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Diaries for critical care patients

8 Jan, 17 | by josmith

Angela Teece (  Trainee Lecturer in Adult Nursing, University of LeedsAngela

Critical care is primarily concerned with curative interventions and the use of technology, and nursing and medical care to maintain life. Patients are frequently sedated for long periods of time that can causes memory loss and unusual perceptual experiences which can make it difficult for survivors to piece together the time they spent in critical care (Samuelson and Corrigan, 2009). The presence of delirium, which occurs in 35-80% of critical care patients (Collinsworth et al., 2016) further complicates recovery. The frequently nightmare dreams are more vivid than fragmented true recollections and can prevent patients developing an illness narrative and understanding the traumatic episode (Jones et al., 2001).

Critical care nurses have a duty to provide rehabilitative care (NICE, 2009). So how can nurses make a positive impact on their patients’ psychological recovery? Patient diaries are increasing in popularity in the UK after originating in Scandinavia. The subject of a recent Cochrane review (Ullman et al., 2015), the evidence base for diaries and guidance for those completing them remains scanty. However, the premise is simple and low cost. Nurses complete entries throughout the patient’s critical care admission, describing events and the environment in layman’s terms. The diary is given to the patient after discharge, often at a follow-up clinic where further support can be accessed. The aim is, simply, to fill in memory gaps and encourage discussion.

What do patients think of their diaries?

‘It was hard… to realise that it was actually about me, and that I could have died’ (Storli and Lind, 2009)diary

‘It is frustrating not to have all the information about one’s critical illness, and much energy is expended trying to piece information together’ (Engström et al., 2009)

‘It’s fantastic that you’ve gone to the trouble of doing this for me!’ (Storli and Lind, 2009)

Have you written in a patient diary?


COLLINSWORTH, A. W., PRIEST, E. L., CAMPBELL, C. R., VASILEVSKIS, E. E. & MASICA, A. L. 2016. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med, 31, 127-41.

ENGSTRÖM, A., GRIP, K. & HAMRÉN, M. 2009. Experiences of intensive care unit diaries: ‘touching a tender wound’. Nursing in Critical Care, 14, 61-67.

JONES, C., GRIFFITHS, R. D., HUMPHRIS, G. & SKIRROW, P. M. 2001. Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Critical Care Medicine, 29, 573-580 8p.

NICE 2009. Rehabilitation after critical illness. In: HEALTH, D. O. (ed.). London: Department of Health.

SAMUELSON, K. A. M. & CORRIGAN, I. 2009. A nurse-led intensive care after-care programme – development, experiences and preliminary evaluation. Nursing in Critical Care, 14, 254-263.

STORLI, S. L. & LIND, R. 2009. The meaning of follow-up in intensive care: patients’ perspective. Scandinavian Journal of Caring Sciences, 23, 45-56.

ULLMAN, A. J., AITKEN, L. M., RATTRAY, J., KENARDY, J., LE BROCQUE, R., MACGILLIVRAY, S. & HULL, A. M. 2015. Intensive care diaries to promote recovery for patients and families after critical illness: A Cochrane Systematic Review. International Journal of Nursing Studies, 52, 1243-1253.

‘Loosing the child’s voice’ and ‘the captive mother’- an inevitable legacy of family-centred care?

2 Jan, 17 | by josmith

This week’s EBN Twitter Chat on Wednesday 4th January between 8-9 pm (UK time) in conjunction with @WeCYPnurses will focus on child & family cunknown-3unknownentred care.

The chat wll be lead by Professor Linda Shields (@lshields50), Charles Stuart University, Australia; Professor Philip Darbyshire (@PDarbyshire), global healthcare consultant; Sarah Neil (@SarahNeill7) University of Northampton, UK; and Dr Joanna Smith
IMG_0206(@josmith175) theUniversity of Leeds, UK.unknown-2

Participating in the Twitter chat requires a Twitter account; if you do not have one you can create an account at Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ adding #ebnjc (the EBN Twitter chat hash tag) to your tweet, this allows everyone taking part to view your tweets.

Professor Linda Shield’s recent publication (Shields Linda (2016) (Family-centred care: the ‘captive mother’ revisited, Journal of the Royal Society of Medicine; 109; 4: 137-140 ( revisited Roy Meadow’s acclaimed article ‘The captive mother’ (Arch Dis Child 1969; 44: 362–367), where he eloquently described the “captive mother” who was forced to accompany her school aged child to hospital when in reality they would spend little time together. Family-centered care has evolved since that time is espoused as the dominant philosophy underpinning care in children’s hospitals around the world. We postulate that that although family-centered care is embedded within most health services policies for children, it is largely untested. Evidence suggests problems with the implementation of family-centred care, with some parents feeling resentful that they have to undertake some of their child’s care. We postulate that Meadow may have been right & that expecting a mother (or other carer) should stay with a hospitalized school aged child, we are not operating within the ethos of family-centred care, potentially compromising the care given.



The article is already generating debate: with suggestions that concepts such as the ‘captive patient’ and ‘family-centred care’ are no longer relevant in today’s world of personalised care and offering care delivery choices ( The child must be treated as an individual, with rights & choices having a voice in their cared.

This Twitter chat provides a chance for nurses to discuss their experiences of working with children & families, & identify some of the common challenges of embedding child & family-centred care into practice such as:

  1. Is family-centred care relevant within contemporary healthcare contexts?
  2. Does family-centred care marginalise the voice of the child?
  3. Given that evidence of its effectiveness is not available, is it ethical to continue pushing for family-centred care?

2016 @ EBN

25 Dec, 16 | by josmith

The holiday season is well underway & here at Evidence Based Nursing (EBN) we recognise that may nurses will be working to provide care & support to people with health issues over the festive period, but hope that for many you are all having a well deserved break. This year, as in previous years, the challenges facing nursing & healthcare have often dominated the news. The weekly EBN blog has enabled the editorial team & our guest bloggers to raise a range of issue relevant to contemporary nursing practice, often responding quickly to current policy and health issues.

Below are some of the highlights & initiatives that occurred at ENB in 2017:

  • In March, we had the pleasure of Dr Kate Granger (doctor, terminally ill cancer patient, founder of t #hellomynameis) hosting a twitter chat focusing on the#hellomynameis campaign. As anticipated the chat was high successful generating 2,842,612 impressions; 524 tweets; 210 participants. A summary of the chat and Storify can be found at:

Sadly, Kate passed way earlier this year.

  • Our EBN Opinion series is going from strength to strength, which summarises out Twitter chats. The latest article focuses on m
    eeting the needs of families: facilitating access to credible healthcare information:

  • October was the launch of EBN Perspectives which brings together key issues from the commentaries in one of our nursing topic themes, the first article summarised commentaries on child health issues:

screen-shot-2016-12-23-at-17-33-00screen-shot-2016-12-23-at-17-36-11With the latest focusing on advanced care planning & palliative care:

  • Our Research Made Simple series continues to be popular offering a concise summary of key issues in research methods & their practical application; the next article focuses on the ethical context of nursing research:

  • This year we presented at two important conferences; the International Academy of Nursing Editors (INANE), conference in August & the Royal College of Nursing International Centenary Conference in November both presentations focused on the ways social media activities can be used in nursing and nursing journals to promote evidence based practice.

We are looking forward to restarting our Twitter chats in January, beginning with

‘Loosing the child’s voice’ and ‘the captive mother’- an inevitable legacy of family-centred care? 4th January 2017, 8-9pm UK time

Learning technology in nurse education 18th January 2017, 8-9pm UK time

Helping Older People with End Stage Kidney Disease make Decisions about Treatment

19 Dec, 16 | by hnoble

Dr Helen Noble, Lecturer & Clare Carswell, Undergraduate mental health nursing student, Queens University Belfast


There are at least 59,000 adult patients receiving renal replacement therapy to treat end stage kidney disease (ESKD) in the United Kingdom. In addition there are over 1.8 million people being treated globally – 77% treated with chronic dialysis and 23% living with a transplant. Kidney disease is categorised into five stages depending on the estimated glomerular filtration rate and evidence of kidney damage. The most severe of these stages is stage 5 Chronic Kidney Disease where the eGFR is < 15 ml/minute/1.73m (table 1).


The number of older patients with ESKD is increasing annually as the population ages. The UK population aged over 65 is predicted to increase by 60%, from 10.3 to 16.9 million by 2035 [], and increased numbers of older patients will commence dialysis worldwide. Older patients who require dialysis report a higher burden of “geriatric syndromes”. These include frailty, falls, and cognitive impairment. There is also evidence that dialysis initiation may be associated with accelerated rates of functional and/or cognitive decline []

Renal replacement therapy includes haemodialysis, peritoneal dialysis or transplantation but choices regarding treatment are perplexing. One particularly difficult decision concerns older people with ESKD, unsuitable for transplantation, who have to decide between dialysis and conservative management. Dialysis involves coming to hospital three times a week for four hours each visit and requires attachment to a dialysis machine which filters the blood and replaces the role of the damaged kidneys. Conservative management offers a supportive and palliative approach to care, without dialysis. Patients are supported and followed up by a multidisciplinary team often in their own homes. Some people regret their decision to start dialysis and some may go on to withdraw from treatment. Others report that they didn’t fully understand the decision they were making. There is a need to ensure that patients making decisions between dialysis and conservative management are supported through this process. Decision-aids may help people who are facing these difficult health treatment decisions.  Decision-support interventions encourage people to be more actively involved in decision making, improve risk perceptions and congruence between the choice made and their personal values. They may also help improve communication between patients and staff.

There are limited decision-support interventions available to assist with complex decision-making in people who are choosing between dialysis and conservative management. The OPTIONS decision-aid has been developed in Australia and is being tested in a multisite randomized controlled trial []. A similar tool is being developed in Ottawa, Canada. In the UK, The excellent ‘Dialysis Decision Aid’ has been developed to help people make decisions about renal replacement therapy but it has less of a focus on conservative management and is aimed at all age groups [].

In the UK there is a need to develop a UK specific decision-aid for people deciding between dialysis and conservative management in order help patients with kidney disease make the best possible decision. In order to test such an aid a randomised trial similar to the one in Australia is recommended.

The importance of public health in the nursing curriculum

12 Dec, 16 | by dibarrett


Lizzie Ette – Lecturer in Nursing, University of Hull

It’s easy to imagine that public health is falling out of favour in the UK in the current era of austerity, which has ushered in cuts for local authorities, who are now predominantly responsible for the public health of their local population. With the Local Government Association (LGA) itself expressing concern and disappointment in the government’s approach to the funding of this essential remit, it would be easy to believe that improvements to public health are a fading aspiration.

However, the NHS’s own Five Year Forward Plan commits to ‘getting serious about prevention’, and cites examples of integrated models of care which are aimed at addressing health needs and promoting better health.

So what does this mean for nurses?  And what kind of nurse education do we need to deliver to ensure that future nurses are as equipped as possible to embrace and contribute to this challenging future?



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

4 Dec, 16 | by atwycross

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

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

27 Nov, 16 | by atwycross

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

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

Recognising, Assessing and Managing Deteriorating Adult Patients

20 Nov, 16 | by josmith

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

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

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

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

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


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

10 Nov, 16 | by dibarrett

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

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

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

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




The Healthcare Practitioner Role in COPD

7 Nov, 16 | by hnoble

Emma McGleenan and Dr Helen Noble, Queens University Belfast

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

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

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



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

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


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