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The need to focus on public health nursing by Wendy J Nicholson, Department of Health 
Public Health Nursing 
Professional Officer – School and Community Nursing. Twitter @WendyJNicholson

20 Jul, 14 | by Calvin Moorley, Associate Editor

The next EBN TWITTER journal chat will take place on Wednesday 23rd July 2014 8-9 pm (UK time) and focus on public health nursing challenges and roles. Before joining in the Twitter Chat you might like to read the associated Blog


Over the last few years we have been fortunate to work with a number of young people who are clearly considering their career pathways – few had even thought about nursing, those that had told me they wanted the drama and excitement of A&E, ITU and theatre, sadly public health nursing wasn’t on their radar. Nothing new you might be thinking, the media stereotypes of nursing really haven’t changed and there is still an overwhelming emphasis on ‘hospitals’.   There is a desire to shift care closer to local communities and to empower individuals to self-manage but can we achieve this with a substantial focus on hospitals or ‘acute’ care? Perhaps the starting point is to challenge the misconceptions –acute care IS provided at home, in local communities and we can avoid hospital admissions, crisis intervention through early support and public health interventions. Supporting individuals at home, in local communities requires skills, expertise and confidence – so why do public health nurses not get the same profile as nurses working in hospital settings? And why can’t we have more creative and community approaches to delivery?

Given the challenges we face as a society care and approaches to population health need to change. We are seeing an increase in long-term conditions, mental health issues and obesity across the life course. It seems timely to focus on public health nursing and their incredible contribution to improving health outcomes and population health.

Public health nursing contribution

Without a doubt the Health Visitor Implementation plan and School Nurse Development plan has led to a focus on the importance of public health nursing input for children, young people and families. We know support during the early years and throughout childhood is incredibility important as it lays down the foundations for healthy individuals and supports the development of healthy communities in the long term. Health visitors and school nurses deal with a myriad of complexities within families and local communities, which draws upon their specialist public health skills and leadership role.

Support and the need to improve health outcomes is not restricted to childhood, consideration needs to be given to support across the whole life course. It’s worth noting there were 300 million GP consultations in 2008/9. General practice nurses are well placed to support those individuals and provide personalised care thus promoting self-care and avoiding un-necessary hospital admissions. The general practice nurse role can have a far reaching community role, supporting individuals and local communities across the life course.

The new and emerging Public Health Nursing Framework was launched recently, it provides a comprehensive framework to support nurses and AHPs in their public health role. It is clear in that ALL nurses have a public health role, with this in mind nurses really do need to ensure they make every contact count and maximise opportunities regardless of the setting!


Questions for the #EBNJC

We know nurses have incredible reach across a variety of communities and settings, we therefore need to harness their skills to ensure every contact counts for every individual or local community there is without a doubt opportunities to really make a difference but perhaps we need to consider:

  • Can we shift the emphasis from hospital to self-care and public health interventions?
  • How do we maintain the re-address the balance and promote the importance of public health?
  • Do all nurses recognise their public health role?
  • Is there a need for more training and support for nurses to realise their potential in public health delivery?

Participating in the EBN Twitter Journal Chat

To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

  • You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
  • Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
  • NB not including #ebnjc means people following the chat won’t be able to see your contribution.

RN Staffing in Hospitals…Are We Asking the Right Question?

15 Jul, 14 | by rheale

By Roberta Heale, Associate Editor

I’ve been working with a number of students in a nursing masters program who have chosen to study teamwork. One study includes a survey question about the percentage of time that a nurse feels that his/her unit is appropriately staffed. I’ve been thinking about this issue and I think that simply asking for the nurses’ perception of staffing is skimming a much more complex issue.

We read stories from around the world about the outrageous workloads of nurses. Stress, burnout, and intention to leave are the buzzwords and the reality for many. Although there are descriptions of the type of work that nurses do, the cause of the nursing work life stresses are rarely addressed. I started working as an RN in the late 1980’s on a medical floor. An RN who had been working there for 30 years told me that when she started it was rare to have a patient with an IV and, if there was one, the doctor had to insert it. By the time I started on that unit, every patient had at least one IV, and there were also many tube feedings, chest tubes, catheters, telemetry monitoring and more. Yet, during those 30 years between her start date and mine, the number of nurses on the unit each day and night shift hadn’t increased. I’m sure that since then with the push for faster hospital discharges and, subsequent increased patient acuity, the workload on that unit has increased even more … without additional RNs. So, even if today’s nurses are asked if they are appropriately staffed on their unit, they’ll likely be answering from today’s perspective…do we have the full number of RNs we are allotted, rather than do we really have the number of RNs we need to safely care for these patients? Instead of answering and addressing the real issue, nurses become stressed, frustrated, overworked and many leave hospital care, or nursing altogether, creating even greater problems in the profession.

We can’t reduce the acuity of patients and that it isn’t ethical to withhold technology to assist patients and their healthcare needs. So, one solution seems to be that the number of  RN staff on a unit should be increased to match the current health care environment. In 2004, California enacted mandatory nurse-patient staffing ratios which has increased RN staffing in hospital settings. The result has been improved patient outcomes and increased nursing satisfaction (Aiken et al., 2010).

Nurses and nursing care is constantly scrutinized and studied. Policies and money often follow the findings. We need to ensure that when we’re asked to complete surveys or take part in studies, that we are asked questions that truly reflect our current practice and we should insist on being part of the interpretation of the findings. Otherwise, I can’t help but feel that things will only get worse.

Aiken, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H.L. (2010). Implications of the California nurse staffing mandate for other states. Health Research and Educational Trust, 45(4), 904-921. doi: 10.1111/j.1475- 6773.2010.01114.x

Can Qualitative research help us to deliver better primary care services? By Calvin Moorley and Josephine Bardi.

6 Jul, 14 | by Calvin Moorley, Associate Editor

On Twitter @CalvinMoorley @JoBardi01

I have recently been collecting data for a research project on life after stroke funded under the Mary Seacole award for Leadership in Nursing. The data collection method is semi structured indepth interviewing and by its given nature is qualitative research (Robson 2011). My project investigates the lived experience of stroke carers within the family setting; it seeks to identify to what extent care giving in life after stroke is influenced by culture. I also had a conversation with one of my MSc Public Health students Josephine Bardi (co-author of this blog) on how qualitative research can help us to understand maternal mortality. In this conversation we discussed what we already know about qualitative research and how it can help us to deliver better primary care and ultimately public health services.

What do we know about qualitative research for health?

  • Qualitative research is robust despite what its critics say for example Tong et al. 2007 have provided a set of criteria for qualitative research
  • Qualitative research is based on the subjective and allows the researcher an insider look into the lives of participants or certain groups.
  • In health care qualitative research can be described as interviews and focus groups (Soafer 2002) and explores complex phenomena experienced by health care workers and clinicians qualitative research
  • Using qualitative research in health care can help us unravel and make sense of the participants experiences.

An example

In my area of research, life after stroke I have found that qualitative research can also help to support quantitative findings (Moorley, 2012) a researcher can use the technique following a thread O’Cathain et al. 2008. For example in my work I found that African Caribbean women reported higher abilities to perform of activity of daily living compared to their other ethnic counterparts in my quantitative data analysis (Moorley et al. 2014). I followed this up in interview questioning to understand the lived experience of this group which was different from what they reported to the health practitioner. Here qualitative research helped me to understand why African Caribbean women over reported their abilities and I was able to make recommendations to the stroke rehabilitation team based on the qualitative findings.

Can qualitative research help us understand maternal health?

Millennium Development Goal (MDGs number 5) states

“In recent years, there has been increased recognition that reducing maternal mortality is not just an issue of development, but also an issue of human rights”. (United Nations Populations Fund, 2010).

What is known about maternal death?

Maternal deathis the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (World Health Organisation, 2014).

Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia (World Health Organisation, 2014). Sub-Saharan Africa still had high maternal morbidity and mortality rates (Rogo et al., 2006; Alvarez et al., 2009).

What contributes to maternal deaths?

According to the WHO (2014) maternal mortality occur due to the following reasons:

  • Poor access health
  • Severe bleeding (mostly bleeding after childbirth)
  • Infections (usually after childbirth)
  • High blood pressure during pregnancy (pre-eclampsia and eclampsia)
  • Complications from delivery
  • Unsafe abortion.

Maternal mortality ratio in developing regions continues to be 14 times higher than in the developed regions (United Nations, undated).

How can Qualitative research help us to understand maternal health and mortality?

Qualitative research may help to explain the experience of bereaved families before and after the death of a mother, daughter, child or both.

For instance, it is useful to find out how a mother-in-law, husband and children felt after the death of a wife and mother or what practices may have led to the death and explore these. What does a community, bereaved family and, looked after children think is the reason for maternal deaths? What is their experience of maternal mortality and to what extent does cultural practices contribute to maternal health and mortality?

The role of qualitative research in delivering primary care services

There is role for using qualitative research that can help in delivering primary and public health care services, firstly qualitative research can help to contextualise quantitative finding and strengthen a study. By undertaking qualitative research we can understand why individuals do not adhere to medications regimens and attribute causes other than pathophysiological for disease (Moorley, 2012). By using qualitative research health practitioners can understand why patients take certain actions, qualitative research opens up a space for discussion with service provider and user, which can ultimately lead to benefits for both groups. Using a qualitative approach such as case study or phenomenological research can help to answer some of the questions we posed in this blog (pertaining to our research), which can in turn be used to deliver primary care services that will contribute to reducing maternal mortality , improved stroke aftercare and better access of public health services.

Questions for the #EBNJC

1. Can you think of a time when qualitative research would have helped you to do your job better?

2. How can we ensure we embed qualitative methods in health research?

3. What benefits can qualitative research bring to primary care delivery?

4. How can qualitative research help in delivering the wider public health agenda and meet needs of local communities?

5. Can we reduce maternal mortality through qualitative research findings?

The next EBN Twitter Journal Chat #EBNJC will take place on Wednesday 9th July 2014 8-9 pm (UK time) and focus how can qualitative research help us to deliver primary care services.

Participating in the EBN Twitter Journal Chat

1 To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

2 You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
3 NB not including #ebnjc means people following the chat won’t be able to see your contribution.


Alvarez, L. J., Gil, R., Hernández, V., and Gil, A, (2009) ‘Factors associated with maternal mortality in Sub-Saharan Africa: an ecological study’, BMC Public Health, 9, pp. 462-469, Academic Search Complete: EBSCOhost. Available at: [Accessed: 3 July 2014].

Moorley, C. 2012 Life after stroke: Personal, Social and Cultural Factors – An Inner City Afro-Caribbean Experience. PhD Thesis University of East London.

Moorley C, Tunariu., A, Cahill., S, Scott O. (20140 Impact of stroke, a functional, psychosocial report of an inner city multiracial population Journal of Primary Care 24(4) 26-34

Partnership for Maternal, New born and Child Health (2011) Commission on information and accountability for women’s and Children’s Health [Online]. Available at: WHO. [Accessed: 5 July 2014].

Rogo, K. O., Oucho, J. and Mwalali, P. (2006) Maternal Mortality. In: Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd edition. Washington (DC): World Bank; 2006. Chapter 16. Available at: [Accessed: 4 July 2014].

Robson., C. 2011 Real World Reserch London Sage

Sofaer., S. Qualitative research methods. Int J Qual Health Care 2002;14:329–36.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357.

United Nations (undated) Goal 5: improve maternal health [Online]. Available at: UN. [Accessed: 4 July 2014].

United Nations Populations Fund (2010) Reducing maternal mortality the contribution of the right to the highest attainable standard of health [Online]. Available at: [Accessed: 5 July 2014].

World Health Organisation (2014) Maternal mortality [Online]. Available at: WHO. [Accessed: 5/7/2014].



Outcome measurement and valuation – what is it and why do we need it?

30 Jun, 14 | by hnoble

Last week I spent a couple of days in York, England exploring outcome measurement and valuation for Health Technology Assessment with academics from the Centre for Health Economics at the University of York. People attended from across the world and I sat beside colleagues from many countries including India, Ghana, Switzerland, Greece, Denmark, Spain and Germany. The world cup took on new significance!

Health outcomes involve changes in health status – changes in health of an individual or population, attributable to an intervention. Sometimes the population or group is defined because different outcomes are expected for diverse people and conditions. Measurement of health outcomes involves carrying out different measurements including, measurement of health status before the intervention, measurement of the intervention, and measurement after to try and relate the change to the intervention.

Health Technology Assessment (HTA) in its simplest form is about determining whether or not health services are safe and effective. The primary goals are to improve safety of healthcare; make decisions on treatment more consistent; ensure cost-effective treatments are utilized and to share information to assist with decision making (see Within HTA we try to determine if the benefit gained from the new treatment is greater than the benefit forgone through displacement.

Outcome measurement for decision making has an important role in patient reported outcomes. Firstly we design health care interventions around basic science and anticipated clinical effects. We then need to understand the clinical impact – such things as cancer progression or clinical interpretation. Finally, we need to understand the impact on patients. We can do this by measuring such things as subjective well-being or function e.g we could measure changes in quality of life in patients with end stage kidney disease, before and after and intervention, by using the Kidney Disease Quality of Life Questionnaire.

The building blocks of outcome measurement include:
Measurement – What is the impact of the disease? What is the impact of the interventions?
Individual preferences – Trading off length of life for quality of life; what weight is given to different aspects of health
Societal preferences – Relevant to disease or other characteristics

If an intervention is to be introduced there are different methods for valuing health and often it is quality of life that is measured. Health related quality of life is a patient’s subjective perception and not determined by a clinician. It is multidimensional and includes physical function, psychological health and social wellbeing. It can be measured using a variety of tools. Disease specific questionnaires can be used e.g. the Chronic Heart Failure Questionnaire; or generic health related quality of life tools which are non-preference based can be used such as the SF-36. Finally preference based tools such as the EQ-5D -5L can be used. The EQ-5D -5L is a very useful measure and recommended by the National Institute for Clinical Excellence as it allows for an economic evaluation where health benefits are expressed in terms of Quality Adjusted Life Years (QALYs). (See

So why is it important that we measure health outcomes? Measuring health outcomes allows us to make decisions about how to best care for our patients and outcome measures help us predict the patients who might benefit most from a particular intervention. It helps us identify any improvement after an intervention is provided. The effective use of outcome measures is an important aspect of clinical care and deciding which outcomes are relevant to a patient group and selecting appropriate measures of those outcomes requires an understanding of the clinical situation, as well as an understanding of the measurement properties of the outcome measures. Outcome measures can be important tools for guiding clinical decision making. However, to function well these tools must be used with skill and understanding.

So if this blog has sparked your interest and you want to know more about Outcome measurement and valuation have a look at the York Expert Workshops at

Why aren’t clinical guidelines used in practice?

22 Jun, 14 | by atwycross

The next EBN TWITTER journal chat will take place on Wednesday 25th June 8-9 pm (UK time) and focus on why clinical guidelines aren’t used in practice focusing on children’s pain management.

Participating in the EBN Twitter Journal Chat

To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at Once you have a Twitter account contributing is straightforward:

  • You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
  • Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
  • NB not including #ebnjc means people following the chat won’t be able to see your contribution.

Before joining in the Twitter Chat you might like to read the associated Blog (which will be uploaded on 23rd June) – go to:

Nurses and other health care professionals have an ethical and professional duty to ensure pain in children is recognised and managed effectively. Effective pain managing is the responsibility of the inter-disciplinary team; having 24 hour contact with children in hospital, nurses often assume the overall responsibility for the management of a child’s pain. Yet, despite advances in our understanding of pain management in children, from assessment, safe and effective use of analgesia in children, and evaluating children’s experiences research findings highlight on-going inconsistencies and inadequate pain management in children.Misconceptions about pain and pain management in children, professional socialisation and deep-rooted organisational cultures remain (1).

Why aren’t clinical guidelines used in practice?

Clinical guidelines are recommendations on the appropriate treatment and care of people with specific diseases and conditions. Clinical guidelines are based on the best available evidence and are designed to make it easier to ensure that evidence based care is provided. The first clinical guidelines relating to pain management were published in the early 1990s but despite this children are still experiencing moderate to severe pain post-operatively (2, 3) and current guidelines are not always adhered to in practice (4, 5). Why is this the case when the evidence to guide practice is readily available in the form of clinical guidelines (e.g. (6-8))? One reason may be the quality of clinical guidelines. A recent review of paediatric clinical guidelines for acute procedural pain concluded that many of them were of average quality (9). Other factors postulated as contributing to sub-optimal practices relate to health care professionals, patients (children and parents), and the organisation (10).

Factors relating to health care professionals

Factors relating to health care professionals include out-dated or inadequate attitudes and knowledge. Evidence that some pain is expected (and accepted) during hospitalisation has been found (11-14). Further, pain management may be seen as synonymous with administering analgesic drugs (4, 11, 15, 16). Pain management may not be given as much priority as other aspects of a nurse’s role (11, 17-19). There is also evidence that the importance nurses attribute to pain management tasks does not reflect the likelihood of the task being undertaken in practice (20) as well as variability in nurses’ aims when managing post-operative pain (13). Gaps have been found in nurses’ knowledge about paediatric pain in relation to: pain assessment (21, 22); analgesic drugs (15, 19, 21-25); pharmacology (21, 22, 24, 25); non-pharmacological methods (15, 19, 23, 25); physiology of pain (15) and the psychology and sociology of pain (15). Research indicates that similar gaps are found among medical staff (26, 27).

Although clinical guidelines are clear in relation to best practice, insufficient theoretical knowledge may not be enough in itself to explain variations in practice. Different forms of knowledge and expertise may shape different professional practices, in varying clinical contexts. It has been suggested tacit knowledge may play an important part in clinician’s approaches to treatment. The current emphasis on evidence-based practice has provoked debate around the role of tacit knowledge in clinical practice (28, 29). The distinction between explicit and tacit knowledge refers to the difference between knowing what and knowing how (30). Explicit knowledge is codified, abstracted and can be transferred through formalised means such as texts, whereas tacit knowledge arises through experience and is personal and contextual as well difficult to make explicit (31). Drawing on this distinction between tacit and explicit knowledge, and their role in shaping clinical practice, may prove valuable in attempting to explain why clinical guidelines are not consistently implemented.

Factors relating to parents and children

Parents are seen by many nurses to be reluctant for their children to receive pain medications (19, 32-34). A lack of cooperation between parents and nurses has also been described (32, 33, 35). Children’s behaviour is seen as a barrier to managing pain effectively; nurses sometimes feel their behaviour did not indicate that the child was in pain (32, 35). A child having a diagnosis suggesting they may be in pain may facilitate optimal pain management (35) while the child’s age is sometimes a barrier particularly for children unable to communicate verbally with the nurses (33, 35). Children were also seen as reluctant to report or rate their pain as well as being unwilling to take analgesic drugs (19, 34).

Factors relating to the organisation

Over the past decade there has been a growing awareness that a unit (ward) has a set of informal rules that determine how pain is managed. This was demonstrated by the results of an ethnographic study on two (adult) units in one hospital in the USA (36). Participants described a clear but different pattern of pain assessment on each ward. The social context of the ward appeared to influence practices. Further, in one Canadian study, paediatric nurses described the unit’s pain management culture as giving pain medications regularly even if they are prescribed prn; this appeared to be the factor that impacted most on practice (4). Another study exploring neonatal pain management also found organisational context affected practices (37).

A key organisational factor that influences pain management practices is the relationship between medical and nursing staff. This was clearly described in Van Niekerk and Martin’s (2003) study where (adult) nurses who did not feel adequately consulted by medical staff were significantly more likely to report encountering barriers such as insufficient cooperation and inadequate prescription of analgesic medications(38). Similar findings about a lack of co-operation between nurses and medical staff have been found in paediatrics(19).


There appear to be many reasons why clinical guidelines are not used consistently in practice. Further research is needed to identify strategies that support the use of this evidence in practice.

Questions for consideration:

  • What factors do you think contribute to clinical guidelines not being used in practice?
  • Do you implement all aspects of pain management guidelines in your practice? If not – why not?
  • Current clinical guidelines state that pain assessment tools should be used but research suggests this does not happen consistently. Why is this?
  • When managing a child’s post-operative pain what is your aim?
  • Do you feel you have gaps in knowledge about managing pain in children? If so what are these gaps?
  • What strategies can we use to improve the use of clinical guideline recommendations in practice?
  • Why does research continually highlight that children perceive there pain is not managed well, and their views are not listened to?
  • What skills are required by nurses to effectively manage pain in a child who is in pain?

Alison Twycross

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

London South Bank University

 Editor: Evidence Based Nursing  

Join in the blog discussion @EBNursingBMJ

Tweet me: @alitwy



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  2. Kozlowski LJ, Kost-Byerley S, Colantouni E, Thompson CB, Vasquenza KJ, Rothman SK, et al.Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing. 2014;15(1):22-35.
  3. Twycross A, Finley GA. Children’s and parents’ perceptions of postoperative pain management: A mixed methods study. Journal of Clinical Nursing. 2013;22(21-22):3095–108.
  4. Twycross A, Finley GA, Latimer M. Pediatric Nurses’ Postoperative Pain Management Practices: An Observational Study. Journal for Specialists in Pediatric Nursing. 2013;18(3):189-201.
  5. Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, et al.Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain. 2012;13(9):857-65.
  6. Royal College of Nursing. The recognition and assessment of acute pain in children – Recommendations: Revised. London: RCN Publishing; 2009.
  7. Association of Paediatric Anaesthetists. Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Pediatric Anesthesia. 2012;22(S1):1-81.
  8. American Academy of Pediatrics, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793-7.
  9. Lee GT, Yamada J, O B, K.,, Shorkey A, Stevens B. Pediatric Clinical Practice Guidelines for Acute Procedural Pain: A Systematic Review. Pediatrics. 2014;Online early.
  10. International Association for the Study of Pain. Why the Gaps Between Evidence and Practice. Seattle: IASP; 2010.
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  27. Kolarik RC, Walker G, Arnold RM. Pediatric residents in palliative care: A needs assessment. Pediatrics. 2006;117(6):1949-54.
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  29. Thornton T. Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement. Philosophy, Ethics, and Humanities in Medicine. 2006;17(1):1.
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  31. Greenhalgh J, Flynn R, Long AF, Tyson S. Tacit and encoded knowledge in the use of standardised outcome measures in multidisciplinary team decision making: A case study of in-patient neurorehabilitation. Social Science and Medicine. 2008;67(1):183-94.
  32. Twycross A, Collis S. Nurses’ Views about the Barriers and Facilitators to Effective Management of Pediatric Pain. Pain Management Nursing. 2013;14(4):e164-e72.
  33. Ely B. Pediatric nurses’ pain management practice: barriers to change. Pediatric Nursing. 2001;27(5):473-80.
  34. Czarnecki ML, Simon K, Thompson JJ, Armus CL, Hanson TC, Berg KA, et al.Barriers to pediatric pain management: A nursing perspective. Pain Management Nursing. 2011;12(3):154-62.
  35. Gimbler-Berglund I, Ljusegren G, Ensker K. Factors influencing pain management in children. Paediatric Nursing. 2008;20(10):21-4.
  36. Lauzon Clabo LM. An ethnography of pain assessment and the role of social context on two postoperative units. Journal of Advanced Nursing. 2008;61(5):531-9.
  37. Stevens B, Riahi S, Cardoso R, Ballantyne M, Yamada J, Beyene J, et al.The influence of context on pain practices in NICU: Perceptions of health care professionals. Qualitative Health Research 2011;21(6):757-70.
  38. Van Niekerk LM, Martin F. The impact of the nurse-physician relationship on barriers encountered by nurses during pain management. Pain Management Nursing. 2003;4(1):3-10.


Nursing and the childhood obesity epidemic

16 Jun, 14 | by rheale

Obesity has become an epidemic in the developing world. In the past 33 years the rates of overweight and obese have risen 28% in adults and 47% in children across the globe. This is an increase from 857 million people in 1980 to 2.1 billion people in 2013 It’s a public health emergency. Countries have declared obesity a disease and the EU is considering labeling obesity as a disability.

There are numerous theories about why we’re getting so fat. Since girls in lower socieoeconomic families put on more adipose tissue than the boys, there is a theory that estrogen is a factor. One study demonstrated that changes at the cellular level related to oxygen when dieting, trigger inflammation in adipose cells. The immune system is considered to play a role The amount of television a child watches and the amount of sleep both child AND parent get are thought to contribute to the obesity epidemic. as does the amount of light in the bedrooms. Our memory of the most recent sweet treat can add to our cravings for more. One study shows that diet sodas helped with weight loss, while others contradict this news. Medication is known to ‘pack on pounds.’

Of course what we eat and how we exercise plays a role. At a recent conference I learned that our weight is a product of 80% our food intake and only 20% our exercise/activity. Weight loss programs contradict each other and have dubious success rates. Radically changing our diets is very difficult and, depressingly, long term weight loss the ‘old fashioned way’ without surgical intervention is almost impossible.  Every day there is more news about obesity, yet the problem continues to grow and the question is what is nurses’ role, particularly when faced with the issue of childhood obesity?

A dietician from a childhood obesity program presented the rising statistics to us and added that the growth charts for weight in children had been adjusted from the 1970’s to accommodate the growing girth of children in our society. A pediatrician mentor once told me that the first thing that every health care provider must do is to tell the parents and patient that they are overweight/obese. I thought this was a bit strange at the time, however, I soon realized when I started to weigh discuss with parents their children’s weight, that they were often in denial about the extent of the problem. One mother argued with me that her 3-year-old child, who was off the percentile chart for weight, was ‘big boned’. She also insisted that the child should continue to drink two large jugs of ‘juice’, the equivalent of sugar water, each day.

Even with contradictory evidence, possible parental denial and lack of any real control over the dietary intake of children, there are many ways that nurses can help. Our role as advocates may incite us to do such things as enforce or create public policies about the amount of exercise children are given at school and to restrict and prevent companies from selling high sugar products on school properties. Nurses can do such things as lobby municipalities to ensure safe bicycle routes to schools with adequate storage to promote cycling to school. Ultimately, however, focus on the family is key. Even if parents and children continue to be in denial, nurses can inform them about childhood obesity and create accessible programming to assist families to address and cope with it. As difficult as it is to address the issue of childhood obesity in our societies, it is vitally important to do so. Nurses are uniquely qualified to meet the challenge through advocacy for change and by caring for one family at a time.

Family-centred care; an aspiration or reality?

9 Jun, 14 | by josmith

The next EBN TWITTER journal chat will take place on Wednesday 11th June 8-9pm and focus on family-centred 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.

Family-centred care is often viewed as a core principle in the care of children and a means of working in partnership with children, young people and families. This approach to healthcare delivery, where there is a mutually beneficial collaboration between patients and health professionals, is widely advocated within children’s nursing and the healthcare literature. Family-centred care has been described as both a method of care delivery and a philosophy that values the vital role of the family in ensuring the health and wellbeing of the child, and involves planning and delivering care around the whole family (Shields et al. 2012). The Institute for Patient and Family-Centred Care (2010, p1) defines family-centred care as, ‘an approach to the planning, delivery and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families’. Despite considerable research, family-centred care is a ubiquitous nebular concept, having differing meaning within and across professional and patients groups. In addition, the evidence-base relating to the impact of family-centred care on care delivery and parental satisfaction is weak, and outcomes are difficult to measure (Shields et al. 2012).Lack of clarity and a common understanding of family-centred care have resulted in questions being asked about the extent to which these concepts are applied in practice (Coyne, 2013).

Challenges in embedding family-centred care into practice include:

  • Individual health professions attitudes towards, values and perceptions of family-centred care;
  • Unclear roles and boundaries between parents and health professionals, entrenched professional practices with health professionals retaining the role of decision maker, care prescriber and care giver;
  • Lack of knowledge and skills in relation to implementing family-centred care, which often operates without effective sharing of information and negotiation of care with families;
  • Lack of specific guidelines or policies, resulting in variability in embracing family-centred care and family-centred care becoming part of everyday practice.


Coyne, I. (2013a) Families and health-care professionals’ perspectives and expirations of family-centred-care: hidden expectations and unclear roles. Health Expectations; early on-line doi: 10.111/hex12104.

Institute for Patient and Family-Centred Care (IPFCC) (2010). Frequently asked questions. (accessed May 2014).

Shields, L., Zhou, H., Pratt, J., Taylor, M., Hunter, J., & Pascoe, E. (2012) Family-centred care for hospitalised children aged 0-12 years. Cochrane Database Systematic Reviews. Issue 2.

Questions for consideration:

Is family-centred care predominantly aspirational and therefore not part of ever-day practice?

What does family-centred care mean to you?

What are the key components of family-centred care that are essential when working with children, young people and families?

What skills are required by nurses working with families to ensure care is family-centred?

Jo Smith, Senior Lecturer Children’s Nursing, University of Huddersfield, Associate Editor EBN.   Join in the blog discussion @EBNursingBMJ  Tweet me @josmith175

The elevator pitch for midwifery care

2 Jun, 14 | by ashorten

A few days ago I was sitting on an aircraft on my way to the International Confederation of Midwives 30th Triennial Congress in Prague. In an effort to reduce my pre-flight anxiety, I was chatting to the person beside me, who happened to be the father of three young children, one of whom was only a few months old. At some point during the long delay between taxi and take-off, I revealed that I was on my way to attend an international midwifery conference. In my experience, when parents of young children find out that I am a midwife they often share their birth stories, express their opinions about midwifery care and sometimes share fond memories about their experiences with midwives. This time I was quite surprised by the candid response “they sure have conferences for just about everything these days”. I tried not to gasp but was compelled to respond with a marketing pitch about midwives. As an American, he may not have been as familiar with midwives or midwifery practice due to significant differences in pregnancy models of care in the United States. I explained that the ICM is not just another conference. This year it is a gathering of over 3000 midwives from all over the world to share research and ideas about “Midwives, Improving Women’s Health Globally” – which happens to be the conference theme.

Midwifery is my passion. I have lived and breathed midwifery and midwifery research for almost 25 years. How could a father of young children not realize that midwives are a critical part of the healthcare system contributing to the health and well-being of mothers, children and families around the globe? As we talked further I discovered that he had never met a midwife, did not realize that midwifery required a high level of education, and thought that midwives were an “alternative” form of pregnancy care for women who wanted to birth at home. He was quite surprised when I explained that aside from having tertiary level education, midwives work in many different settings, including hospitals, birth centers, primary care clinics and women’s homes, just to mention a few. I briefly outlined that research clearly demonstrates the benefits of midwifery care in more ways than I had time to explain before the plane would be at cruising altitude and we would be swept into the in-flight entertainment. I did the “take off” pitch for midwifery care in the hope that this father would share the information with others and spread the word for midwives.

It is easy to assume that everyone knows about our profession and how we contribute to the health of our communities. It may be that we get swept up in our professional lives, sharing new information with each other, including at our professional conferences. It is easy to forget that we need to share new evidence about what we do with our patients and the wider community. We need to continue to seek ways to educate our patient community about the role nurses and midwives can play in optimizing their health throughout their lives. Professional nursing organisations are increasingly recognizing the importance of not only serving their members but in educating the general community about what we do, how we are educated and what current research actually shows about the value of the services we provide. For example the American College of Nurse-Midwives launched a publicity campaign titled “Our Moment of Truth” with the aim of educating women about nurse-midwives and their role in women’s health throughout their reproductive lives, not just for pregnancy care.1 This national awareness initiative consists of an interactive web-site and tools to support women as well as to re-introduce the value of midwifery care to US women. There are numerous resources for women as long as they know that the web-site exits.

Of course, we don’t always have professional marketing flyers or fact sheets at our fingertips when we need them for an impromptu community education announcement! So aside from professional advertising campaigns and web-site tools, we all need to be ready for the “elevator pitch” when someone wants or needs to know more about our profession and what we can do for them. It is also important that, when we have good evidence that nursing and midwifery care can improve health outcomes and satisfaction with healthcare experiences, we are prepared to share it with the people who will benefit from that care. That means we not only need to stay on top of the current research about our profession and our models of care but that we should know how to communicate a quick and effective message to the general public about it, whether on a plane, in the supermarket or even socializing with friends. You never know when the opportunity will come up or when you will be asked the question “what is a midwife?”

I hope that my fellow passenger went home and told his family about meeting a midwife on the way to an international midwives conference so that they can go on to share the message with others that midwifery care is research-based and that midwives are highly educated professionals who work in many settings.

As I listen to the research and clinical practice issues being discussed this week from around the globe, I am already thinking about the new messages I am hearing about the important role of midwifery in promoting health and protecting the lives of women and babies. I am almost hoping someone will ask me on the return flight home “what happens at a midwives conference?” This time I will be armed with new evidence and a rekindled fire that comes from attending a conference with 3000 midwives!

Allison Shorten RN RM PhD

Yale University School of Nursing




Understanding the emotional health and wellbeing of our Military Children and Young People

26 May, 14 | by hnoble

Paul Watson RN (mental health) Twitter @Paul_RMHN

Recent conflicts in both Iraq and Afghanistan have seen British Armed Forces at war for over 12 years. The extreme length of combat operations has seen a growth in both governmental and public support for the ‘troops on the ground’. There has been a distinctive escalation in government and private funding specifically to address the needs of military personnel and their families, through both long standing organisations including the Royal British Legion and newly formed charity organisations including Help 4 Heroes and Combat Stress to name a few (Gribble et al. 2014). Importantly there has also been some key policy change within the United Kingdom (UK), namely the Armed Forces covenant (MOD, 2012) to support those men and women returning from combat with both physical and psychological injuries and their reintegration into the civilian population. There are an estimated 170,000 “full time” service children (The Royal Navy and Royal Marines Children’s Fund, 2009). Service Children are defined as having one or both parents serving in Her Majesty’s  Forces (O’Neil, 2013).

The Office of National Statistics (ONS) identified that mental health affects between 10-20% of all children and young people in the UK (ONS, 2005). Furthermore, 12% of 5-16 year old children and young people have a diagnosed mental health condition, with conduct disorder nearing 7% and emotional disorders around 5%. To contextualise, in 2013 records indicated that in the UK there are 13.3 million children and young people up to and including 16 years of age (ONS, 2013). American research shows that there is a further 11% increase of military dependent children and young people who access mental health service when one or both parents are deployed to war (Johnson & Ling, 2012). Arguably within the UK, the effects of parental or sibling deployment could similarly affect the emotional health and well-being of service children and young people (Fossey, 2012). Therefore, potentially creating a greater need for military children and young people to access mental health services and the services of specialist school nurses.

Academics globally including the UK, have explored the impact war has on military personnel and the potential effects they may experience when returning home. In the UK theKing’s Centre for military health and the Academic Centre Defence Mental Health are the predominant facilitators in producing both qualitative and quantitative research around the effects war has on British service personnel and veterans’ health. Their extensive research looks at a multitude of pre and post combative effects on health including: post traumatic stress disorder (PTSD) (Sundin et al. 2010), traumatic brain injuries (TBI) (Jones, Rear, & Wessely, 2007), pre-deployment stress (Sharpley et al. 2008), mental health (MacManus et al. 2014) re-integration and the military family (spouse/partner) (Burgh et al. 2011; Harvey et al. 2011) to mention but a few. Importantly, this indicates  that there is a great amount of effort made to acquiring greater knowledge and develop an evidence base to understanding the effects combat has on some military personnel.

American research highlights the emotional effects that war has on children and young people left behind during parental/sibling deployment, and their need for public and voluntary support. Children and young people also suffer the psychological effects of parental/sibling deployment (Cederbaum et al. 2013). Additionally, children and young people present with a change in behaviours, both internally (Lester et al. 2010) and externally (Reed, Bell, & Edwards, 2011) demonstrating the need for continual social connectivity (Mmari et al. 2010; O’Neil, 2013). Worthy of note is that children and young people also struggle with the reintegration and mental health of a returning deployed parent or sibling (Harvey et al. 2011) in part due to role confussion.

Those who experience Service/Military life are unique and often face very different challenges compared to the civilian population (O’Neil 2013). Service life offers families both positive and negative experiences and in the main families will take these challenges within their stride. This blog highlights that some military children and young people have an increased risk of poor emotional health and behavioural difficulties during parental or sibling deployment. Furthermore, military dependant children and young people are at greater risk of maltreatment due to the increased parental stress and anxiety on the parent who remains at home. Therefore, it is important that structures are in place to support the stay-at-home parent to address their emotional and psychological needs, to enable them to support their child’s emotional and behavioural needs, thus remaining childocused and meeting the needs of the whole family.

Paul Watson was a military child and served in the British Armed Forces 1996-2003. Paul is now a registered mental health nurse, undertaking his SCPHN School Nursing PgDip focusing on the lives of military children.

Join us Wednesday 28th May 2014  20:00 -21:00 for #EBNJC on understanding emotional health needs of military children and young people.

Reference List

Burgh, T. D., White, C., Fear, N., & Iversen, A. (2011). The impact of deployment to Iraq or Afghanistan on partners and wives of military personnel. International Review of Psychiatry , 23, 192-200.

Cederbaum, J., Gilreath, T., Benbenishty, R., Astor, R., Pineda, D., DePedro, K., et al. (2013). Well-Being and Suicidal Ideation of Secondary School Students From Military Families . Journal of Adolescent Health , 1-6.

Fossey, M. (2012). Unsung Heroes: Developing a better understanding of the emotional support needs of service families. Centre for Mental Health. London: Centre for Mental Health.

Gribble, R., Wessely, S., Klein, S., Alexander, D., & Fear, C. D. (2014). Public Awareness of UK Veterans Charities. The RUSI Journal , 159 (1), 50-57.

Harvey, S., Hatch, S., Jones, M., Hull, L., Jones, N., Greenburgh, N., et al. (2011). Coming home: social functioning and the mental health of UK Reservists on return from deployment to Iraq or Afghanistan. Annals of Epidemiolology , 21 (9), 666-672.

Johnson, H., & Ling, G. (2012). Caring for military children in the 21st century. American Acadamy of Advanced Nursing , 1-8.

Jones, E., Rear, N., & Wessely, S. (2007). Shell shock and mild traumatic brain injury: a historical review. American Journal of Psychiatry , 164 (11), 1641-1645.

Lester, P., Peterson, K., & Reeves, J. (2010). The long war and parental combat deployment: Effects on military children and at-home spouses. American Academic Child and Adolescent Psychiatry , 49, 310-320.

MacManus, D., Jones, N., Wessely, S., Fear, N., Jones, E., & Greenberg, N. (2014). The mental health of the UK Armed Forces in the 21st century: resilience in the face of adversity. Army Med Corps Journal , 1-6.

Mmari, K., Bradshaw, C., Sudhinaraset, M., & Blum, R. (2010). Exploring the role of social connectedness among military youth: Perspecptions from youth, parents and school personnel. Children and Youth Care , 39, 351-366.

MOD. (2012). Armed Forces Covenant. Retrieved April 18, 2014, from

O’Neil, J. (2013, January). Written evidence from Joy O’Neill, Founder and Chair, The Service Children Support Network. Retrieved January 2, 2014, from Parliament – Defence Committee:

ONS. (2005). Mental health of children and young people in Great Britain, 2004. Retrieved December 06, 2012, from

ONS. (2013). Statistical Bulletin: Families and Households. Retrieved April 2, 2014, from Office of National Statistics:

RBL. (2005). Profile of the Ex-Service Community in the UK. The Royal British Legion. London: RBL.

Reed, S., Bell, J., & Edwards, T. (2011). Adolescent well-being in Washington state military families. American Journal of Public Health , 101, 1676-1682.

Sharpley, J., Fear, N., Greeberg, N., Jones, M., & Wessley, S. (2008). Pre-deployment stress briefing: does it have an effect? Occupational Medicine , 58 (1), 30-34.

Sundin, J., Fear, N., Iversen, A., Rona, R., & Wessley, S. (2010). PTSD after deployment to Iraq: conflicting rates, conflicting claims. Psychological Medicine , 40, 367-382.

The Royal Navy and Royal Marines Children’s fund. (2009). The Overlooked Casualties of Conflict. Portsmouth: The Royal Navy and Royal Marines Children’s fund.



The physical health of individuals with serious mental illness Josephine Bardi (RMN), MSc Public Health candidate Twitter @JoBardi01

19 May, 14 | by Calvin Moorley, Associate Editor

“The problem of physical health in individuals with severe mental illness remains a global public health concern” (World Psychiatric Association, 2009, p.1).

Individuals with severe mental illness (SMI) particularly those with schizophrenia, schizoaffective disorder and bipolar disorder are vulnerable to poorer physical health which results in higher rates of mortality and morbidity when compared to the general population. They die an average 20 years younger than the general population due to side effects of psychotropic medication such as lifestyle choices and lack of adequate information.

Side effects of psychotropic medications

Individuals with SMI suffer from metabolic issues including; weight gain, diabetes and cardiovascular diseases due to the side effects from long-term use of psychotropic medications. The clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) sponsored by the National Institute of Mental Health revealed that antipsychotic medications help to improve quality of life (QoL) for individuals with SMI. However adverse effects of antipsychotic medications, over sedation and extrapyramidal reactions are key factors for poor physical health amongst the chosen population. For instance, individuals can gain weight 5-6kg during the first two months of starting antipsychotic medications like Clozapine and Olanzapine and, their weight continues to increase past the first year. Nonetheless, without antipsychotic medications most people with SMI might suffer serious and disabling symptoms such as: hallucinations, delusions, impaired cognitive and social functioning.

Obesity and cardiovascular diseases

A body mass index (BMI) ≥ 25 is considered obese. Individuals with SMI are predisposed to being overweight due to adverse effects of psychotropic medications, higher percentage of body fat which leads to obesity from lack of physical activity.


177 million people (2.8% of the population) in the world were diagnosed with diabetes and expected to rise to 370 million (4.4% of the population) by 2030. Diabetes is increasing in the UK with 24,000 people dying yearly. Universal screening for diabetes rarely occur in individuals with SMI even though they suffer type 2 diabetes mortality outcomes are three times higher than the general population.

Risky Sexual Behaviour

Individuals with SMI are often unaware of their HIV status and they are unlikely to seek voluntary testing. They are exposed to increased risk of infection due to high-risk behaviours from substance misuse through sharing of needles. Additionally, they have disproportionately higher rates of sexually transmitted infections and diseases (STIs and STDs). They are unable to effectively communicate safer sex with partners, have poor interpersonal and assertiveness skills which may result in lack of social support and lower sexual risk-reduction. They may also reside in areas with high rates of STDs, STIs and HIV and experience higher rates of readmission, which hinders long term relationship.


Higher rates of smoking are the major cause of excess mortality in people with SMI. They are reported to be heavier smokers as a result of increase levels of nicotine dependence with daily smoking consumption averaging at 65% compared to roughly 21% in the overall population.

Poor dietary intake

NICE (2006) guidelines suggest a healthy BMI of between 18.5-24.9 and a referral to a dietician where the BMI is dramatically higher or lower than the recommended range. It seems though, that regardless of the continuous awareness campaign strategies, individuals with SMI are yet to fall into the category of people who are aware of the importance of healthy eating. Along with the central nervous system, medications such olanzapine and clozapine are linked to food craving, binge eating, weight gain and hypertriglyceridemia.

Physical activity

Individuals with SMI are less likely to participate in physical activities. Unquestionably, consistent physical activity decreases the risk of long-term physical illnesses and stimulates the release of acetylcholine which calms individuals, improves cerebral blood flow, muscle relaxation and body temperature. However these are not often discussed during assessments.

Respiratory diseases – Tuberculosis

TB in individuals with SMI seems largely related to those who share injections during drug use and live in overcrowded houses with infected persons. The NHS provides mobile Tuberculosis (TB) screening units where individuals receive chest x-ray to determine their TB status. Similar to above listed physical health illness, individuals with SMI have higher mortality rate as they are not aware of the risk of exposure, screening and treatment options.

Considering the magnitude of the identified physical health illnesses, it will come as no surprise then that physical health problems in individuals with SMI account for higher mortality rates when compared with mental health problems.

What is the role of the mental health nurse (MHN) in monitoring the physical health of individuals with serious mental illnesses?

Since the 1950s psychiatry has transformed radically from MHNs providing support for individuals asylums to gradually becoming qualified professionals identified worldwide as providers of key functions much the same as a century ago but, holistically through assessment of physical, mental, social and spiritual needs of service users. During the second half of 2009 there were changes in the funding and allocation of resources between primary and secondary health services in the United Kingdom. Consequently the DH (2009) focused more on the physical health of individuals with SMI with a corresponding shift towards the role of the MHN yet, MHNs are reported to lack the skills to effectively monitor the physical health of individuals with SMI. It is worth stressing that most mental health nurses are trained in the basics of anatomy and physiology so, arguably, they are not entirely to blame for their lack of physical health skills as this may be solely attributed to the difference in training syllabus between MHNs and other branches of nursing.

Neglecting this aspect of care impacts on the individuals with SMI with a mortality rate of 4,008 deaths per 100,000 compared to 1,122 deaths per 100,000 which is 3.6 times higher than the general population. For this reason, it is paramount that holistic and comprehensive assessment is carried out in collaboration with individuals with SMI so that needs can be identified, goals set and interventions implemented. However, several studies have found irregularities in the competencies of MHNs in the assessment and recording of physical health results. The upshot being poorer physical health outcomes due to poor assessments experienced by the individuals with SMI even when they are able to access physical health care.

Josephine Bardi is currently completing her MSc in Public Health at the University of East London


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Department of Health (2006b) Choosing Health: Supporting the physical needs of people with severe mental illness – commissioning framework [Online]. Available at: [Accessed: 18 November 2012].

Lieberman, J. A., Stroup, S., and McEvoy, J. P. et al. Clinical antipsychotic trials of intervention effectiveness (CATIE) investigators (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. The New England Journal of Medicine, 353 (12), p.1209-1223.

Nash, M. (2010) Assessing nurses’ propositional knowledge of physical health. Mental Health Practice, 14 (2), p. 20-23.

Ratcliffe, T., Dabin, S. and Barker, P. (2011) Physical healthcare for people with serious mental illness: Clinical governance: An International Journal 16 (1), p. 20-28.

Robson, D. and Haddad, M. (2012) Mental health nurses’ attitudes towards the physical health care of people with severe and enduring mental illness: The development of a measurement tool. International Journal of Nursing Studies, 49 (1), p. 72-83 EBSCOhost: MEDLINE [Online]. Available at: [Accessed: 29 November 2012].

The Health and Social Care Information Centre (2012) Mortality rate in sufferers of serious mental illness three times as high as in the general population [Online]. HSCIC. Available at: [Accessed: 12 December 2012].

World Psychiatric Association (2009) Physical health care in persons with severe mental illness: a public health and ethical priority. World Psychiatry 8 (1), p. 43-44.


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