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Managing pain in children: How far have we come in the past 20 years? Where do we need to get to?

4 Dec, 16 | by atwycross

imageIn October it was 20 years since the first Pediatric Pain Letter ( was published. Over the years this publication has disseminated a huge about of information about pain in children. Despite this, and other work in the area, children continue to experience unrelieved moderate to severe pain while in hospital (Kozlowski et al. 2014, Twycross & Finley 2013). In 2015 we published a review of the literature looking at nurses’ postoperative pain management practices (Twycross et al. 2015). We concluded that nurses’ assessment and management of children’s pain is still not always consistent with published guidelines. Results of studies looking at the reasons for this were inconclusive with contradictory results. Many of the studies included were of low quality or chart audits meaning that data was probably incomplete. We suggested that research needs to be carried out to examine the impact of organisational factors on nurses’ pain care practices and that intervention studies are needed to determine the most effective strategies to support and improve nurses’ pain care for children. more…

Clinical academic roles: Some reflections on the benefits, the challenges and the next steps

27 Nov, 16 | by atwycross

Clinical academics make an invaluable contribution to healthcare yet it is estimated that only 0.1% of the Nursing, Midwifery and Allied Health Professional (NMAHP) workforce are currently in these roles. The absence of a clear clinical academic pathway has been a barrier to NMAHP pursuing these roles (Coombs et al., 2012). Earlier this month the Association of UK University Hospitals released guidance on transforming healthcare through clinical academic roles in NMAHP ( The guide provides a practical resource to develop and sustain NMAPH clinical academic roles. It is aimed at healthcare provider organisations and anyone interested in fostering clinical ascreen-shot-2016-11-25-at-11-33-30
cademic roles for NMAHP. In each section, a ‘what’, ‘why’ and ‘how’ format is used accompanied by case study examples.

I am a full-time PhD student and part-time paediatric oncology nurse. As I reach the end of my first year in both roles I am grateful for this document and the fact that it encourages healthcare providers to support positions like mine. My clinical role has valuable benefit to my academic work. Metaphorically, I bring my patients and their families to my academic work and use their experiences to critique my own research and the wider literature. My patients provide me with the motivation to excel in my research and to ensure it is effectively disseminated to benefit them. Similarly, my academic role enables me to bring an evidence-based perspective to my clinical role. As a newly-qualified nurse, this grounding in evidence-based research helps me look critically at procedures and gives me an awareness of the experiences of my patients and their families beyond what I see on my ward. more…

Recognising, Assessing and Managing Deteriorating Adult Patients

20 Nov, 16 | by josmith

By Gilberto Buzzi Senior Lecturer, School of Health and Social Care / Institute of Vocational Learning | London South Bank gilberto-buzziUniversity e-mail:

When patients are admitted to hospital, the expectation is that they entering a place of safety. Their families, relatives and friends trust that once in the hands of healthcare professionals, their loved ones are not only going to find comfort but also receive the best treatment possible. Patients trust they will be looked after by competent and confident nurses who will prevent their situation from getting worse, and in the event their condition deteriorates, that they will indeed manage it effectively. Sadly, this is not always the case. Hospital mortality statistics have been linked to staff failures to identify or manage early signs of deterioration.

Recognising and responding to deteriorating hospitalised patients is an important global issue in nursing. By closely monitoring changes in physiological observations and interpreting early sings of physical and psychological decline, nurses are more likely to identify, manage and therefore avoid serious adverse events before they occur. The National Early Warning System (RCP, 2012) has been introduced to help address this issue. The system is based on objective physiological parameters being scored according to the amount of deviation from normal. The scores are weighted depending on the severity of deviation.  screen-shot-2016-11-18-at-17-37-47
The aggregate score is then calculated and acted upon accordingly. As with everything, the tool is only as good as the professional using it. Therefore, all nursing staff caring for patients in acute hospital settings must be competent in monitoring, measurement, interpretation and prompt response to the acutely ill patient, appropriate to the level of care they are providing as supported by their code of conduct (NMC, 2015).

To be able to calculate accurate NEWS the following should be assessed and documented.

  1. RR (respiratory rate) Record rate on every set of observations (RR is an early indicator of clinical deterioration.
  2. Oxygen Saturations (SpO2) Oxygen saturation should be measured by pulse oximetry.
  3. Temperature (Internal body temperature is preferable over axilla).
  4. BP (Systolic blood pressure) in case of acute deteriorating or if automated machines giving an inaccurate or suspect reading then check with a manual sphygmomanometer.
  5. HR (heart rate) Palpate the pulse, assess rhythm and rate and volume.
  6. Level of Consciousness (AVPU – Alert, responds to Voice, responds to Pain or Unresponsive, is a quick and easy method to assess level of consciousness. Change in consciousness is another sensitive indicator of clinical deterioration.


Fields of nursing: do we need them, what should they be and when should nurses choose theirs?

10 Nov, 16 | by dibarrett

Dr David Barrett, Director of Pre-Registration Nurse Education, Faculty of Health and Social Care, University of Hull

One of the perennial issues faced by nurse education and the nursing workforce is the formalisation of different categories of Registered Nurse. Whether called ‘fields’, ‘branches’ or ‘specialties’, there is continual discussion about what constitutes a standalone area of nursing and at which point in a nurse’s career specialisation should take place.

Discussion of this issue is particularly lively within the UK. Currently, there are four fields of nursing – Adult, Children, Learning Disabilities and Mental Health – with student nurses selecting their chosen field at the time of application to University, and then completing a degree (or higher) level programme of study focused on that field (albeit with some shared elements across fields).

However, this structure is under review and likely to change. The publication of ‘Raising the Bar’ – a review of nurse education in England – challenged the current model. The review suggested that current system of a three-year, field-specific programme of study did not produce flexible practitioners with the transferable skills necessary to work with patients and clients in a range of settings (Willis, 2015). The review proposed a more generic model, specifically suggesting that students complete two-year ‘whole-person’ education, before specialising in the final year of their programme and first year post-registration.




The Healthcare Practitioner Role in COPD

7 Nov, 16 | by hnoble

Emma McGleenan and Dr Helen Noble, Queens University Belfast

“Chronic obstructive pulmonary disease (COPD) is an umbrella term for chronic lung conditions characterised by airflow obstruction that cannot be fully reversed, such as emphysema and chronic bronchitis” (Osadnik et al, 2012). COPD is the third leading cause of death in the world. Over 29,776 deaths occurred due to COPD in 2012 within the UK (British Lung Foundation, 2012). The disease needs to be fully understood by health professionals in order to provide the best care possible and reduce the global impact of the disease. There is no cure for COPD. Management of COPD involves the use of bronchodilators, corticosteroids and oxygen therapy. Inhaled corticosteroid therapy reduces frequency of exacerbations when given in combination with an inhaled long-acting beta2 agonist and improves quality of life. As the main symptom of COPD is dyspnoea, The Medical Research Council dyspnoea scale is used to assess the severity of the shortness of breath and whether it is in the presence of exertion or not. It is graded from grade one to five and it allows the progression of the disease to be monitored. Pulmonary rehabilitation should be considered in the management of COPD. This involves exercise training, education and psychosocial support. Pulmonary rehabilitation involves aerobic exercise to rebuild skeletal muscle e.g. cycling and walking. Healthcare professionals can educate patients on airway clearance techniques which have shown some benefits to COPD patients. NICE (2015) recommend that every patient with COPD undertakes a comprehensive reassessment including a psychosocial assessment, important because patients with COPD have an increased associated risk of suffering from depression and anxiety.

There is little research available on interventions for sexual dysfunction for people with COPD specifically. However, erectile dysfunction is estimated to be between 72 and 87% in men with moderate to severe COPD. Current and up to date advice should be given to patients about this area and nurses should encourage patients to express any concerns they have. People with COPD also have an overwhelming fear of dying due to suffocation and health care professionals can help alleviate this by maintaining good communication, in particular, in relation to end of life care.

COPD is a debilitating, progressive disease of the airways which leads to individuals feeling fatigued and as a result socially isolated. Healthcare professionals play a very important role in supporting patients to invest in their health, to stay positive, address all concerns, and to manage their condition effectively.   Government initiatives also help to manage and prevent COPD. Tele-monitoring has become popular with an emphasis on people managing their own conditions at home. There are some cases where COPD is not preventable but in a large number of cases it is and smoking cessation is the best way to prevent someone developing COPD. It is the role of healthcare professionals to attempt to persuade people to quit smoking using methods such as brief intervention training.



British Lung Foundation (2012) Chronic obstructive pulmonary disease (COPD) statistics Available at: (Accessed: 28/12/2015)

Osadnik C R, McDonald C F, Jones A P, Holland A E. (2012) ‘Airway clearance techniques for chronic obstructive pulmonary disease’ The Cochrane Collaboration


Cognitive Behavioural Therapy and Nursing Practice

30 Oct, 16 | by rheale

This week’s EBN Twitter Chat is on Wednesday 2nd November between 8-9 pm (BST) and will be hosted by Stacey Roles (@StaceyRoles) clinical nurse specialist, Sudbury, Ontario, Canada.

Roberta Heale, (@robertaheale) Associate Editor at EBN and Associate Professor, Laurentian University School of Nursing, Sudbury, Ontario, Canada.

The Twitter chat this week will focus on a commentary written by Stacey Roles (@staceyroles) about whether combined cognitive behavioural therapy (CBT) and motivational interviewing (MI) improves medication adherence.  However, given that the underlying principle of CBT is to teach the patient to identify, evaluate and respond to dysfunctional beliefs and thoughts, the implementation of it is far more widespread than this specific topic and we anticipate that the discussion encompass the broader topic of CBT.  As a form of psychotherapy, CBT focuses on problems and actions rather than unconscious meanings behind behaviours. CBT is an evidence-based and widely used treatment option.

To read @StaceyRoles commentary, please click on this link:

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 Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

Questions to consider prior to the Twitter Chat:

1.     What are your experiences with patient’s response to CBT?

2.     How do you think CBT could be incorporated into your clinical setting?

3.     What adjunct therapies, if any, do you think are required in combination with CBT?



Chronic Pain Management: Moving Beyond Pharmacotherapy

23 Oct, 16 | by rheale

By Roberta Heale, Associate Editor EBN, @robertaheale @EBNursingBMJ

Pain is an essential part of life.  It tells us when and where we’ve sustained an injury.  This acute pain ensures that we seek out and address the problem at hand.  However, some pain continues for much longer than necessary. Pain signals remain active, muscles tense in response, energy is lowered and there are changes in appetite.  People often experience depression, anxiety or anger as a result of living with these ongoing effects.

Treatment of chronic pain can be complex. There are a whole host of medications ranging from opioids to antidepressants to medications addressing neuropathic pain.  Although useful in many cases, medications are not without side effects and there can be negative outcomes, including addiction.  More and more we see alternative therapies being implemented to help in the management of chronic pain such as yoga, massage and acupuncture.  In recent years, attention has turned to treatments that address mental and psychological coping of patients, such as cognitive behavioural therapy (CBT).

One such therapy is acceptance and commitment therapy (ACT).  ACT is a form of therapy that falls into the umbrella of CBT.  ACT is defined by the Association for Contextual Behavioural Science as:

…a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behaviour change strategies, to increase psychological flexibility. Psychological flexibility means contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behaviour in the service of chosen values.1

EBN published a commentary on research that explored the use of ACT for chronic pain management in older adults and the small study showed some promise.

Chronic pain is ubiquitous in health care and in life.  Given this, we, ourselves, need to make a commitment to continue in this trend of exploring alternative, non-pharmacological methods to help our patients cope with and thrive despite chronic pain.  Encouraging them to try CBT or ACT may be a first step.  Conducting research to better understand the complexity of chronic pain and viable treatment options is another essential step.

1.  ACBS. (n.d.)  ACT. Acceptance and Commitment Therapy.  Retrieved from:



Arts in Renal Care: creatively impacting healthcare and education.

17 Oct, 16 | by hnoble

This week’s EBN Twitter Chat is on Wednesday 19th October between 8-9 pm (BST) and will be hosted by Dr Helen Noble (@helnoble) lecturer in Health Services Research, Queens University Belfast.

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 Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.


Healthcare benefits greatly from collaboration with the arts, as this renders clinical practice truly inter- and multidisciplinary in the broadest of terms. An additional benefit is in enhancing healthcare education in challenging areas such as fostering empathy. The collaboration between medicine and the arts and humanities is rapidly becoming established as a powerful and fruitful alliance in improving healthcare delivery, education and outcomes See examples at and That said, the relationship between arts and healthcare, although long recognised, remains poorly defined. Whilst both areas might benefit from collaboration and partnership, with potential to promote well-being and improve quality of life, the interaction between healthcare and arts provides wide application, yet potentially poor focus. The meeting of arts and healthcare offers great potential for new ways of understanding how care can be provided to patients coping with chronic diseases such as renal, lung and heart disease or cancer. The challenge is to obtain sufficient evidence to support practical engagement in terms of arts based interventions.

The management of care for people with long-term conditions, should be proactive, holistic, and patient-centred, and should support a co-ordinated and integrated service delivery model that requires an active role for service users, with collaborative and individual care planning at its heart. A partnership model where patients take key roles in determining their care and support needs is essential. But is it possible to nurture the concept of service user and carer involvement in the use of the arts as a therapeutic medium and a mechanism for supporting the empowerment of service users? Arts in healthcare brings to bear a significant evidence base which demonstrates the benefits of the arts for individuals living with chronic and life-limiting conditions, such as service users with end-stage renal disease. Cultural activities and creative engagement, such as engagement in music, art, dance, or creative writing promote a sense of well-being and improvement in quality of life. Health outcomes may be positively affected. Can the arts can provide a way of seeing, engaging and expressing in a novel, meaningful, and hopefully impactful manner?


Academics at Queens University Belfast have been working closely with renal clinicians and people with renal disease to develop a programme of research with the ultimate aim of improving the physical and psychological quality of life of those with renal disease. A more recent collaboration has been between academics, service users, clinicians, and artists. Many of the staff and service users have artistic interests including music, poetry, glass-making, photography and dance. Arts and health, as yet an emerging field, has the potential to benefit service users with kidney disease and a Renal Arts Group has been established. The collaboration was established when a patient contributed a selection of poetry written about his life with kidney disease. This was integrated into a film to be used as an educational tool for renal staff. The film is being shown at the Northern Ireland Festival of Social Science in Nov 2016. The Renal Arts Group was awarded ESRC Northern Ireland Festival of Social Science funding for this public event titled: ‘Waiting for a transplant on dialysis: living while dying with kidney disease’ and has also received a small grant from the British Kidney Patient Association to pay for service user transport costs and refreshments at Renal Arts Group meetings.

Hopefully you can join the Twitter chat and help us answer some of the questions posed in this blog. We look forward to you participating.

Degree level education in nursing – time to move the discussion on.

10 Oct, 16 | by dibarrett

Dr David Barrett, Director of Pre-Registration Nurse Education, Faculty of Health and Social Care, University of Hull

There is now an established body of evidence that in any given clinical setting, the greater the proportion of Registered Nurses (RNs) with graduate-level education, the better the patient outcomes. In one of the most far-reaching, comprehensive and robust studies in this area, Aiken et al (2014) found that a 10% increase in Bachelor’s Degree-educated nurses in the RN skill mix was associated with a 7% reduction in 30-day inpatient mortality. A recent systematic review and meta-analysis supported this finding, establishing that a 10% increase in the proportion of nurses with Bachelor degrees was associated with a 6% reduction in overall mortality (Liao et al, 2016). There is also evidence to suggest that increasing the proportion of graduate nurses is linked with shorter length of stay and reduced incidence of complications such as venous thromboembolism (Blegen et al, 2013).

Though findings such as this tend to focus on Western healthcare and relate largely to the care of surgical patients (Liao et al, 2016), the conclusion reached is clear: more nurses with degree-level education leads to better patient outcomes. However, there has been little consideration of the crucial follow-up question: why does a greater proportion of degree-level nurses improve patient outcomes?



The challenges of embedding spirituality into acute healthcare settings

2 Oct, 16 | by josmith

This wescreen-shot-2016-09-23-at-12-50-34ek’s EBN Twitter Chat is on Wednesday 5th October between 8-9 pm (BST) and will be hosted by Dr Janice Jones (@JaniceJ6873404) senior lecturer in the Institute of Vocational Learning, London South Bank University,

Wilf McSherry, Professor in Dignity of Care for Older People School of Nursing and Midwifery, screen-shot-2016-09-23-at-12-51-43Staffordshire University, The Shrewsbury and Telford Hospital NHS Trust, UK; Part-time Professor VID Specialized University (Haraldsplass Campus), Bergen, Norway (@WilfredMcSherr1), and

Dr JIMG_0206oanna Smith (@josmith175) lecturer in Children’s Nursing, University of Leeds. The chat will focus on the challenges of embedding spirituality into acute healthcare settings.

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 Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

Cultural, religious and spiritual beliefs influence how an individual makes sense of the world, often shaping their experiences. During acute or life-threatening illness drawing on these beliefs can provide comscreen-shot-2016-09-23-at-12-48-12fort, strength and support and often assume greater importance in times of stress. Spirituality can foster the development of coping strategies during acute illness where there is often a search for meaning and purpose in response to changing circumstances. 1 There is increased recognition that individual beliefs such as faith and hope can impact on the healing process, usually enhancing, but sometimes hindering, recovery. Incorporating spiritual care into practice helps health professionals to understand patients’ perspectives, and has the potential to increased patient satisfaction with care delivery.

Meeting the spiritual beliefs of patients in acute health care setting is challenging because of the increased demands on acute care services and meeting the needs of an increasingly diverse populations. Traditional working practices must adapt and respond to change yet ensuring patients are treated with respect, dignity and compassion remain fundamental to the provision of holistic, person-centred care needs to respect the patient’s cultural, religious and spiritual needs. 2 Spiritual care matters because it focuses care delivery on the individual, and recognises and utilises patients’ own resources, strengths, aspirations, hopes and experiences.3

Question to think about in advance of the Twitter Chat:

  1. What are your experiences of supporting patients in meeting their spiritual needs in acute healthcare settings?
  2. How can health professionals working in acute healthcare settings can practice holistically to address their patients’ spiritual needs?
  3. Lack of preparation to address the spiritual needs of patients is often cited as a barrier to implementation. What are your experiences of pre registration preparation or CPD opportunities to enhance your understanding of spirituality?
  4. How do you feel the wide range of dimensions relating to spirituality from religious and non religious perspectives relate to healthcare practice?


1Clarke, J. (2013) Spiritual Care in Everyday Nursing Practice. A New Approach. Basingstoke: Palgrave Macmillan;

2McSherry, W., Smith, J. (2012) Spiritual Care. In McSherry, W., McSherry, R., Watson, R. (eds) (2012) Care in Nursing: Principles, values and skills. Oxford: Oxford University press;

3McSherry, W., Jamieson, S. (2013) The qualitative findings from an online survey investigating nurses’ perceptions of spirituality and spiritual care. Journal of Clinical Nursing, 22, 3170-3318.

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