep learning curve in ways that had not even been anticipated. Since then, I have seen this same doctor on numerous occasions, interacting with patients and families. He still sits at the bedside talking to patients and families face to face without a computer in sight. He has clearly developed strategies to maintain this precious personal communication with his patients, while still feeding the computer with the necessary information for documenting patient assessment and response to care.

I am often amazed at how quickly new forms of technology become the norm. I cannot imagine life without a smartphone and easy access to the internet 24 hours a day is no longer a sophisticated luxury. On the healthcare frontline it has very quickly become normal to see nurses dragging their WOWs (workstation on wheels) and COWs (computers on wheels) between and around patient rooms in health care facilities. It also feels quite normal to see primary care providers logging on to the computer system as they enter the consultation room, pausing briefly to shake hands and introduce themselves, as they prepare to simultaneously and seamlessly discuss and document the reason for your visit. However, even after two years I see clinicians struggling with the demands of the new and often updated digital repository, robotically filling in the blanks as they appear on screen, searching for the right place to put things, sometimes frustrated that the information they are trying to input does not fit the information category provided by the program. At times it even appears that they are putting square pegs into round holes and crossing fingers that the clinician following them will be able to find key pieces of information being shared.

In my observation, some clinicians are better than others at establishing rapport and communicating to their patients that they are actually listening actively to their narrative, even though more often than not their eyes are fixed to their screens. I have observed clinicians who are masters in the art of maintaining just enough eye contact to communicate that they are interested in the story yet still diligent in capturing the details in the digital system. Others still use pen and paper to jot down notes as they give full attention and face the patient, choosing to document their findings at the conclusion of the consultation, checking with the patient that what they have gathered is correct, making sure they are both on the same page for plans moving forward. Clinicians have adapted to new technology in different ways, and in some cases the technology itself – designed to improve information sharing – has become a barrier to effective communication.

As expected, the digital natives seem to struggle less with new technology, accepting that EMRs are here to stay. Rather than fighting the inevitable, they quickly learn how to maximize the benefits of the systems and build upon them. They constantly look for ways to refine the capabilities of the system, so that the technology is working for them, rather than the other way around. We have much to learn about making the most of the EMR and the information within it, and this is a priority for nursing and healthcare research. We need evidence about the ongoing impact of EMRs on patient care and patient outcomes.

Putting these ongoing transitional challenges aside, there are many exciting ways for us to communicate with patients and to enhance information exchange. The EMR is only part of the larger puzzle, but it is likely to be an ever increasing conduit of communication between patients, families and clinicians in future healthcare.

Global interest in mobile health (mHealth) strategies, where information exchange can be integrated within systems of healthcare, including the EMR, has exciting possibilities for the future.2 There is great potential to expand our healthcare reach to populations where people have previously lived with an absence of high quality evidence-based information to promote their health. Now many more communities have access to mobile phone technology to access texting services, hotlines, telemedicine and new decision support ‘apps’. In particular, support of growth of mHealth in Lower and Middle Income Countries (LMICs) has been recognized as an important research priority with great potential for increasing use of evidence-based health strategies that make a real difference to population health.2

There is increasing excitement about the potential for interactive digital patient decision aids to be housed within or linked to the EMR. This will enable patients to receive the right information, at the right time, and for providers to communicate with patients as they interact with decision aids, clarifying values and preferences in preparation for shared decision making. Easy access to high quality evidence-based information is central to effective preparation for decision making. Health information technology provides greater capacity to engage patients, accommodate individual learning needs and bridge communication gaps than the more traditional paper-based tools (books, booklets, pamphlets etc.). We are still exploring questions about what can be achieved with digital modalities over paper-based tools but the field is promising.

With any innovation, it is important to have the necessary passion, vision, resources and evidence to overcome the barriers to achieving a change that is worthwhile and increases access to more effective models of care. We must keep one eye focused on the tipping point, to ensure that the technology we integrate into clinical practice does not create additional barriers to effective care and communication. We must never stop evaluating the care we provide and gathering evidence about the consequences to guide our decisions about which systems work best and how the best patient outcomes can be achieved.

Allison Shorten, RN RM PhD

Yale School of Nursing


  1. Shorten A. (2013, February). Patient centered care and the electronic medical record, Evidence Based Nursing Blog (BMJ Group Blogs).
  1. Mehl, G., Labrique, A. (2014) Prioritizing integrated mHealth strategies for universal health coverage. Science. 345 (6202), pp. 1284-1287.
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