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Practice Experience and Implementation of Evidence

25 May, 15 | by rheale

By Roberta Heale @robertaheale @EBNursingBMJ

A few months ago I wrote about wholistic care and the implementation of acupuncture into my practice. I completed the first course in March and, this past weekend, just completed the second. I’ve taken an anatomical acupuncture program, which translates acupuncture from Traditional Chinese Medicine into a western medicine, anatomical perspective.  It has been an intensive and humbling experience.

I have been reminded that evidence based practice not only includes utilization of the best evidence and partnership with the patient, but also integration of the practitioner’s experience.  Patricia Benner, in her seminal work “From Novice to Expert. Excellence and Power in Clinical Nursing Practice” outlines the transition of nurses from the novice level, where everything is ‘parts’ to expert where situations are taken in as a ‘gestalt’.  I reflect upon this now as I take on a new challenge.

I’ve spent many years working as a nurse practitioner in family practice settings; before that as a registered nurse in acute care floors in hospital.  I had simply taken for granted the ‘muscle memory’ for familiar tasks like giving injections or performing examinations. The physical examination skills required to locate appropriate acupuncture points and the skill in ‘needling’ is different enough from my practice to knock me back to a novice state.  It’s been a long time since I was a novice in my practice and, I have to say, it’s frustrating!

I realize also that these are the physical skills related to acupuncture.  I have a long way to go before I have the intuitiveness to know the subtleties…the ‘feel’ of a needle, the reaction of a patient to the treatment…all the things that are now ingrained in my current practice.  It’s an uncomfortable place to be, but has renewed my empathy for student nurses and new grads as well as my appreciation for the process of implementation of research into practice. Implementation of evidence is much more than simply reading research and applying the findings.  The stage of expertise of the health care practitioner plays an important part of the process and influences the entire patient experience.

I’ll have to keep these things in mind as I begin to practice acupuncture.  I’ll try to be patient with myself and to be cognizant of the need for me to practice, practice, practice to move along the spectrum toward the expert level.


Shape of Caring Review: Impact for Children’s Nursing Education

17 May, 15 | by atwycross


Alison Twycross (@alitwy), Editor and Jo Smith (@josmith175), Associate Editor of Evidence-Based Nursing will be leading this week’s ENB Twitter Chat (#ebnjc) on Wednesday 20th May between 8-9pm UK time focusing on the recently published Shape of Caring Review: Raising the Bar (2015) (available from: and the implications for the education of children’s nurses. We hope that as many children’s nurses as possible join us.

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:

  • Go to your Twitter account
  • Follow the discussion by searching for #ebnjc once linked to the discussion, click “all tweets” to keep up-to-date with recent tweets
  • Add the EBN chat hash tag (#ebnjc) to your tweets to join in, this allows everyone taking part to view your contribution

The recommendations from Shape of Caring: Raising the Bar (2015) review of models of education and training for nurse registrants and healthcare assistants in England include:

  • Exploring the ‘2+1+1’ model of training: two year training focusing on the whole person (physical and mental health), one year in a chosen specialism, followed by a full years preceptorship.
  • That the one year specialisms would include adult, child, mental health, learning disability and community nursing.
  • Having a greater focus on mental health issue across all specialists.
  • Having a strong grounding in critical inquiry to foster an ability to engage in research and implement research findings into everyday practice.

What appears to be being suggested is a return to a generic nurse education with two years focusing on the whole person and, for children’s nurses, one year focusing on the care of children. What worries us about this proposal is that it could herald a return to an old style common foundation programme, where often curricula were primarily focused on meeting the physical health needs of adult patients. This is in part due to the fact that in many Schools of Nursing the number of children’s nursing students is much lower than for adult nursing. This has sometimes resulted in students needing to undertake additional sessions to apply knowledge to caring for children, young people and families. Given that the new community field of nursing recommended by the Shape of Caring review appears to be for adults we are concerned that the needs of children and young people will not be adequately addressed under the Shape of Caring proposals.

It is important to remember that the proposals in Shape of Caring: Raising the Bar (2015) are currently recommendations and so as children’s nurses we have the opportunity to make sure our voice is heard. The purpose of this week’s Twitter Chat is to debate some of the key issues. In preparing for the debate you might want to read the following:

  • Royal College of Nursing (2007) Preparing the Child Health Nurse – fit for the future. Available from:
  • Twycross, A. (2007) Modernising nursing careers: Implications for children’s nurses, Paediatric Nursing, 19(9): 39-40.

Both these documents present the argument for a children’s nurse fit for the future – a child health nurse. This nurse will be able to:

  • Care for children from 0-18 years with a physical illness and mental health issue
  • Care for children in the hospital and community
  • Care for children with a learning disability
  • Undertake health promotion activities with children, young people and families

This requires a child health nurse who is knowledgeable, skilled, and competent. The new child health nurse needs to have an understanding of and be knowledgeable about issues relevant to the care of children, young people and families including:

  • Family-centred care
  • Communicating with children of all ages and their families and how to engage in shared decision-making
  • Psychological theories of child development
  • Sociological theories of childhood
  • How children and young people’s anatomy and physiology differs from that of adults with different responses to therapeutic interventions across the age span
  • Children’s rights and balancing children’s right to participate in their health care decisions while ensuing the best interest of the child remain paramount
  • Ethical and legal guidance relevant to children of all ages
  • Pain assessment management for children aged 0-18 years
  • Safeguarding (child protection) polices
  • The public health agenda specific to children and young people

There are some areas where shared learning with other fields of nursing is appropriate such as: research methods and the skills to appraise and use the best available evidence underpinning care; health promotion and critical evaluation of the effectiveness of service and care delivery.

As children’s nurses we need to ensure that future nurse education equips the new child health nurse to meet the needs of children, young people and their families in an increasingly challenging health care environment with advancements in medical technology, changing disease profiles and the influence of lifestyle choices on health, and changing expectations. If we fail to ensure that we have an education system that equips the child health nurse for the future challenges we will be failing 22% of the population.

Questions to consider:

  1. How will the Shape of Caring recommendations impact on the education of children’s nurses and more importantly impact on the care provide to children, young people and families?
  2. Do you think a two year whole person approach followed by one year specialism will produce a child health nurse fit for purpose?
  3. How do you envisage the operationalization of the one year preceptorship?
  4. What is your vision for the child health nurse of the future?


Ordinary to extraordinary: skilled communication in nursing

11 May, 15 | by hnoble

Megan Blinn and Helen Noble

Queens University Belfast, Northern Ireland.

Communication is generally acknowledged as essential to nursing practice and managing clinical situations in challenging clinical environments, working within a system that serves increasing numbers of people with complex health needs using static or dwindling resources. There are many definitions of communication in the nursing literature. Riley defines communication as “a reciprocal process…between two or more people” (Riley 2012, p.3) and Petrie considers it “information which people send out to and receive from each other…” (Petrie 2011, p.17). Communication, therefore, refers to both a process and a product. The product may be verbal, non-verbal, written or electronic and the process must have as its goal a common understanding of the message that is sent and received in order to contribute to safe and effective care. Good communication is an advanced skill that develops from the innate human desire to relate to others. In order to achieve high level communication, a nurse requires self-awareness, willingness to listen, insight into other people’s needs and responses, and the ability to think logically and choose the most appropriate words at the right time. Communication barriers may be present in the nurse or the other persons with whom she communicates. In clinical settings, these barriers range from unchangeable attributes, for example, permanent cognitive deficits, to malleable ones such as differing languages, reduced consciousness or temporary inattention and an attempt to remove barriers or ameliorate their effects while managing clinical care is paramount.

Patient care is the ultimate function of clinical nursing and communication is the foundation of the nurse-patient relationship should be “open, honest and transparent” and suited to the needs and abilities of the patient or client with whom the nurse interacts. When nurses practise patient-centred communication, they are fulfilling the expectations of patients, regulatory bodies, and government. Where the communication is substandard, the management of patient care and outcomes are poorer In the recent investigation of care in the Mid Staffordshire National Health Service (NHS) Foundation Trust, poor communication played a part in almost every aspect of systemic failure (Francis, 2013). Though nurses were not solely at fault for these failures, nurses who fail to use communication and interpersonal skills appropriately are likely to fail patients who need high quality care and advocacy in hospitals struggling to serve them.

Though respect for and the duty of care to patients may encourage nurses to communicate well, respect for individuals should also underpin team interaction. Creating a work environment that encourages open communication contributes to a sense of well-being for nurses and can empower, build trust and improve clinical care. Unfortunately, many nurses work within systems where professional hierarchies might influence the way members of the healthcare team view one another; indeed, even those writing about the issue continue to use terms like “lower status health professionals” (Nembhard et al., 2011, p. 26), while critiquing problems arising when doctors, nurses and unregistered staff work together.

As stated, nursing is predicated on a helping relationship between two people but modern healthcare systems require a team of nurses working together within a multidisciplinary group to provide care for their patient or client. The responsibility for team functioning, and, ultimately for effective patient care, is divided between the organisation and the individuals within it. The organisation must be responsive to economic contingencies, service user needs, and the needs of the healthcare professionals. Nurses and other individual healthcare professionals must take responsibility for skills development which includes checking individual values, attitudes and beliefs that influence their practice and communication within and beyond their working team. It is beyond the scope of this assignment to look in detail at the deeper aspects of values, attitudes, beliefs and their impact on organisational culture but as the basis for individual actions they must be acknowledged.   Teams in contemporary clinical settings have not time to fully explore the emotional and psychological underpinnings for individual communications; however, every member of a team has a responsibility to acknowledge that each person, whether patient or nurse, has an inner experience that informs how they perceive clinical interactions and communication. Each person must ensure that they participate in assertive and open communication that enables teamwork and quality care for patients.

Communication is the ordinary human behaviour that may become the extraordinary skill employed by a nurse in the clinical setting to manage safe, effective, respectful care for every patient. Compassionate and respectful communication can also serve the team in which the nurse works by contributing to collaboration. Each nurse has a responsibility to develop communication skills alongside other clinical skills in order to meet professional requirements, serve patients and work with colleagues through the challenges of contemporary healthcare.


Francis QC, R. (2013) Report of the Mid Staffordshire NHS foundation trust public inquiry executive summary. London: HMSO. Available at: (Accessed: 13 November 2014).

Nembhard, I., Alexander, J., Hoff, T. and Ramanujam, R. (2009) ‘Why Does the Quality of Health Care Continue to Lag? Insights from Management

Research.’, Academy of Management Perspectives, 23(1), pp. 24–42.

Petrie, P. (2011) Communication skills for working with children and young people: introducing social pedagogy. 3rd edn. London: Jessica Kingsley Publishers.

Riley, J.B. (2012) Communication in nursing, 7th edn., St. Louis: Mosby-Elsevier.

Vaccination Pain Management in Children

3 May, 15 | by atwycross

A Twitter Chat with Dr. Christine Chambers (@DrCChambers) and Dr. Denise Harrison (@dharrisonCHEO).

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:

  • Go to your Twitter account
  • Follow the discussion by searching for #ebnjc and click on “All Tweets”
  • Add the EBN chat hash tag (#ebnjc) to your tweets to join in

Amidst the recent outbreaks of infectious diseases (e.g., measles), the decision to vaccinate or not is one that has received considerable public and media attention. Parents’ worries about the links between vaccines and autism (and other harms) continue to be fuelled by misinformation and ill-informed celebrities, despite the fact that these claims have been totally disproven by research evidence and experts.

However, the pain and fear associated with vaccinations is an often overlooked barrier that can affect willingness to vaccinate. One in 10 children and adults has a significant fear of needles that cause them to avoid going to the doctor and receive proper medical care. The majority of these individuals can trace their fear back to one poorly managed painful procedure as a child.

Fortunately, there is now strong evidence supporting the efficacy of various pain management strategies for needle pain in children. Research has shown that various pharmacological (e.g., topical local anaesthetic creams, breastfeeding and sugar water for infants), psychological (e.g., distraction, deep breathing), and physical (e.g., holding infants upright front-front and having older children sit rather than lie down) strategies significantly reduce pain and distress from procedures like vaccinations. Despite the fact that these pain management strategies have been recommended in clinical practice guidelines, fewer than 5% of children receive any kind of pain management for procedures like vaccinations. This is a problem because research shows that poorly managed painful procedures early in life can change the way children’s bodies and brains response to pain, making them more vulnerable to later pain.

So why aren’t children getting pain management for these types of procedures? Join us for our Twitter Chat on May 6th to discuss vaccination pain management in children. The chat is appropriate for health professionals, researchers, parents, and the public. We will explore topics such as the different types of pain management available, barriers and successes, and strategies for making pain management for vaccination a health priority.

We will also share our own research and experiences translating our research into evidence-based resources for parents and the public.

These include the “It Doesn’t Have to Hurt” video series led by Dr. Chambers in the Centre for Pediatric Pain Research. ( The series includes a fun 2 minute YouTube video for parents called: “It Doesn’t Have to Hurt: Strategies for Helping Children with Shots and Needles”. In the video, a cute 4 year old girl shares with parents what they should – and shouldn’t – do to help make needles hurt less. All the tips are based on research, including some of our own.

The “Be Sweet to Babies” initiative by Dr. Harrison research (Facebook: also includes a brief You Tube video for parents called “The secret to a calm and peaceful vaccination ( another video series produced in multiple languages showing effective pain management in newborn infants during blood sampling ( The pain reduction strategies shown in these videos are also based on high quality research evidence.

We will be posing these questions throughout our chat:

Q1: Do you use pain management for vaccination for infants and children? What do you use?
Q2: Do you use breastfeeding or sucrose for vaccination pain in babies?
Q3: How about psychological strategies like distraction?
Q4: Do you use topical anaesthestics?
Q5: If you have experienced barriers to pain management for vaccination, what are they?
Q6: Have you had any positive experiences with pain management for vaccination?
Q7: How can we make pain management for vaccination a priority?

We look forward to seeing you on Twitter and hearing your responses to these questions!

Christine Chambers (PhD, RPsych) and Denise Harrison (RN, RM (Australia), PhD).

Accessing & using evidence to underpin the care when working with children, young people & families by Alison Twycross and Jo Smith

27 Apr, 15 | by josmith

Evidence-based nursing has been defined as the ‘process by which evidence, nursing theory, and clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide the delivery of optimum nursing care’ (Scott & McSherry, 2009, p 1089). In an increasingly digital environment, the richness and complexity, range and quantity of evidence on which to base practice sometimes results in information overload. The journal of Evidence-Based Nursing (EBN) supports nurses to access research studies and reviews that report important advances relevant to best nursing practice, through the publication of commentaries that not only summarise research but offer a critique of the it by an expert in the area. The commentary authors highlight implications for research and implications for clinical practice.

In addition, EBN offers a range of opportunities for nurses to engage in debates about contemporary issues in nursing through our Blogs and Twitter chats, facebook pages and podcasts – access for more details of these activities. Each month EBN has a theme, and in May, we will be focussing on child health issues. The current issue of EBN (April 2015) has a range of commentaries on topic child health issues including:

  • Nut allergy;
  • Links between parent health literacy and obesity;
  • Parents’ perceptions of their child’s weight;
  • Increased BMI and behavioural problems in children;
  • Support for toddlers of low income families and improvements in child development;
  • Reducing anxiety in children undergoing elective surgery;
  • Preparing adoptive parents to live with a child with reactive attachment disorder;
  • Adherence to antiepileptic drugs in children.

As children’s nurses and researchers we believe that children’s nurses must underpin care with the best available evidence. In May our Twitter chats will be focussing on:

  • Wednesday 6th of May between 8-9pm UK time, ‘managing children’s vaccination pain’. This Twitter chat will be co-hosted by Dr Christine Chambers (@DrCChambers) and Dr Denise Harrison (@dharrisoncheo) from Canada who undertaken a significant amount of work in this area;
  • Wednesday 20th of May between 8-9pm UK time, ‘The Shape of Caring Review and implications for the training and education of children’s nurses’. For this chat we will be joined by Fiona Smith, RCN Professional Lead – Children and Young People (@FionaSmithRCN) and Kath Evans, Children’s Nurse, Head of
    Patient Experience, NHS England (@KathEvans2).

To participate in the Twitter chat you need to have 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 or @EBNursingBMJ;
  • 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 week (28th – 30th April) is the first joint Royal College of Nursing Children and Young People’s conference and Royal College of Paediatric and Child Health conference focussing on ‘Advocating for children in a rapidly changing world’, and offers an exciting programme including a wide range of symposia and workshops, keynote speakers from diverse professional background, updates on key clinical issues, and the latest evidence to inform practice. Throughout the conference Alison (@alitwy) and Jo (@josmith175) will be tweeting key messages and issues relevant to the EBN readers. Please join in and let us know what you think are the important messages from the conference adding #ebnjc to your Tweets.

Further reading:

Scott K, McSherry R. Evidence-based nursing: clarifying the concepts for nurses in practice. Nursing in Critical Care, 2009: 3; 67-71 p 1089.

Alison Twycross

Head of Department for Children’s Nursing and Reader in Children’s Pain Management, London South Bank University Editor: Evidence e Based Nursing

Email:, @alitwy


Joanna Smith

Senior Lecturer Children’s Nursing, School of H&H Sciences, Divsion Maternal & Child Health, University of Huddersfield Associate Editor: Evidence Based Nursing

Email:, @josmith175


Learning about physiological birth in the USA: Evidence and reality

21 Apr, 15 | by ashorten

As an Australian midwife who has been teaching maternal-newborn nursing for over 22 years, I am still excited to hear students share their clinical stories with each other as they learn about maternity care. Now that I am in the United States, students’ stories reflect a unique and different culture. Each year my students visit a wide variety of hospitals to gain experience working with childbearing women and they ultimately become an important part of many women’s childbirth stories.  As students share their first experiences of labour and birth with their peers in the classroom, I am always excited to hear their accounts of caring for their first labouring woman and love listening to personal reflections of their “first birth” experience.

I am sometimes puzzled by the unique culture of “normal” childbirth in the USA and how this differs from my own experiences of midwifery. Over my years in teaching I have found that students are a wonderful gauge for what is going on in clinical reality and a great source of open and sometimes brutal critique of the healthcare system. They readily compare what we talk about in the classroom and what they read about in the literature with what they actually observe and experience in the real clinical world. Given their passion for high quality evidence based care I am confident that the students of today will be great future leaders and agents for change. But while they struggle to navigate the student role, they are often frustrated by culture-based practice and feel a need to fill the gaps between evidence and practice.

Each week at the beginning of the class I ask my students to reflect on their clinical experiences in the previous week. I usually begin with “who saw a birth last week?” I see excited hands go up and I ask students to describe their first experience of labour or birth to their peers.  So often, the description of the first observed birth experience starts with “yes I saw a birth last week, but it was a caesarean section.”  I should not be surprised by that, given that in the USA, 1 in 3 births is surgical. I usually go on to ask what they learned from the birth experience. I might ask whether the baby was placed skin to skin, or whether the mother breastfed and what they observed about opportunities for the family and newborn to bond soon after surgery. It is clear from my student’s accounts over recent years that there is recognition in many clinical settings of the importance of positive caesarean section experiences for women and their babies, including the use of early skin to skin contact after surgery. I am also certain that students gain much from observing surgical birth, if anything, to be able to compare it to normal physiological birth when the opportunity eventually presents itself.

When I go on to ask the question, “Who has seen a normal physiological birth?” few students raise their hand. When I try to expand the question to encourage those who have actually seen a baby born vaginally to speak up, the culture of labor and birth is evident. Physiological labor and birth are still rare events for student nurses to observe in many hospital settings in the USA. Interventions such as induction of labor, augmentation of labor and continuous electronic fetal monitoring are still widespread, and use of epidural for pain relief is experienced by the vast majority of women. Few women are given the option to eat during labour and many spend their labour in the bed, almost disconnected from the experience, as their body contracts painlessly until it is time to push.

So, how do we educate students about the benefits of physiological birth when physiological labour is so hard to find in reality? How do we get the right balance between teaching students evidence based care and preparing students for what they will actually see in clinical settings? How do we prepare students to make a positive contribution to childbirth experiences that are far from ideal? There are no easy answers to these questions. What I can recommend is remaining positive and working hard to ensure students are aware of the best available evidence to support their clinical decision making in the future. I encourage them to learn from all experiences, even if it is learning about the things they want to change. I suggest that they seek out positive role models and embrace opportunities to observe the practices of the many great clinicians out there supporting women and families and practicing evidence based maternity care.

There is light on the birthing horizon and research remains a critical ingredient for better practice. Therefore, as researchers, even though the clinical world can be frustrating and slow to change, we must continue to explore the most effective models of care for keeping healthy pregnant women ‘low risk’. As teachers, we should continue to educate our nursing students about normal physiological labour and effective ways to support women in achieving normal physiological births, even if they might not have the opportunity to see it. As we discover more about the potential epigenetic effects of caesarean birth1 and understand more about the importance of the mode of birth on the long term health for mothers and babies, there will be greater impetus for change in the way care is delivered. I remain positive that physiological birth will become “normal” again.

Allison Shorten RN RM PhD

Yale University School of Nursing

Connecticut, USA.


1. Almgren M, Schlinzig T, Gomez-Cabrero D, et al. Cesarean delivery and hematopoietic stem cell epigenetics in the newborn infant: implications for future health? Am J Obstet Gynecol 2014;211:502.e1-8



Learning disability nurse education: the impact on patent care

12 Apr, 15 | by josmith

By Niall Dew, Head of Practice Education for the Department of Health Sciences, University of Huddersfield will be leading this week’s ENB twitter chat on Wednesday the 15th of April between 8-9pm UK time focusing on ‘the impact of learning disability nurse education on patent care.’ 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 or @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.

I feel the need to start by saying that although some of my comments might be perceived as negative, I wholeheartedly believe that learning disability nurse education is not only essential but has a positive impact on the lives of people with a learning disability. Perhaps, as a learning disability nurse, you might expect me to say that but I have seen the impact of lack of understanding from individuals, organisations, and countries where people with learning disabilities are ‘at best’ ignored and at worst mistreated, even die because of ignorance about their specific needs.  Having read with interest the recent report by the Learning and Intellectual Disability Nursing Academic Network (LIDNAN) and the UK Council of Deans of Health, these documents unfortunately just re-affirm an ‘old story’ and more importantly highlight that despite the interventions of professionals, private, voluntary and charitable organisations we still live in a society that, to all intents and purposes, still fails to acknowledge the status of people with a learning disability. I noted yet another Department of Health consultation has begun on improving the rights of people with learning disabilities this time with those with autism and mental health conditions.  Despite reports and consultations, my over thirty plus years varied and diverse experiences, since commencing as a student nurse at Lennox Castle Hospital in Scotland, the consistent themes and questions remain the same: have experienced are:

What is a learning disability?

What skills do you need to look after someone with a learning disability?

Who is best placed to look after the needs of people with a learning disability?

What should a learning disability nurse do?

People I talk to, both socially and as part of my work, still struggle to define what a learning disability is and often get it confused with mental health, educational underachievement, special educational needs and low IQ. Without regurgitating the many to text book definitions I often have to refer to a commonly understood group of people who may have a range of learning disabilities, people with  Down Syndrome; this doesn’t sit easily with me. People who do know about learning disability often have some personal experience either through contact with a family member or someone with a learning disability. Even with this knowledge I am still surprised to meet people who, for example have a relative with autism, tell me that their child or sibling with autism has a learning disability because this is clearly the only diagnosis they have been given.

I have to take some responsibility here and it certainly makes me question the impact that I have had as a lecturer who teaches learning disability students and maintain that everything I have done since beginning my training, 30 years ago, is ultimately to improve the lives of people with learning disabilities. So why, despite the best efforts of dedicated nurses who specialise in the care of people with learning disability, is their quality of life still lagging behind the rest of similar populations?

 Does this actually matter?

Yes I think it does. Learning disability is a complex set of factors that impact on a person’s social, emotional, physical, psychological and spiritual well being. Simplifying the needs of people with learning disability is not constructive and indeed report after report has shown that misunderstanding learning disabilities causes deaths. 

During the twitter chat I thought it might be useful to try to explore some of the reasons why learning disability as a subject remains something that remains misunderstood, underrepresented or at worse omitted from nurse education. Specifically I hope the debate can consider the following questions

Why does nursing sometimes fail to adequately care for people with learning disabilities in their care? 

Why is learning disabilities still misunderstood in contrast to the understanding of mental health, Alzheimer’s, autism, heart disease and cancer……?


LIDNAN and Council of Deans Report

DH Consultation of People with Learning Disabilities

Death by indifference


Healthcare and the LGBT Community

6 Apr, 15 | by rheale

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

In December, EBN’s Editor, Alison Twycross, wrote about living in a gendered world. I recently watched a television segment that included an interview with US ex-Navy Seal, Kristen Beck, who lived as Christopher Beck throughout most of her life before revealing her feminine identify   The segment renewed my interest not only about society’s views about gender and roles, but also about healthcare and the LGBT community.

A search quickly brought up numerous articles about health risks and barriers appropriate healthcare of this group of people who simply identify differently than the rest of the population. There is a higher risk of depression and suicide, substance misuse, and violence than in the straight community. Lesbians are far less likely to have had a PAP test, or recent mammogram than straight women. Gay men have higher rates of eating disorders than straight men. Transgendered people often fight stigma every day and this ongoing battle is also reflected in their interactions with healthcare providers. These are a few of the identified issues, and added to this is the misconception that LGBT denotes a homogeneous group when, in fact, each individual is unique and has unique health concerns.

I’m much more conscious in my work as a primary health care nurse practitioner of the fact that many of my practices may not be congruent with the needs of the LGBT community. I practice with an evidence-based approach, but does this mean that following the PAP guidelines will address a patient who is a lesbian? Are assumptions I make about the patients I see a barrier to me offering routine HIV testing? Am I effective in approaching reproductive issues with LBGT patients? Is there anyone qualified in my organization to provide marriage counseling for a same-sex couple?

Improving the Health Care of Lesbian, Gay, Bisexual and Transgendered People: Understanding and Eliminating Health Disparities is an excellent resource for health providers like me who want to truly meet the unique needs of LGBT patients. The first recommendation is to start by creating an inclusive environment. A question about gender on the intake form could be developed to include a number of options.   Health care providers are encouraged to think about inclusivity when asking about relationships (are you married, do you have a boyfriend, girlfriend? What do you call your partner?). The report also recommends to follow guidelines developed for specific populations, such as annual sexual health screening for MSM.

A good therapeutic relationship involves trust, respect and mutual understanding between healthcare provider and patient. Awareness of the needs of LGBT patients, and efforts toward inclusivity, are important steps toward promotion of optimal health.  Increasing awareness and making changes to my practice is an ongoing journey, often taken with my patients who are grateful to have healthcare options that reflect their realities.


Pain management: the use of Patient Controlled Analgesic Systems

29 Mar, 15 | by josmith

Sharon Wood, Lecturer in Pain Care, University of Leeds will be leading this week’s ENB twitter chat on Wednesday the 1st of April January between 8-9pm UK time focusing on ‘the use of patient controlled analgesic systems’. 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 or @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.

Patient controlled analgesia systems (PCAS) have been routinely used to manage post-operative pain in the UK for over 20 years; despite this patients continue to report unrelieved post operative pain. There are no national standards or recommendation for PCAS in the UK leading to individual hospital Trusts developing their own clinical guidelines. This may be one of the factors that contribute to under-managed postoperative pain. Yet, PCAS have benefits compared to continuous analgesia infusions, which include increased user satisfaction and greater user control, no delay between the perception of pain and administration of analgesia, an overall reduction in analgesia used, and in the case of opioids less sedation (Demirel et al., 2014).

PCAS is traditionally used for postoperative pain in the UK but has the potential to be an effective strategy in additional pain management situations, for example, pre-operative pain management for patients with fractured hip. A recent study found PCAS an effective strategy for managing pain in the Emergency Department (Birnbaum et al., 2012).

PCAS, usually with a background infusion, is an effective and safe method of administering analgesics in children, particularly in children 11- 18 years of age, with a high degree of child and family satisfaction. Nurse-controlled analgesia (NCA) is also used in children’s settings, with the nurse, within prescription limitations, able to administer controlled boluses of analgesic drug at times of increased pain. Nurses should involve the child, if appropriate, and parents about the need for additional but it is the responsibility of the nurse to press the button to administer the drug,

Question for consideration:

What factors have you encountered that may have contributed to under-managed post-operative pain which PCAS? Have you any possible solutions to mange this more effectively?
Have you used PCAS for other groups of patients with pain and if so what were the strategies that were employed and were these effective?
Are there any clinical situations where you have found NCAS an effective pain management strategy or it has value as an option in clinical practice?


Birnbaum, A., Schechter, C., Tufaro, V., Touger, R., Gallagher, E. J. and Bijur, P. (2012) Efficacy of Patient-controlled Analgesia for Patients With Acute Abdominal Pain in the Emergency Department: A Randomized Trial. Academic Emergency Medicine, 19: 370–377.

Demirel, I., Ozer, A. B., Atilgan, R., Kavak, B. S., Unlu, S., Bayar, M. K. and Sapmaz, E. (2014) Comparison of patient-controlled analgesia versus continuous infusion of tramadol in post-cesarean section pain management. Journal of Obstetrics and Gynaecology Research, 40: 392–398.

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.
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