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Ebola: Will Nurses Have a Choice?

26 Oct, 14 | by rheale

In August, Jo Smith, another Associate Editor of EBN, wrote a blog about Ebola. The question was whether it was a global health problem. At that time, the disease had been largely a scourge in West Africa. Since then, we’ve seen the first cases of Ebola in the US and, it feels like only a matter of time before the disease is found in a wide range of countries.

Just over 10 years ago, the world was dealing with SARS, and not long before than, HIV/AIDS. Caring for these patients hasn’t been without dangerous consequences. In Toronto, two nurses and three other health care workers lost their lives from SARS.

Despite the risk, nurses have cared for patients with these scary infections, even in the earliest stages when knowledge about how to prevent the spread of infection wasn’t entirely understood. Some people understand the incredibly important role that nurses play in these circumstances, such as television personality Rick Mercer:

In the past, these nurses and health care providers have been seen as heroes. Not so in the recent cases where nurses in Dallas contracted Ebola after caring for a patient with the disease. They were criticized on a number of fronts including failing to take proper infectious control precautions and travelling in the days after working with the Ebola patient. The outcome of this was information arising from the nurses themselves, through a national nurses association, outlining the lack of proper protective equipment, failure to place the Ebola patient in isolation early, and even the fact that the nurses caring for the patient with Ebola had other patients in their workload. Nurses United has since posted a letter to President Barak Obama, outlining the minimal requirements for caring for patients with Ebola.

One wonders, though, is it enough? Refusal to work is a topic on the minds of nurses and nursing organizations across the globe. In his blog, Dr. Brian Goldman, discusses the response of Canadian nursing associations. He rightly identifies the risk that nurses, in particular face because they spend the most time and the closest contact with high-risk patients. There is a lack of specialized knowledge about the specific infectious control procedures required to safely care for people with Ebola.  I also wonder if there is a will on the part of hospitals to appropriately train and staff the units where Ebola is present. There is a law in my province of Ontario that gives a limited right of refusal of a healthcare worker if there are circumstances where the worker feels there is danger.

As countries prepare for the potential of Ebola within their borders, one wonders what the nursing response will be if/when it arrives. If nurses are not given the tools and knowledge for safe care and are criticized as they were in Dallas, maybe, just maybe, will they say no?

Roberta Heale, Associate Editor EBN, @robertaheale

Option Grids: Expanding our toolkit for supporting shared decision making

19 Oct, 14 | by ashorten

I am always looking for new ways to improve the way we support patients to make informed choices about their healthcare, using the best available evidence from research. Shared decision making necessitates information sharing and giving patients a voice in decision making. It is often easier said than done and both patients and care providers need new ways to build better connections. This is, in reality, a huge challenge. Healthcare services are incredibly busy and resources are stretched. Time is limited and conversations are plagued by huge variations in health literacy and language. Fragmented models of care, where patients see different providers at each visit, leads to inconsistencies in information sharing. Patients can become frustrated and confused when information is not standardized and they receive different answers to the same questions, depending on the biases of the different providers they speak with. Then we have the added but influential input from family, friends and the media bring to the mix. We need new tools in our toolkit for providing consistent, evidence-based information, delivered from the perspective of patients.  Providers need tools to lay the foundation for effective shared decision making, in a way that meets an individual’s personal decision making style.

I have recently been exploring Option Grids – decision support tools originated by Glyn Elwyn and others in 2009 at Cardiff University. Option Grids help patients compare treatment options using patient generated frequently asked questions and concise evidence based answers.1 Evidence is gathered from sources such as the National Institute for Clinical Excellence (NICE) in the UK, with the aim for best available evidence to inform the answers to patient questions.1 The grid format provides a short (one-page) easy to read (reading age 10-12 years), easy to use (takes just a few minutes) comparison of options.1 Patients simply work through key questions and answers, comparing their options across the grid. Patients are asked to identify and highlight what questions or issues matter most to them and discuss these key questions in more detail with their provider.1 For more information about the Option Grid Collaborative, at The Dartmouth Center for Health Care Delivery Science in the USA, visit the Option Grid site .

The sophisticated simplicity of these decision support tools makes them valuable for a wide range of patient care settings and decision scenarios. In the context of pregnancy care, for example, there are currently Option Grids for decisions about Screening for Down’s Syndrome in Pregnancy, Amniocentesis testing and Newborn Circumcision. Option Grids for contraceptive decision making are currently listed as being under development. I am sure there are many more to come in the future.

Option Grids have great potential for broad application and I can see how they might be useful not only in medical screening and treatment consultations but in many everyday nurse and patient decision discussions. I encourage care providers to check out the web site for a list of currently available Option Grids as well as those currently being developed. Patients need a voice and it is important for nurses and midwives to expand our toolkits to better support patients who might have difficulties knowing what questions to ask or how to ask them. Taking the time, even if it is limited, to identify issues that are important to patients and their families can make a difference to the outcome and experience of healthcare decisions.

Allison Shorten RN RM PhD

Yale University School of Nursing



  1. Elwyn G, Lloyd A, Joseph-Williams N, Cording E, Thomson R, Durand MA, Edwards A. Option Grids: Shared decision making made easier. Patient Educ Couns. 2013; 90 (2): pp. 207–212
  2. Option Grid® <accessed October 19th 2014>


Why is pain still not managed effectively?

13 Oct, 14 | by hnoble

Due to unforeseen circumstances this week’s Twitter Chat focusing on the care of people with learning disabilities has had be postponed. Watch this space for details of its rescheduled date. Given this I am taking the opportunity to report on some of my reflections while at the World Congress on Pain.

Along with several thousand other people I am currently at the World Congress on Pain in Buenos Aires, Argentina. One of the things I have been reflecting on whilst here is why, if so many people are interested in pain, patients are still experiencing moderate to severe unrelieved pain. We know what we should be doing but this knowledge doesn’t seem to be used in practice. For example, for paediatric acute and postoperative pain there are clinical guidelines available (Association of Paediatric Anaesthetists 2012) yet we know that children continue to experience moderate to severe pain in hospital postoperatively (Kozlowski et al. 2014, Stevens et al. 2012, Twycross et al. 2013).

The workshop I am involved in tomorrow explores this in relation to acute pain for children in hospital. My paper reports on a systematic review that explored nurses’ postoperative pain management practices over the past 20 years. The results of the systematic review revealed some improvements. For example, there is some use of self-report tools and opioids are administered more often. However, these practices are not consistent. There is still a lot of room for improvement. Many of the papers included in the systematic review were chart audits. This means much of what we know is based on documented practices rather than what actually happens in the clinical setting. Three observational papers did provide a greater understanding of current practices (Byrne et al. 2001, Shrestha-Ranjit & Manias 2010, Twycross 2007).

One of the key things that needs exploring is the reasons suboptimal practice continues and which strategies are most effective at changing practice. I am presenting a second paper on behalf of an ex-PhD student (Dr Anna Williams) that looks at nurses’ conceptualisations of children’s pain. This paper draws on sociological principles to help us understand nurses’ thinking about different types of pain (routine pain; pain versus fear; complex pain). The management of a child’s pain seems to depend on how nurses conceptualise the pain. Professor Bonnie Stevens from Toronto Sick Kids Hospital and the University of Toronto is presenting a paper reporting on the success of knowledge translation strategies in changing practices in hospitals across Canada. Some of the preliminary results have already been published (Stevens et al. 2014).

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 (Lauzon Clabo 2008). 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 (Twycross et al. 2013). Another study exploring neonatal pain management also found organisational context affected practices (Stevens et al. 2011).

We perhaps also need to explore the reasons why clinical guidelines aren’t used in practice. One reason may be the quality of some guidelines. A recent review of paediatric clinical guidelines for acute procedural pain concluded that many of them were of average quality (Lee et al. 2014). However, just having a good quality guideline does not mean it will be implemented in practice. In Lee et al.’s review the vaccination guideline (Taddio et al. 2010) scored the best for quality, yet is still not being using in practice.

The current emphasis on evidence-based practice has provoked debate around the role of tacit knowledge in clinical practice (Gabbay & LeMay 2004, Thornton 2006). The distinction between explicit and tacit knowledge refers to the difference between knowing what and knowing how (Polanyi 1966). 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 (Greenhalgh et al. 2008). Clinicians in multidisciplinary teams have been shown to draw on tacit knowledge in their use and interpretation of standardised outcome measures, adjusting patient scores in accordance with their tacit knowledge of individual patients (Greenhalgh et al. 2008). In pain assessment, the impact of clinical judgement and tacit knowledge has begun to be addressed in work that suggests a self report score is only one factor health care professionals consider when deciding how much pain children are in (Voepel-Lewis et al. 2012). Additional research is needed to explore if and how tacit knowledge impacts on pain assessment practices and how this impacts on the quality of pain management practices.

Dr Alison Twycross

Head of Department and Reader in Children’s Pain Management

Department of Children’s Nursing

London South Bank University




Association of Paediatric Anaesthetists (2012): Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Pediatric Anesthesia 22, 1-79.

Byrne A, Morton J & Salmon P (2001): Defending against patients’ pain: A qualitative analysis if nurses’ responses to children’s postoperative pain. Journal of Psychosomatic Research 50, 69-76.

Gabbay J & LeMay A (2004): Evidence based guidelines or collectively constructed ‘mindlines?’. Ethnographic study of knowledge management in primary care. British Medical Journal 329, 1013.

Greenhalgh J, Flynn R, Long AF & Tyson S (2008): 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 67, 183-194.

Kozlowski LJ, Kost-Byerley S, Colantuoni E, Thompson CB, Vasquenza KJ, Rothman SK, Billett C, White ED, Yaster M & Monitto CL (2014): Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing 15, 22-35.

Lauzon Clabo LM (2008): An ethnography of pain assessment and the role of social context on two postoperative units. Journal of Advanced Nursing 61, 531-539.

Lee GT, Yamada J, O B, K.,, Shorkey A & Stevens B (2014): Pediatric Clinical Practice Guidelines for Acute Procedural Pain: A Systematic Review. Pediatrics Online early.

Polanyi M (1966) The Tacit Dimension, 3rd edition edn. Routledge & Kegan Paul, London.

Shrestha-Ranjit JM & Manias E (2010): Pain assessment and management practices in children following surgery of the lower limb. Journal of Clinical Nursing 19, 118-128.

Stevens B, Riahi S, Cardoso R, Ballantyne M, Yamada J, Beyene J, Breau L, Carnfield C, Finley GA, Franck L, Gibbins S, Howlett A, McGrath PJ, McKeever P, O’Brien K & Ohlsson A (2011): The influence of context on pain practices in NICU: Perceptions of health care professionals. Qualitative Health Research 21, 757-770.

Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, Stinson J, Le May S & Pain. atCTiCs (2012): Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain 13, 857-865.

Stevens BJ, Yamada J, Estabrooks CA, Stinson J, Campbell F, Scott SD, Cummings EA & CIHR Team in Children’s Pain (2014): Pain in hospitalized childre: Effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes. Pain 155, 60-68.

Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp. M., Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J & Shah V (2010): Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. Canadian Medical Association Journal 182, E843-855.

Thornton T (2006): Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement. Philosophy, Ethics, and Humanities in Medicine 17, 1.

Twycross A (2007): Children’s nurses’ post-operative pain management practices: An observational study. International Journal of Nursing Studies 44, 869-881.

Twycross A, Finley GA & Latimer M (2013): Pediatric Nurses’ Postoperative Pain Management Practices: An Observational Study. Journal for Specialists in Pediatric Nursing 18, 189-201.

Voepel-Lewis T, Piscotty RJ, Annis A & Kalisch B (2012): Empirical Review Supporting the Application of the “Pain Assessment as a Social Transaction” Model in Pediatrics. Journal of Pain and Symptom Management 44, 446-457.

Patient-centred Renal Care – A Multidisciplinary Approach to Holistic Health

5 Oct, 14 | by hnoble

The 43rd European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) International Conference was held in Riga, Latvia in September 2014 (see This annual event brings together members of the renal healthcare team who strive to improve the care offered to people with renal disease and their carers. The conference is a place to share experiences and knowledge and is an event where rich learning occurs and collaborations are made. The EDTNA/ERCA is a multi-disciplinary organisation for those working in renal care and through the scientific programme of their annual conference offer a significant and valuable contribution to the care given to those referred to renal services.

In response to a call for abstracts to address the theme of the 2014 conference: `Patient-centred Renal Care – A Multidisciplinary Approach to Holistic Health` a significant 188 abstracts were accepted, including 116 poster presentations and 62 oral presentations. The conference agenda included 22 guest speakers invited by EDTNA/ERCA from 10 different countries worldwide. Other activities included Workshops, Masterclasses and Lunchtimes sessions. Service users participated in the conference and this year Ugnė Šakūnienė spoke on ‘The experience of patients with kidney disease in Lithuania’. Brian Gracey, Linda Gracey and Fiona Loud along with Dr Nicola Thomas ran a Masterclass titled ‘How patient involvement can improve quality of care’.

Workshops focused on topics including acute kidney injury, transplantation, dementia in kidney disease and enhancing a team’s performance through effective leadership practice. The programme also included Masterclasses concerned with user Involvement and shared decision making; the patient experience in relation to psychological care and cultural diversity; vascular access and the heart and hemodynamic and clinical relationships. Lunchtime sessions included: The Dialysis Outcomes and Practice Patterns Study (DOPPS) Programme, (see, Complex Case Management, Renal Education Accreditation and a National Presidents’ workshop. The conference was hugely successful and well evaluated but wouldn‘t be possible without Association volunteers, Industry partners and a skilled Secretariat. Together these partners ensured the whole event ran smoothly.

The 44th EDTNA/ERCA International Conference will take place in Dresden, Germany 26th – 29th September 2015. Quality and safety in renal care is the focus of this Conference where important exchanges of information and experience will again take place utilising the expertise of health care professionals, service leaders, academics, researchers, people with renal disease and industry partners who come together to share innovations and knowledge. Dresden is a beautiful place which has developed out of its history, tradition, art, architecture and culture . Hopefully you may want to avail yourselves of the opportunity to take in the unique atmosphere of this city whilst contributing to a forum which continually strives to improve care for those with renal disease and their carers.

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

28 Sep, 14 | by Calvin Moorley, Associate Editor

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

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

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

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

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

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

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

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

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

Participating in the EBN Twitter Journal Chat

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

  • You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ on Twitter
  • Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).

NB not including #ebnjc means people following the chat won’t be able to see your contribution

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


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

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

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

DOH/Hunt (2013) the forgotten million available at

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

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

MIND (2014) Loneliness available at

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

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

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

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


Patients need help to navigate the maze of healthcare

22 Sep, 14 | by ashorten

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

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

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

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

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

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

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

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

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

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

Allison Shorten RN RM PhD

Yale School of Nursing


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

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

14 Sep, 14 | by Calvin Moorley, Associate Editor

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

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

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

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

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

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

Participating in the EBN Twitter Journal Chat

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

  • You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ on Twitter
  • Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).

NB not including #ebnjc means people following the chat won’t be able to see your contribution


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

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

7 Sep, 14 | by rheale

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

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

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

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

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

Nurses and Interprofessional Teamwork. Where do we stand? Roberta Heale, Associate Editor, EBN @robertaheale Join Twitter Chat Wed, Sept 3, 8-9pm UK time #ebnjc

30 Aug, 14 | by rheale

The past decade has seen a push toward the evaluation of teamwork in healthcare, particularly interprofessional teamwork. The World Health Organization indicates that ‘interprofessional collaboration in education and practice…will play an important role in mitigating the global health workforce crisis” (2010, p. 7). In addition, Effective teamwork promotes a work environment that has a positive impact on both staff and patients. However, simply working together doesn’t necessarily mean that there will be effective teamwork (Kalisch & Lee, 2009).

There is a wealth of research data related to interprofessional teamwork. There is recognition of interprofessional teamwork in acute care and a primary healthcare reform across the globe that includes the development of interprofessional teams. So…what does interprofessional teamwork mean to nurses?

Nurses have traditionally worked within teams. Hospital units are characterized by teams of nursing staff who are often the ‘permanent’ staff on a unit. Other health care providers including physicians, social workers, respiratory care etc. filter in and out of the unit and work in collaboration with the nursing staff to ensure optimal patient care. Research has found that positive teamwork was associated with greater staff retention and less job stress and burnout (Rafferty et al., 2001). However, there are many barriers to positive interprofessional teamwork. Collaboration among team members is one of the ongoing issues of teamwork. For example, a poor physician/nurse relationship was the number one reason for intention to leave the nursing profession in a research study of nurses in Europe (Heinen et al., 2013).

Barriers and facilitators to interprofessional teamwork are understood, however, the impact of these on team functioning isn’t well known. I, along with colleagues, developed the Interprofessional Team Functioning Survey. It captures a team members’ perception on how well a team is functioning. Items reflect the typical barriers to teamwork including communication, education about teamwork, an understanding of other team member’s roles and organizational policies to facilitate teamwork. Also included is a question about the member’s perception of hierarchy among team members. A study of primary health care nurse practitioners in Ontario, Canada demonstrated well functioning interprofessional teams, however, there is a need for better organizational support and formal education about interprofessional teams to facilitate better teamwork.

This is a brief snapshot into the perceptions of a small group of specialized nurses.  Given the prevalence of inter professional teamwork, it is helpful to explore this phenomenon among all nurses.

EBN’s Twitter Chat on Wednesday, September 3 from 8-9 pm UK time will focus on nurses’ experience with interprofessional teamwork.

Points to consider for the chat:

1. What has your experience been with interprofessional teams?

2. Do interprofessional teams help, or hinder nursing care and patient health outcomes?

3. What work needs to be done to improve interprofessional team functioning?

Participating in the EBN Twitter Journal Chat

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

• You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter

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


Heale, R., Dickieson, P., Wenghofer, E., & Carter, L. (2013). Nurse practitioners’ perceptions of interprofessional team functioning with implications for nurse managers. Journal of Nursing Management. DOI: 10.1111/jonm.12054

Heinen, M. M., van Achterberg, T., Schwendimann, R., Zander, B., Matthews, A., Kózka, M., et al. (2013). Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries. International Journal of Nursing Studies, 50(2), 174–184. doi:10.1016/j.ijnurstu.2012.09.019

Kalisch, B.J. & Lee, H. (2009). Nursing teamwork, staff characteristics, work schedules, and staffing. Health Care Management Review, 34(4), 323-333.

Rafferty, A.M., Ball, J., & Aiken, L.H. (2001). Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Quality in Health Care, 10, ii32-ii37. World Health Organization (WHO) (2010) Framework for Action on Interprofessional Education and Collaborative Practice Available at:

The Blue Gym – Oceans and Human Health by Dr Fiona McGowan Senior Lecturer School of Health, Sport and Bioscience University of East London

23 Aug, 14 | by Calvin Moorley, Associate Editor

Recently I was invited to join the editorial board of the Journal of the Marine Biological Association. With a background in health and social care, a PhD in medical sociology and my current role as a Senior Lecturer in Public Health and Health Promotion, I would seem to be rather an ‘atypical’ candidate for this role. My knowledge of biscuits is quite extensive but still limited to those, which are edible, and more usually prefixed with the word ‘chocolate’ rather than ‘sea’!!

However, this opportunity to contribute to a markedly different subject area, indicates something of a sea change (!!) Increasingly, as we learn (and experience) more about climate change, ocean acidification, pollution, the links between human health and the marine environment become ever more apparent. Though it is not all negative. For example, the concept of the ‘blue gym’ is a new area of research that explores how health and wellbeing are correlated to living near the coast and reveals the benefits of proximity to the sea on both physical and mental health.

The importance of ‘green space’ in improving mental health by alleviating stress and depression, enhancing and promoting physical activity is now well established. In comparison the ‘natural ‘ environment relating to water – the coasts and seas – is only just emerging as an influential determinant of population and individual health. Yet, this relationship is becoming increasingly important in light of rapidly growing coastal populations and climate change. Significant public health benefits can be bought about through a better understanding of the highly complex marine environment and human health interactions click on link below.

Oceans and humans

This illustrates some of the key areas where the risks and benefits for human health and wellbeing are linked to the marine environment.


These developments signal the need for greater interdisciplinary projects, partnerships and collaborations. My associate editorship is one small indicator of this. I am now involved in the planning of two special issues of the JMBA which will have a much broader remit, with contributions from those working in public health and health promotion, biological and environmental sciences, behavioural and social sciences – reflecting that though the focus of marine biology has traditionally reflected a reductionist ‘hard science’ approach, there is now a real need to be more inclusive, collaborating with academics, researchers, practitioners and professionals with wider areas of expertise relating to human health and wellbeing.


A further development is the Oceans and Human Health integrated research project – an interdisciplinary project which brings experts together not only from the field of marine science but also those representing environmental and social science, medicine and public health. Last month, the European Centre for Environment and Human Health (ECEHH) and the European Marine Board jointly organised the first OHH workshop where a number of key professionals, researchers and academics gathered to identify and discuss the risks and benefits from interactions with the coastal and marine environment. Most symbolic is that this event demonstrated the necessity of knowledge exchange, information sharing and wider community engagement. One of the key aims of OHH is to build an effective collaborative body of researchers and professionals working together to realise the ways in which human health and the blue environment impact each other– negatively and positively, indirectly and directly. For both, there are consequences, both damaging and beneficial, some more immediate than others – BUT only by gaining greater understanding and adding ‘weight’ through projects such as OHH can any meaningful action result.


As mentioned earlier, the intention of the forthcoming JMBA issues will be to promote, facilitate and encourage knowledge exchange between a wide range of disciplines. The common objective for ALL is to gain a better appreciation and greater understanding of the interdependency of human health and the oceans, seas and coasts.


For more information visit

( See ‘ A message from Bedruthan’ in the list of documents)

Dr Fiona McGowan

Senior Lecturer Public Health/ Health Promotion





Analysis and discussion of developments in Evidence-Based Nursing

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