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Primary Health Care

Beyond the Sleeping Pill: Cognitive Behavioral Therapy for Insomnia

11 Jun, 17 | by rheale

Contributed by Roberta Heale, Associate Editor EBN, @robertaheale, @EBNursingBMJ

There’s not a more frustrating than tossing and turning all night.  However, between 30-50% of adults identify ongoing sleep disturbances.  While restless sleep once in a while is a nuisance, insomnia is a different story. It can be a significant problem particularly with older adults who are at higher risk of depression, falls, stroke, decline in cognitive and overall functioning.  The risks are exacerbated when mixed with sleeping pills which, themselves, increase the risk of falls, fractures and mortality. 1

So what is there to offer a patient other than medication?  Turns out, a lot.  One treatment is showing great promise, Cognitive Behavioural Therapy-Insomnia, or CBT-I.  Using the same exploration of the interactions between thoughts, emotions and behaviours, the focus is on sleep.  Sleep patterns, sleep hygiene, anxieties and thoughts that run through a patient’s mind at night are addressed.  CBT-I requires a commitment from the patient to make changes to their routines and practice the techniques that are offered, however, the outcomes can be very good.

One study, reviewed in a commentary in the EBN journal, identifies the usefulness of CBT-I.  Check out: Cognitive–behavioural therapy for insomnia is effective, safe and highly deployable  Encouragingly, although training is required to deliver CBT-I, but one does not need to be a healthcare professional to provide CBT-I therapy, which adds to the potential of this treatment.

Sleep permeates every part of our lives.  With so many adults struggling with insomnia, CBT-I is an encouraging, positive, non-pharmacological option.

1. Alessi  C, Martin  JL, Fiorentino  L, et al. Cognitive behavioral therapy for insomnia in older veterans using nonclinician sleep coaches: randomized controlled trial. J Am Geriatr Soc 2016;64:1830–8.


Cardiovascular health is a global priority

14 Jul, 15 | by Gary Mitchell, Associate Editor


Dean Davidson

Dean Patricia Davidson @nursingdean from  John Hopkins University’s School of Nursing @JHUNursing will be leading this week’s EBN Twitter Chat (#ebnjc) on Wednesday 15th July between 8-9pm UK time (3pm-4pm EDT) focusing on cardiovascular health as a global priority.

Participating in the Twitter Chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account contributing is straightforward:

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

Cardiovascular Health

Epidemiological transitions have signalled the need to not just focus on infectious diseases but also non-communicable diseases. This is a new paradigm in global health, which has traditionally been geared towards the management of infectious diseases. It has also expanded the roles of nurses and cast the spotlight on their important impact on health care from prevention to palliation.

Non-communicable diseases (NCDs) refer to health conditions or diseases that are non-infectious and non-transmissible. Of great significance to nurses is that many of these conditions can be prevented.

According to the Word Heath Organization, NCDs kill 38 million people each year, with 28 million of these deaths occurring in low and middle-income countries. Cardiovascular diseases account for most deaths from NCDS, or 17.5 million people annually, followed by cancers (8.2 million), respiratory diseases (4 million), and diabetes (1.5 million).

Many of these conditions are chronic, complex and progressive, placing considerable burden on the individual, families, communities and society. As indicated above, cardiovascular disease is the NCD responsible for the most deaths worldwide, and much of this burden is attributable to heart attacks and strokes.

Yusuf and colleagues in the global INTERHEART study documented that nine easily measured risk factors (smoking, lipids, hypertension, diabetes, obesity, diet, physical activity, alcohol consumption, and psychosocial factors) account for over 90% of the risk of acute myocardial infarction. This pattern of risk factors was the same across genders, racial and ethnic groups as well as geographic regions.   Although addressing these factors is overtly simple and low cost, many of us working in the field acknowledge that behaviour change is complex and moderated by physical, social, psychological and economic factors.  We also recognize we need positive policy environments to ensure health environments.

Knowledge is a necessary but insufficient condition for behaviour change but we have to engage society, individuals and providers more broadly to really create a context for a healthy environment.

Public health strategies, such as tobacco control, and boosting health infrastructure must form part of a multifaceted approach to this problem, in addition to an on-going focus on primary care.

Nurses play a critical role in the management of cardiovascular diseases across the health care continuum from prevention to diagnosis and death.  This requires a complex suite of knowledge, skills and values to advocate for the well-being of patients.  The importance of leadership is crucial for improving cardiovascular outcomes.  A range of competencies and skills is required for nursing to provide effective and efficient care. In addition to expert knowledge in cardiovascular care, nurses need to implement and evaluate evidence-based practice within culturally appropriate frameworks as well as advocating for patients and their families. .

Although cardiovascular diseases are preventable, they remain the most common cause of death in the world.

Most important is that although there have been some improvements in developed countries, many low-income and middle-income countries are experiencing a rapid increase in these conditions with limited infrastructure to both prevent and manage these conditions.

This emphasizes the need for crucial conversations to address cardiovascular health from the perspective of the health care system, individuals and health care providers.  Recognizing we live in a global world and our lives are intimately connected is a critical factor in ensuring cardiovascular health is a global priority. We look forward to your views and opinions in our twitter chat.



Anand, S. S., Islam, S., Rosengren, A., Franzosi, M. G., Steyn, K., Yusufali, A. H., … & Yusuf, S. (2008). Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. European Heart Journal, 29(7), 932-940.

Davidson, P. M., Meleis, A. I., McGrath, S. J., DiGiacomo, M., Dharmendra, T., Puzantian, H. V., … & Riegel, B. (2012). Improving women’s cardiovascular health: A position statement from the International Council on Women’s Health Issues. Health Care for Women International, 33(10), 943-955.

Lanuza, D. M., Davidson, P. M., Dunbar, S. B., Hughes, S., & Geest, S. D. (2011). Preparing nurses for leadership roles in cardiovascular disease prevention. European Journal of Cardiovascular Nursing, 10(2 suppl), S51-S57.

Diabetes Week: Communication and Awareness

15 Jun, 15 | by hnoble

A Twitter Chat with Dr. Neil Black (@RneilABlack) – Wednesday 17th June @8-9pm.

Dr Black, from the Western Health and Social Care Trust in Northern Ireland, will lead the Twitter chat this week focusing on diabetes communication and awareness. Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account contributing is straightforward:

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

Written by Dr Neil Black:

I feel really privileged to have been asked to write this blog during Diabetes week which is about spreading awareness regarding diabetes.  I’d like to use this to share two things that I’ve learnt from people living with diabetes themselves. Whilst I’ve been involved in diabetes care for almost 14 years, this was turned around completely about 3 years ago. What happened?  Well, I really started to listen to people living with the condition.

What do people with diabetes want those who are newly diagnosed to know? How do we talk to people who have been newly diagnosed with diabetes? How can we communicate about complications of diabetes? Last week’s @OurDiabetes Tweetchat was revealing and added much to my awareness. A strong running theme was that people wanted to be told that they weren’t alone and how to connect with others with diabetes. While this was a group of people with type 1 diabetes, the points ring true for those with other forms of diabetes. A knowledge even that someone exists who understands what you are going through could make a big difference. Actually being able to get in contact with others with your type of diabetes could be a life-saver. People wanted to know that while having a new diagnosis of diabetes takes up a lot of time in your life, that you had to make room for it but not let it set the agenda for the rest of your life: diabetes should fit around your life, not life around diabetes. They wanted to know how to manage it themselves and be supported to do so. Talking about a new diagnosis of type 2 diabetes is different, because it has likely been there undiagnosed for years. Sometimes this means that we discover it only when that person presents with a complication of diabetes. I tell people that it is good news they have been diagnosed as now we know that they need protection and how to give it, where prior to diagnosis they had the condition but were at greater risk of the complications. Talking about complications is a sensitive subject in itself. People living with diabetes tell me that they want tact and for us to concentrate on how to reduce risk – they know they could develop complications already and what matters to them is how they can protect themselves.

I’d like to come back to types of diabetes as, after all, it is Diabetes Week. I mentioned earlier that those with established type 1 diabetes want people with newly diagnosed diabetes to know that they are not alone and how to contact others with their condition. Well, 90% of people who have diabetes have type 2 and only 10% have type 1. It’s a common misconception that people with Type 2 diabetes are to blame for their condition. It is true that a sedentary lifestyle, excessive unbalanced dietary intake and being overweight increase the risks of Type 2 diabetes. It is also true that making lifestyle changes and losing weight reduce the risk of developing Type 2 diabetes or delay its onset.  However, many people with type 2 diabetes have a family history of the condition and if you have one sibling or parent with Type 2 diabetes, your lifelong chances of developing it are about 50% compared to about 5% for the general population. So, people with Type 2 diabetes have inherited strong genetic factors that led to their condition. It seems less reasonable to blame people with Type 2 for their diabetes. Interestingly, people with other forms of diabetes may also lay blame on those with Type 2 diabetes for their condition. I hope that seems less reasonable now.

People with Type 1 diabetes can present as a medical emergency in diabetic ketoacidosis but, even if they do not, require insulin injections from the start. A temporary recovery of pancreatic function lasting a few to several months (the ‘Honeymoon Period’) can occur with the person needing very low insulin doses or no insulin at all, but eventually the pancreas cannot make enough insulin and insulin injections or infusion then needs to be lifelong. It is better to think of insulin as a vital life-sustaining hormone for people with Type 1 diabetes, rather than a ‘treatment’ as consistent lack of insulin administration inevitable leads to becoming medically unwell and death if untreated. We should respect people who live with Type 1 diabetes and respect the insulin they take.

Less common forms exist, for example Latent Autoimmune Diabetes in Adults (LADA) appears to be type 2 diabetes at diagnosis but, sometime later, the person develops a dependence on insulin as their pancreas has been attacked just as in Type 1 diabetes. We know that 10-15% of people with apparent Type 2 diabetes actually have LADA which is really part of the spectrum of Type 1 diabetes and together form a spectrum of ‘autoimmune diabetes’. Secondly, about 1-2% of people in the UK with apparent Type 1 diabetes actually have a genetic cause of diabetes called Maturity Onset Diabetes in the Young (MODY). This is important as we think that we are only aware of 20% of cases at best. Making a diagnosis could mean that we can stop insulin therapy which otherwise would be lifelong. Thirdly, gestational diabetes starts in pregnancy and poses risks for the mother and child before, during and after delivery. While it usually resolves immediately after delivery, it usually recurs in later pregnancies and indicates that the woman’s lifetime risk of Type 2 diabetes has risen from 4-5% to 40-50%.

Diabetes week gives an important chance to get these points across. Diabetes is not about blame, but about respect for the person who lives with it. People who live with diabetes need support from each other and healthcare professionals. We can only deliver good care if we follow these principles.

Questions for consideration during our chat:

Q1: How do you think we can best support people as they are informed of newly diagnosed diabetes?

Q2: Do self-help groups for people with diabetes work?

Q3: What are you doing during diabetes week at your place of work?

Q4: Have experienced barriers/support to good provision of education for people with diabetes?

Using health promotion theory with patients

16 Feb, 15 | by josmith

Nova Corcoran, University of South Wales will be leading this week’s ENB twitter chat on Wednesday the 18th of February between 8-9pm focusing on ‘5 Quick ways to use health promotion theory with patients’. Participating in the twitter chat requires a Twitter account; if you do not already have one you can create an account at Once you have an account contributing is straightforward – follow the discussion by searching links to #ebnjc @EBNursingBMJ, or better still, create a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

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

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

Promote the benefits of change –not just the health benefits

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

Promote patient behavioural control

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

Identify barriers to change

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

Recognize the wider environment

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

Tailor information to the patient

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

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

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


Change4life (2014) Smart Swaps available at

NHS (2014) Smokefree calculate the cost available at

Filter (2014) Distractor app available at

A useful online resource for nursing theories is available at


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

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

Acupuncture and My Search for Chronic Pain Treatments

8 Feb, 15 | by rheale

by @RobertaHeale, Associate Editor, EBN

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

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

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

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

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

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

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

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

Reaching unreachable Groups by Nova Corcoran, Senior Lecturer, University of South Wales. Twitter @NovaCorks

3 Aug, 14 | by Calvin Moorley, Associate Editor



Firstly, the title of this blog is misleading. No group is unreachable. A better term is ‘hard to reach’ as this implies the possibility that they can be reached. Why are they hard to reach? Here are two suggestions. Firstly, the very nature of society and our norms, values and practices exclude certain people so they become removed from participation in society. For example the common belief that poor people are poor due to their own personal failing; notably the belief that “they” are lazy, addicted to drink and drugs and don’t manage their money properly (See the OXFAM 2013 Truth and Lies debate on Poverty for more on this) perpetuates how individuals respond to those who are poor and how society responds to poverty elimination. Secondly, if we are not reaching certain groups we are probably using the wrong approach and are unable to engage these groups in a meaningful way. Both of these arguments are not a criticism of individual healthcare workers but they are the result of the way society responds to socially excluded and minority groups. In turn this influences the ways we work and respond to the diversity of need in these groups at all levels of practice, from the healthcare university curriculum to the allocation of healthcare resources at national level.

Groups that are perceived as unreachable are those that are hard to engage in a meaningful way. In healthcare this may be people who disengage with treatment, are lost to follow-up or who do not follow preventive care or advice. It may also be people who find it difficult to access healthcare services, do not know about services available, or do not perceive a need to engage with or access healthcare. They are often groups who are a minority group in relation to their culture, ethnicity, language or social circumstances. For example, in the area of TB hard to reach groups include homeless, substance misusers, prisoners, vulnerable and migrants. NICE (2012) note that these groups are hard to reach as they are difficult to engage in treatment, have low levels of compliance and high levels of non-completion of drug regimens.

Unreachable groups may also experience multiple barriers in accessing health care and following healthcare advice. Structural barriers include transport, cost, time, language or culture. There may be individual knowledge deficits, conflicting beliefs, misperceptions of healthcare, negative experiences of healthcare or lack of confidence and support in changing behaviour. This is not a problem specific to the UK and many of the debates around unreachable groups are the same across the globe. For example a study on the ‘unreachable poor’ in Bangladesh note that lack of awareness of healthcare services, inconsistency in services, not living in close proximity to services and perceptions that services do not meet needs were cited as reasons for non-access (Ahmed et al. 2006). These reasons are no different to what people might say about non-access of healthcare in the UK.

As practitioners we need to reflect on our practice, and consider how to include those who are ‘unreachable’ into the scope of our healthcare discipline. With this idea in mind what follows is a list of nine ideas to help turn unreachable into reachable.

  1. You are the right person

Who you are should not stop you from reaching out to groups, you just need to go about it in the right way so do not let it be a barrier just because you might be demographically or socially different. Look around you for ideas; for example there are also some great internet handbooks available such as the FPA (2007) handbook for people working with refugees and asylum seekers in the area of sexual health.

  1. Positive connections

To engage people you need to find what it is that motivates them to connect to what you are saying. Asking encouraging, open ended questions can facilitate discussion and remember the context in which people live as this can help make connections with people. Go to the places where people live, consider what they are interested in, what they like and what they do. Look at what resources are available in the area as this will give you a much better understanding of the situations facing people and will help you to make connections.

  1. Review what you are offering

The marketing term AIDA (Attention, Interest, Desire, Action) may be useful to frame what you would like people to do and how you encourage them to do this. You need to engage their attention (A), keep their interest (I) Explain what it is they need to achieve and how this is going to help them in a meaningful way (D) Be very clear about the action you want people to take (A). The more you understand the circumstances in which a person lives, the more you can tailor this to their individual needs.

  1. Use your target group

The more you involve your target group in what you want to do the better. Whether this is how a new service should run, what a leaflet should look like, when a clinic should open or how to reach people; involvement of the target group is essential. Netto et al. (2013) and Corcoran (2011) provide guidance on cultural tailoring to specific ethnic groups as a starting point.

  1. Use diverse settings

Social spaces may be better locations to provide services than healthcare facilities. The main bonus being that they are situated in the communities they serve; hence the rationale behind mobile breast-screening units in supermarket car parks or sexual health clinics in shopping centres. Cafes, hairdressers, barbers, clubs or places of worship all have elements that are inclusive and reach groups who may not traditionally access healthcare facilities. They have partnership potential, a community focus, they may offer supportive relationships or have useful facilities i.e. space (Moorley & Corcoran 2014). A good example is the Black Barber shop programme (Releford et al. 2010) in the US which offers blood pressure checks and lifestyle advice in barbershops.

  1. Use Gatekeepers

Those who are living in a local community and who have a degree of respect within that community are in a good position to advocate and mediate for change. A good example in the context of healthcare are ‘promotores de salud’ or community health workers in the US who work with Hispanic groups who traditionally lack access to healthcare; they live in the communities they work and share many of the characteristics of their target groups (CDC 2004). Other gate-keepers include key people who may be a focus for a group gathering, for example church leaders, pro-active service users, influential peers or those running community groups. They may also have access to groups who are less visible, i.e. housebound, or specific ethnic groups.

  1. Judgments and stereotypes

It can be easy to stereotype people into categories based on their culture, ethnicity or appearance. Don’t do it! Never make an immediate assumption about someone based on what you see or your previous experiences. Everyone is different and will therefore respond to you differently so try and keep an open mind and be flexible in your approach.

  1. Know you area

Back up what you say by what is happening around you. You cannot tell a patient to take up swimming if there isn’t a local swimming pool nearby. The patients’ that you see live in the local area so have an idea of what exists to support them in their preventive and curative behaviours. What assets do they have as individuals? Having a dog (can help increase exercise), a friend in a similar situation (peer support) is just as important as community support groups, weight loss classes, safe places to exercise or social groups.

  1. Learn from others

Take a moment to think about this; who do you listen to and why do you listen to them? AND who do you talk to and why do you talk to them? Communication is a two way process. What others do that encourages you to listen and talk should be emulated in your own practice. In addition those we label as ‘unreachable’ have much to teach us, so if we talk ‘with’ them (not ‘to’ them) and listen to their voices, this will help us to develop our understanding and skills in working with hard to reach groups.

These ideas are really only starting points and the reason that I chose nine points instead of ten. There is much that could be added and I am hoping that our journal club discussion will be able to come up with the tenth point. So if you have any ideas or examples of working with hard to reach groups join the debate on this topic in the: Evidence Based Nursing twitter journal club on Wednesday 06th 2014: 20.00-21.00 #ebnjc and add any more ideas or experiences to the list.

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.



Corcoran N (2011) Working on Health Communication Sage, London

CDC (2004) Community Health Workers/Promotores de Salud: Critical Connections in

FPA (2007) Sexual health, asylum seekers and refugees; A handbook for people working with refugees and asylum seekers in England available at…/sexual-health-asylum-seekers-and-refugees.pdf


Moorley C & Corcoran N (2014) Defining, profiling and locating older people: An inner city Afri-Caribbean experience. Editorial. Journal of Clinical Nursing 23 2083-2085 available at

Netto G, Bhopal, R, Lederle N, Khatoon J & Jackson A (2013) How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 25 (2) 248-57. Abstract available at

NICE (2012) Identifying and managing tuberculosis among hard to reach groups PH37 available at

Oxfam (2013) Trust and lies about poverty available at

Releford BJ, Frencher SK, Yancey AK, Norris K (2010) Cardiovascular disease control through barbershops: Design of a nationwide outreach program. J Natl Med Assoc. Apr 2010; 102(4): 336–345. Abstract available at

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).
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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].



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