Thursday, 17 October 2019

Voluntary stopping of eating and drinking is a rare but nevertheless relevant phenomenon in long-term care

Sabrina Stängle*, MSc, RN
Wissenschaftliche Mitarbeiterin
ZHAW Zürcher Hochschule für Angewandte Wissenschaften Institut für Pflege, Departement Gesundheit Technikumstrasse 81, Postfach CH - 8401 Winterthur Tel. +41 58 934 4144

Voluntary stopping of eating and drinking (VSED) is a way to end life prematurely. People who choose this path are able to make decisions, are able to eat and drink and are neither cognitively impaired nor suffer from mental illness. They decide to follow this path in order to end unbearable suffering that cannot be alleviated despite medical progress. Aware of the phenomenon, VSED was included as a controversially discussed option in 2018, when the guideline of the Swiss Academy of Medical Sciences "Dealing with Dying and Death" was updated. The guideline is trend-setting for health professionals. However, it was unclear what relevance VSED has in Switzerland. For this reason, the objectives of this study were to assess the incidence of VSED in long-term care and to gain insights into the attitudes of long-term care nurses about the VSED. Heads of Swiss nursing homes (535; 34%) took part in an online survey on this subject. The results could show that almost every second institution among the participants has already accompanied a VSED case. Moreover, among all persons who died in Swiss nursing homes in 2016, 1.7% are due to VSED. Participants' overall views on the VSED are very positive, whereas it is assumed that it is a phenomenon of old age. Professionals still lack sufficient knowledge about this phenomenon, which could be clarified through training.

* Forthcoming article: Stängle S, Schnepp W, Büche D, Fringer A (2019) Long-term care nurses´ attitudes and the incidence of voluntary stopping of eating and drinking: a cross-sectional study Journal of Advanced Nursing (in press)

Saturday, 5 October 2019

The colour of your skin may influence your pain relief

Roger Watson, Editor-in-Chief

The colour of your skin may influence the extent to which you obtain pain relief from a health professional. This is reported in a systematic review by Aronowitz et al (2019) from the USA titled: 'Mixed Studies Review of Factors Influencing Receipt of Pain Treatment by Injured Black Patients'.

The study aimed to: 'explore the factors that influence provider pain treatment decision making and the receipt of pain management by injured Black patients in the United States'. Twenty studies were found which met the criteria of the study and the main results were: 'that healthcare provider characteristics, racial myths about pain sensitization, and assumed criminality all impact provider treatment decision making and the receipt of pain treatment by injured Black patients'.

The authors concluded: 'Racial disparities in pain treatment are clearly unjust and can understandably sow mistrust in healthcare providers among individuals in communities harmed by these disparities, which can lead to an avoidance of care. The results of this review provide important areas for further study, including how intentionality of injury may impact provider-perceived patient trustworthiness and the receipt of pain treatment by injured patients. The assumed criminality of certain populations, particularly people of color, can negatively impact the way people are treated by law enforcement, potential employers, healthcare providers, and the general public. How the assumed criminality of certain patients by providers may impact the quality of care that these patients receive has not been thoroughly explored, but is vital to address healthcare disparities.

You can listen to this as a podcast


Aronowitz, S. V., Mcdonald, C. C., Stevens, R. C. and Richmond, T. S. (2019), Mixed Studies Review of Factors Influencing Receipt of Pain Treatment by Injured Black Patients. J Adv Nurs. doi:10.1111/jan.14215

Friday, 13 September 2019

Celebrating Women : Women and Ethical Employment

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board 

In contemporary society much is spoken about the travesty of unethical employment. In the destructive life of a mardi gras bead, David Redmon cites the hidden dangers associated with the colourful beads, mostly associated with mardi gras. Combined with the risks posed to human health, linked to poor working conditions, exposure to neurotoxic chemicals such as lead poisoning, as well as the impact on the global environment this trinket, has a lot to answer for. Many of these workers are children whose lives are controlled not by what time they need to get up for school, but by the number of beads they can make and the wages they can earn to feed their families.

Historically women and children have borne the brunt of patriarchal intentions made all the more intolerable by the cruel vagaries of Victorian England and the often-unendurable conditions in which women and children lived, worked and died. Such conditions such as those associated with the plight of the matchstick girls, the Cradley Heath Women Chain makers and the New Jersey radium girls are recorded in the annals of history as a stark reminder of the importance of ensuring ethical employment is high on the agenda of all governments.

Such accounts continue to tell the stories of the many actions undertaken by women that would see them challenge the paternalistic world in which they lived and worked and for many ultimately win. This is perhaps no more evident than the matchstick girls strike of 1888 when 141 women and girls came on strike following a resounding call to action. The narrative of those who worked in the Radium Industry a poison which significantly contributed to the early deaths of many women who worked within its walls, caused teeth to fall out, jaws to necrose and flesh to ulcerate. And to the Cradley Heath Chain makers whose miserable wages and impoverished lives led to the strike of 1910 when women downed tools as a result of the starvation wages and strict regimes imposed.

In Victorian England nursing was also considered sweated labour, but was it really necessary that ‘to help a million sick, you must kill a few nurses’? For nurses too were subject to the horrors of employment and with blood poisoning from sewer gas, TB and other infectious diseases, including cholera and typhoid, rife in the hospital setting, along with many others, nurses paid the ultimate price; they were dying as a result of caring for the sick.

Today, the World Health Organisation’s response to workplace wellbeing is clear, that the health of the worker should be protected, whilst the World Employment Confederation presents a strong business case for ethical employment.

In their quest to ensure fair work for all, the government of Wales has released a Code of Practice , which seeks to ensure good employment practices for the millions of workers at every stage of the supply chain. Although the Welsh Government has moved forward with a code of ethics, there is still much work to be done before this is enshrined in legislation

The NHS too is playing its part.  All healthcare practitioners have a role to play in ensuring ethical employment and reducing the risks associated with the environment. In 2018 Great Ormond Street Hospital launched ‘the gloves are off campaign’ the aim of which is to reduce the associated risks of dermatitis, due to overuse, improve hand hygiene compliance and improve the environmental impact as well as reduce the risk of hospital acquired infections.

Nursing continues to remain a gendered specific profession. We may no longer be killing nurses, with blood poisoning from sewer gas, TB and other infectious diseases but are we not killing their passion, spirit and willingness to nurse.

All of these scenarios have one thing in common; they are all associated with product development and service delivery. It is the responsibility of each and every organisation involved in the supply chain to ensure ethical employment practices are adhered to. We have a long way to go.

Different times, same issues

Aligning Safe Staffing with Patient Safety: Is this Two Sides of the Same Coin?

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the second of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

Research undertaken by Dr Linda Aiken and others has identified a strong link between, nursing skill mix and improved patient outcomes:

‘We find a nursing skill mix in hospitals with a higher proportion of professional nurses is associated with significantly lower mortality, higher patient ratings of their care and fewer adverse care outcomes’ (Aiken et al. 2016).

Nursing research has also identified an increased risk of patient mortality, during hospital admissions when nurse staffing levels are reduced and there is a reliance upon nursing support staff to cover the shortfall.

The Royal College of Nursing (RCN) report Nursing on the Brink makes their position clear:

‘Having the right number of registered nurses and nursing support staff with the right knowledge, skills and experience in the right place at the right time is critical to the delivery of safe and effective care for patients and clients’.

With Westminster demonstrating a lack of accountability in ensuring safe nurse staffing levels, many see this as a flagrant lack of commitment to a nursing workforce that is teetering on the edge. The RCN is calling on parliament, not only to ensure accountability for staffing becomes the domain of the Secretary of State for Health and Social Care but also that accountability for the health and care workforce is firmly enshrined in English law.

Encouragingly legislation has been passed in both Wales and Scotland, which goes some way to making safe staffing a reality, but What about England? What about Northern Ireland? Nurses who take the fight to the doorstep of Westminster, must be prepared to be in this for the long haul, for history demonstrates that what we do today, requires patience, resilience and a sense of determination to succeed. This understanding however, should not dampen the spirits of any nurse who finds themselves working in understaffed clinical areas, for every great achievement must begin by taking the very first step. In the meantime, while we campaign for safe staffing levels to be enshrined in English law, what can nurses do to reduce the significant challenge to maintaining patient safety?

Find your voice and speak up 
It is not simply the role of nurses to speak up, but all healthcare professionals. Freedom to speak up was introduced following a 2015 review into whistleblowing practices within the NHS, the aim of which was to create a culture shift in the way in which safety issues are addressed ultimately reducing the need to ‘whistle blow’.

Disappointingly the continued culture of blame in the NHS fails to consider the consequences of poor staffing levels, inadequate skill mix and continued lack of investment. With the RCN demonstrating the impact of the loss of the nursing bursary and the cumulative effect of 40,000 nursing vacancies in England alone, nurses are being increasingly challenged in their attempts to ensure the delivery of safe and effective care. And when mistakes do happen, the impact can be devastating, not only for patients, carers and families but also for those healthcare professionals involved. Creating a just culture in healthcare settings is as important as ensuring safe staffing is enshrined in legislation. Nurses should not fear the stigma of blame when things go wrong; instead they should be encouraged to speak up in order to reduce the associated impact and for valuable lessons to be learned. It is however important to note, that a just culture does not absolve nurses of their accountability to deliver safe and effective patient care, simply that a fair and honest approach is taken.

The significant shortage of nurses is now considered to be affecting patient care and threatening lives. One way in which nurses can find their voice is by contributing to the 100 voices campaign. By sharing experiences, reflections and actions, nurses can contribute not only to the educating of others but also in ensuring lessons learned are encased in policy and health care reform. 

Pursue Learning Opportunities When Jeremy Hunt the then Secretary of State for Health declared in the report Building a Knowledge enabled NHS for the Future that:

‘The world’s fifth largest organisation needs to become the world’s largest learning organisation’. 

he was absolutely right.

However, when crisis after crisis continues to plague the NHS, as evidenced in the recent Whorlton Hall abuse scandal it is a strong reminder of the polemic approach that governments take when responding to any crisis.

Improving patient safety through education and training is recognised as an essential requirement and in recent weeks the government has gone some way to improving funding for continuous professional development for nurses, but this is only skimming the surface. More commitment is needed to ensure the future of nursing is guaranteed, throughout all sectors and in all specialties. A lack of funding for pre-registration nurse education has been cited as a reason for the reduction in the number of students entering nurse training. If the government is to be congratulated for their commitment to ensuring high quality patient care, then investment in the nursing workforce is crucial.

Demonstrate Strong Leadership
Strong leadership in nursing is considered one of the most important aspects of ensuring safe and effective care. All nurses have the capacity to lead; crucially however nurses must also have the ability to reflect and act in dynamic situations, not only to ensure that patient safety is maintained but that risks are identified quickly and service delivery transformed.

Nurses have a unique role to play in encouraging other nurses to speak up when they have concerns. All nurses have both a duty of candour and a responsibility for ensuring continued patient care and this cannot be achieved by nurses who are afraid to speak up and act. Supporting individual nurses with a degree of compassion and understanding when things do go wrong can make the difference between someone returning to work or not, staying in the profession or leaving or in some severe cases even prevent nurses from taking their own life. Errors in general occur as a result of bad systems, not bad people. Whether you agree with this or not is a matter of personal belief, however what is clear is that mistakes occur as a result of a very complex chain of design, systems, inadequate training and human factors.

In today’s turbulent healthcare climate, the responsibilities placed on nurses, is overwhelming. Nurses are no longer able to guarantee the delivery of safe and effective care, perhaps we never could, but we can continue to raise awareness of the impact that poor staffing, poor levels of skill mix and a lack of appropriate education and training can have on patient care. To do this may instil a sense of hope that things can be different.

Wednesday, 11 September 2019

Promoting a safe and just culture in nursing: Aligning Human Factors with the Courage to Speak Up

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the first of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

The theme "Patient Safety: a global health priority", with the rather apt slogan “Speak up for patient safety” is a call to action for all healthcare workers across the world to help reduce the 134 million adverse events, which results in 2.6 million deaths each year globally.
Ensuring patient safety is an essential role of all healthcare organisations and arguably all health care professionals; this role, being enshrined within both the UK Nursing and Midwifery Council and General Medical Council Codes.

Human Factors
Within healthcare in recent years, the term human factors has been synonymous with patient safety. In an attempt to make sense of the causes, the facts and the myths associated with near misses, healthcare failings and individual responsibilities, the study of human factors has sought to identify problems and generate effective solutions in order to reduce the risks associated with maintaining patient safety.

In accordance with the World Health Organisation, human factors examines the correlation between humans and the processes and systems with which they interrelate, the aim of which is to improve efficiency, creativity, productivity and job satisfaction, whilst seeking to reduce the risk of errors. Investigating adverse incidents within the healthcare setting, often identifies a failure to apply these basic principles.

Contemporary organisations, particularly the aviation industry has recognised human factors as being an important element of safety; this recognition now evident within the NHS. The Clinical Human Factors Group (CHFG) highlights the seriousness of the iatrogenic consequences of accidents and incidents borne out through error. Disturbingly statistical data highlighted by the CHFG makes for stark reading; most of all the cost to human life insurmountable. But it doesn’t have to be this way? Improving safety through speaking up is both an ethical and financial imperative, and organisations should be responsible for encouraging employees to speak up and share their concerns.

For many healthcare professionals their first introduction to human factors may be as a result of an incident in which a patient was harmed, as a result of potential failings. It should not be this way. By gaining an insight into the complexity associated with human factors through educational tools including the well-publicised videos ‘Just a routine operation’ and ‘Gina’s Story’, many healthcare workers can learn about the devastating effect experienced by many. Many more stories, such as these no doubt exist.

These real-life events have in some way occurred as a result of clinical error and a lack of professional judgement, perhaps something that any one of us could be subject to, if exposed to the right situation. We just need to be in the wrong place at the wrong time, for catastrophe to happen.

The Swiss Cheese Model
One theory, of how such incidents occur was proposed by James reason in 1978; known as the Swiss Cheese Model. This model can help to identify potential hazards, demonstrate how incidents occur and help to illuminate or clarify potential causes in accident investigation. When all the holes line up, anything is possible. Inadequate staffing levels for example, could be a contributory factor in helping to align those holes, another perhaps inadequate skill mix. Agency staff can be a buffer to reducing the risk, or can be a mitigating factor, but buffers should no longer be acceptable. Other factors such as skill set and skill mix, attitude, beliefs and values, all play their part, the willingness to challenge senior staff and as nurses make your voice heard could be argued is a significant factor, and is particularly evident in the Elaine Bromiley tragedy as shared in the video ‘Just a routine operation’. Promoting a positive safety culture in which all staff feel able to speak up may also be a positive step in reducing risk.

Developing a safety culture
Developing a safety culture in which all staff, irrespective of roles and responsibilities feel empowered to raise concerns is an essential element of any healthcare organisation seeking to reduce patient harm, and not simply the NHS. From domestic staff to consultant and all roles in-between, staff must be aware of the importance of raising the alarm, when they think something may be wrong or when it has gone wrong. Disappointingly staff working within healthcare settings continue to be overwhelmed by the challenge of speaking up, so eloquently discussed by Professor Mannion in his article ‘Speaking Up in Health Care: The Canary in the Mine?’ that they fail to do it. So, despite the introduction of Freedom to Speak up Guardians created as a response to the Francis report; a lack of confidence in speaking up remains evident.

The World Health Organisation has produced a multitude of technical reports, a link which can be found here. These reports describe the nature and impact of harm, and provide some potential solutions and rational steps to take in order to help improve patient safety.

Sunday, 18 August 2019

Which parents are more likely to call an ambulance unnecessarily for a sick child?

Roger Watson, Editor-in-Chief

Having a sick child is stressful for parents and there is always the issue of whether or not to summon help, sometimes from the ambulance service. Not every instance of parents calling an ambulance is necessary, but which parents are most likely to make unnecessary calls? This as the subject of a study by Ueki et al. (2019) from Japan titled: 'Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross‐sectional study' and published in JAN. The aim of the study was to: 'examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily' and over 170 parents who had visited the emergency department of a hospital were questioned.

The results showed that 'parents who did not use resources to obtain information regarding their child’s illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances. The authors concluded: 'Publicizing available resources regarding child health information, social health care activities to raise parents’ health literacy and explanations in accordance with parents’ uncertainty, especially when faced with new symptoms in their child, might reduce unnecessary ambulance use.'

You can listen to this as a podcast

Ueki, S. , Komai, K. , Ohashi, K. , Fujita, Y. , Kitao, M. and Fujiwara, C. (2019), Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross‐sectional study. J Adv Nurs. doi:10.1111/jan.14161

Tuesday, 6 August 2019

Declarations of political belief are not necessary or desirable in academic journals

Niall McCrae and Jonathan Portes
King’s College London

Brexit, the withdrawal of the UK from the European Union, has caused ripples throughout academe and in the literature of health professions. Our article ‘Attitudes to Brexit: a survey of nursing and midwifery students’ (McCrae & Portes, 2018) is a unique contribution to the lively and sometimes rancorous discourse. However, its publication in JAN irked Clifton and Banks (2019), who argue that editorials should not be contaminated with original research data.

On a point of principle, Clifton and Banks express their surprise at ‘a full-blown empirical research paper masquerading as an editorial’. This would be fair criticism if a study bypassed the peer-review system, but it did not. The manuscript was initially reviewed and the editor-in-chief decided not to publish in the submitted form, suggesting instead that we restructure it as an editorial on a matter of much interest to nurses in the UK and Europe.  And while we did not claim any conclusive results, our methods and findings, and the limitations of our study, were presented clearly and rigorously. 
Remarkably, Clifton and Banks, after asserting that it is inappropriate to include empirical research within an editorial, decided to bolster their own editorial by conducting fresh empirical research.  ‘We then conducted a very quick and crude scope of the JAN archives for the last five years, to determine how many empirical research articles are classified as editorials.’ Yet accuracy in reporting the results appears to elude them: ‘The answer is very few.’ We’re not asking for an F-test here, but some numbers would help.

Clifton and Banks then switch tack to allege that our article ‘lacks balance’, despite stating that the topic is immaterial to their argument, and their acknowledgment that the ‘point of any editorial is to present an opinion, often controversial’.  They criticise our lack of declaration of political interest at the foot of our article.  Of course, any financial interests or support should be declared; every journal requires this. If we’d had any funding for this research, we would have said so.

But politics are different. We are not aware of any healthcare, humanities or social science journal that requires authors to declare their beliefs. It would be appropriate for a writer to state as a potential conflict of interest a formal role as advisor to a political party, for example, but that does not apply to either of us.

The political transparency for editorials demanded by Clifton and Banks is neither necessary nor desirable.  If an editorial is politically influenced, this will be apparent in what is written. The implication of their argument is that if we wrote an editorial on why Brexit is good or bad for the National Health Service, then we should declare our attitude to Brexit. This is circular reasoning.

Clifton and Banks suggest that editorial submissions be reviewed by more than one editor. This may be a constructive idea, but the purpose of double review should not be to monitor opinion. Clifton and Banks state: -
‘The history of nursing in the UK is underscored with a series of cabals, hidden networks and vested interests. If we want a candid and modern profession, we need more transparency and openness in all aspects of the profession, including academic publishing.’
All professions and institutions are prone to group-think, but this is a very odd charge to levy against us. We suggest that Clifton and Banks have chosen the wrong target for their warning against undue influence. While being colleagues at King’s College London, we are hardly co-conspirators on either nursing (a field in which Portes has no expertise) or on Brexit, where our views - to put it mildly - are very different (as a publication search would show).  But we are both committed to scholarly debate and investigating complex phenomena in our disciplines.

A requirement for declaring political views would not be enforceable (and should not be). Voting is a private exercise in wielding the pencil in the polling booth. This does not prohibit people from divulging their political beliefs, and there is plenty of open discussion among nurses. But nobody should be forced into stating their likes and dislikes. Would an author stating membership of a populist or communist party be fairly considered for publication, and if the article were published, would this have adverse consequences for that author’s career?  A standard for political declarations might reinforce orthodoxy and quell dissent. 

Our critics informed readers of their own political stances: Clifton ‘voted remain in the 2016 referendum’ and Banks ‘was a longstanding member of the UK Labour Party’. In their efforts to practice what they preach, they unwittingly leave readers with an unanswered question. How did Banks vote in the referendum? We hope that he does not have anything to hide!


Clifton A, Banks D (2019): When is an editorial not an editorial: when it is empirical research! Journal of Advanced Nursing doi: 10.1111/jan.14160

McCrae N, Portes J (2018): Attitudes to Brexit: a survey of nursing and midwifery students.  Journal of Advanced Nursing, 75, 1-9

Sunday, 14 July 2019

Trial registration in nursing: room for improvement

Roger Watson, Editor-in-Chief

Since the advent of the AllTrials campaign, the registration of clinical trials has improved. Ideally, trials should be registered, with a published protocol, prior to their start date and certainly before publication. Since the start of 2019 JAN insists the all trials which it publishes - in fact all studies of patient interventions as defined by the WHO (Noyes 2018) - are registered prospectively and demonstrably. If they are  not, they will be rejected.

I am very grateful to Professor Richard Gray from LaTrobe University in Melbourne, Australia who, along with colleagues (2017, 2019), has been monitoring the situation in nursing. He has also been, specifically, monitoring the situation in JAN and has published reviews for 2017 and 2018. The most recent contribution, published in JAN is: 'A review of prospective registration of trials published in nursing science journals in 2017'. This study aimed to: 'determine the proportion of trials published in nursing science journals in 2017 that were prospectively registered'. The results of the study are summarised by the authors as follows: 'Of 151 randomized controlled trials published in nursing science journals in 2017, 17 (11%) were prospectively registered. Thirty-six (24%) trials were retrospectively and 93 (62%) not registered. We could not determine the registration status of five (3%) trials. The registration number was included in the abstract of two prospectively and eight retrospectively registered studies. Compared with the rest of the world, trial registration rates were significantly lower in Asian countries'. I am happy to say that JAN - at 18th place in the 'league table' - comes out well; but we could do better.

The authors conclude: 'Funding bodies, study sponsors, journal editors and trialists all have an important role to play in improving prospective trial registration. We intend to repeat this review with trials published in 2018 (and again in subsequent years). It is our hope is that by headlining the number of trials in the disciple that are prospectively registered we raise awareness among colleagues and as a result, improving the quality of future nursing science'.

You can listen to this as a podcast


Gray, R. , Gray, G. and Brown, E. (2019), A review of prospective registration of trials published in nursing science journals in 2017. J Adv Nurs. doi:10.1111/jan.14131

Gray, R. , Brown, E. and Gray, G. (2019), A review of prospective trial registration in the Journal of Advanced Nursing in 2018. J Adv Nurs. doi:10.1111/jan.14090

Gray, R. , Badnapurkar, A. and Thomas, D. (2017), Reporting of clinical trials in nursing journals: how are we doing?. J Adv Nurs, 73: 2782-2784. doi:10.1111/jan.13149

Noyes, J. (2018), Which studies should be registered on a clinical trials registry?. J Adv Nurs, 74: 2479-2479. doi:10.1111/jan.13696

Wednesday, 26 June 2019

Being bullied is bad for your health

Roger Watson, Editor-in-Chief

Bullying in healthcare has received increasing attention in recent years generally and on the pages of JAN. Bullying is an unpleasant and unnecessary phenomenon but what is the evidence that is it harmful to health? A UK-based study by Lever et al. (2019) and published in JAN titled: 'Health Consequences of Bullying in the Healthcare Workplace: A Systematic Review' aimed to: 'review both mental and physical health consequences of bullying for healthcare employees'.

Forty-five studies were included in the review and the results showed that: 'bullying was associated with mental health problems including psychological distress, depression and burnout, as well as physical health problems including insomnia and headache. Bullied staff took more sick leave.

The authors concluded: 'This systematic review has shown that perceived workplace bullying in healthcare settings is prevalent and associated with negative mental and physical health consequences. Primary prevention of workplace bullying and/or early intervention, should lead to an improvement in the mental and physical health of staff and patients. In addition, a reduction in bullying should lead to cost savings due to a decrease in sick leave and costly events associated with presenteeism such as additional patient care or litigation.

You can listen to this as a podcast.


Lever, I. , Dyball, D. , Greenberg, N. and Stevelink, S. A. (2019), Health Consequences of Bullying in the Healthcare Workplace: A Systematic Review. J Adv Nursdoi:10.1111/jan.13986

Sunday, 23 June 2019

Commentary on: A systematic review of the use of music intervention to improve outcomes for patients undergoing hip or knee surgery

Lene S. Petersen, Ole Richard Due-Hansen, Tahir Masud, Jens-Ulrik Rosholm
We read with interest the article by Sibanda et al A systematic review of the use of music interventions to improve outcomes for patients undergoing hip or knee surgery”(1).  We find the non-pharmacological approach very important and have performed a feasibility study to examine whether music can prevent delirium in older hospitalized patients in a geriatric medicine unit.

Delirious patients are described as costly for the health care. Delirium is associated with longer hospitalization, higher mortality and increased risk of permanent neurocognitive deficits (2-3).  To our knowledge no previous studies have investigated the idea of using music to prevent delirium in a conventional geriatric medicine ward.  Our study was performed on the principles of Bowen et al for feasibility studies (4).

The study was carried out at the Department of Geriatric Medicine at Odense University Hospital in Denmark, which has 40 inpatient beds. The study period was divided into two “non-music  control periods” (24 days and  32 days), interspersed by one  “music intervention period” (20 days). The music played was calm music i.e. 'MusiCure' [5] composed by Niels Eje and intended to mask  every-day noise in the department.  Music was played from 8 am to 12 pm and from 2:30 pm to 8 pm using ordinary stereo-equipment in 10 bedrooms. The music was only turned off/muted by the staff in extraordinary circumstances. If the music was turned off, the reason was recorded. The sound level was adjusted daily to 50 decibels in the middle of the room.

All patients, irrespective of diagnosis, hospitalized in the Department of Geriatric Medicine were assessed for inclusion in the study. Informed consent was obtained from the participants. Exclusion criteria were:
·         Critical illness
·         Informed consent not achieved
·         Language barriers
·         Hearing loss so that the patient could not hear the music
·         Patient’s hospitalization overlapping two of the periods
·         Discharged before assessment
·         Dead during hospitalization
·         Insufficient information

The delirium diagnosis was made with the Confusion Assessment Method (CAM) using Mini-cog as the screening tool. The tests were performed between 9 am and 12pm by the same three investigators (a physician and two nurses), all educated in CAM-testing. The primary outcome was the proportion of delirious patients per day at the time of testing. Participating patients, staff and relatives, were asked to complete a questionnaire regarding their opinion about the intervention

One hundred and sixty-eight patients were recruited into the study with a mean age of 83 (SD 68-95) years. There was a non-statistically significant trend towards a reduction in delirium days in the “music period” compared to the “non-music periods” (Table 1).

Number of patients
Prevalence of delirium
% and 95% CI
Non-music 1
Non-music 2
Combined non-music
Table 1 Prevalence of delirium during music and non-music periods.

A total of 37 patients, 41 relatives and 33 staffs answered the questionnaires and it showed that the intervention was generally well accepted by the patients, staff and relatives. A total of only 45 interruptions of the music were registered during this study.  32 of these were due to technical problems.

Our study demonstrated that it is feasible to set up a study with the aim of assessing if calm, specifically composed music can prevent delirium on a geriatric medicine ward. The music intervention was well accepted by staff, patients and relatives, was performed without any major difficulties, and showed a tendency towards reduced delirium, suggesting that a further adequately powered study is indicated. It is important to bear in mind that such a study would demand extra resources to perform CAM-scorings, registrations and establishment of music equipment plus composing/purchasing the right music. Power calculations (with two-sided α = 0.05 and power = 0.80) showed that a future definitive trial would need the randomization of at least 366 patients in each group (intervention and control) in order to detect a 20% reduction in the incidence of delirium.

A number of limitations to the feasibility study need to be considered. Firstly patients were admitted for up to 24 hours in the acute admissions ward before transfer to the geriatric medicine ward. Secondly CAM-scoring was only performed once a day, with the risk of not diagnosing  all delirium episodes. Finally, only a limited number of the participants gave their opinion about the playing of music.

We conclude that it is feasible to set up a larger adequately powered study to examine whether a music intervention can prevent delirium. There is no conflict of interest to disclose.

MD Lene S. Petersen
Department of Geriatric Medicine
Odense University Hospital
Sdr. Boulevard 29
DK-5000 Odense C
Phone +45 20325985


2.      Kirshner HS. Delirium: a focused review. Curr Neurol Neurosci Rep 2007 Nov; 7(6):479-82.
3.      Mercantonio E. Delirium in Hospitalized Older Adults. N Engl J Med 2017; 377: 156-1466
4.      Bowen D. et al. How We design Feasibility Studies. Am J Prev Med. 2009 May;36(5):452-457.

Monday, 17 June 2019

Nurses are in danger from occupational radiation

Roger Watson, Editor-in-Chief

Scrub nurses are in more danger from occupational radiation than doctors, according to a study from Australia by Wilson-Stewart et al. (2019) titled: Occupational radiation exposure to the head is higher for scrub nurses than cardiologists during cardiac angiography and published in JAN. The study aimed: 'to compare the head dose of a cardiologist to scrub and scout nurses during cardiac angiography' and studied over 600 coronary angiograms performed by one doctor and 22 nurses.

The results showed that: 'scrub nurses received on average 41% more head dose than the
cardiologist during diagnostic procedures and 52% higher doses during interventional cases'. The authors concluded: 'While there have been many studies examining occupational head dose to the medical operators during fluoroscopic procedures, there is very little reported evidence regarding dose to the nursing personnel. In this research, occupational radiation dose to the heads of nursing staff is significantly higher than the dose to the medical operator. While the recorded doses in this study were well beneath the recommended annual limits, the ideal situation is to minimize the risk of occupational exposure, therefore it is advisable that all staff wear protective lead glasses and skull caps... Future research in this area should include specific investigation of nursing staff to highlight factors which have an impact on occupational radiation dose'.

You can listen to this as a podcast.


Wilson‐Stewart, K. , Hartel, G. and Fontanarosa, D. (2019), Occupational radiation exposure to the head is higher for scrub nurses than cardiologists during cardiac angiography. J Adv Nurs. doi:10.1111/jan.14085

Monday, 3 June 2019

More napping on night shift

Roger Watson, Editor-in-Chief

It may be my imagination but there seems to be a lot of attention being paid to what nurses do during night shifts. Indeed, we return to the subject of napping which was the subject of a previous post. This time I consider an article from Israel by Zion and Shochat, published in JAN in 2019 and titled: 'Let them sleep: The effects of a scheduled nap during the night shift on sleepiness and cognition in hospital nurses'. 

The aim of this study was to: 'to examine the effectiveness of a scheduled 30‐min nap and its interaction with individual factors on sleepiness and cognition during an 8‐hr night shift.' One hundred and ten female nurses participated and a range of information was gathered about them such as age, chronotype (night or day), body weight, number of children. They all took a 30 min nap on 'nap night' after which sleepiness was monitored along with physical activity and they were given a test of mental ability. These were compared with the nights when no nap was taken.

Sleepiness was reduced on nap nights and performance on mental ability tasks was also greater on nap nights. The authors conclude: 'A scheduled nap may provide a useful countermeasure against the
negative consequences of night‐time shift work in female nurses above and beyond interpersonal differences. The implementation of this strategy is cost‐effective but requires a change in managers’ attitudes and the establishment of policies that allow nurses to nap in a safe environment without compromising the quality of patients’ care.'

You can listen to this as a podcast


Zion, NShochat, T. (2019) Let them sleep: The effects of a scheduled nap during the night shift on sleepiness and cognition in hospital nursesJ Adv Nurs