Thursday, 27 November 2014

Is there an economic case for nursing?

Roger Watson, Editor-in-Chief

Interest in nurse staffing levels and whether or not nursing is money well spent is intense. Perhaps international economic recession has focused attention on this against a background of changing demographics leading to deteriorating dependency ratios, increasing illness and the ‘bottomless pit’ that healthcare has become—especially in the developed world—as ever more illness becomes treatable, people survive longer and some seek healthcare for reasons that, to many, seem trivial. A systematic review from Australia by Twigg et al. (2014) titled ‘Is there an economic case for investing in nursing care –what does the literature tell us?’ and published in JAN investigates the economic case by looking at the existing evidence.

As with so many systematic reviews and studies on the cost of nursing care, the outcome is ambiguous. This will be sad news for those who simply advocate spending more money on nurses to increase nursing care with the aim of improving patient outcomes. Again, in common with many reviews, the problems are methodological with disparate methods being applied and multiple outcomes being used. In the words of the authors: ‘This review was unable to determine conclusively whether or not changes in nurse staffing levels and/or skill mix is a cost-effective intervention for improving patient outcomes due to the small number of studies, the mixed results and the inability to compare results across studies.’ Nevertheless, this rigorous review provides a valuable insight into the ‘state of the science’ of economic evaluation of nursing and should be a stimulus for further work with agreed outcomes and methods whereby the issue can be investigated consistently.


Twigg DE, Myers H, Duffield C, Gies M, Evans G (2014) Is there an economic case for investing in nursing care – what does the literature tell us? Journal of Advanced Nursing doi: 10.1111/jan.12577

Friday, 21 November 2014

Do nurse staffing levels influence patient outcomes?

Roger Watson, Editor-in-Chief

As much as I would like it to be, the relationship between nurse staffing and patient outcomes is not clear. A recent article from an Australian study by Winton et al. (2014) titled ‘The relationship between nurse staffing and inpatient complications’ and published in JAN cites methodological problems as one reason. Of course, this is a difficult area to investigate. It would be hard envisage clinical trials which compared nursing care with no nursing care  — which I imagine would easily demonstrate the value of nursing per se — and the situation is further complicated by definitions of nursing (RNs versus unqualified assistants) and the various levels of skill mix that can be implemented. It is even further complicated by the myriad outcomes and patient complications that could be selected as comparative measures. Nevertheless, this area merits investigation as arguments about staffing levels and skill mix are common, and those who hold healthcare budgets need to know how to spend their money (often it is our money) wisely. Insufficient nursing care may lead to expensive complications but unnecessary spending on nursing staff may waste valuable resources.

The article by Winton et al. (2014) compared 256,984 hospitalizations with and without complications against staffing levels in a retrospective longitudinal study and found that the pattern was not consistent. Specifically, they said: ‘our results did not support the widely held assumption that improved nurse staffing levels are associated with decreased patient complication rates.’ Clearly, further investigation is required.


Winton LW, Bremner AP, Geelhoeld E, Finn J (2014) The relationship between nursestaffing and inpatient complications Journal of Advanced Nursing doi: 10.1111/jan.12572

Thursday, 13 November 2014

Nightingale versus Seacole…round two!

Roger Watson, Editor-in-Chief

You may recall ‘Nightingale versus Seacole…round one!’ which I wrote after we published McDonald’s (2013) less than complimentary piece on Mary Seacole’s contribution to modern nursing. That piece did not go unnoticed and as a result Staring-Derks et al. (2014) have recently published an article titled, ‘MarySeacole: global nurse extraodinaire’. I say as a result, rather than in reaction to, as Staring-Derks et al– while citing McDonald’s article – decided not to confront her arguments ‘head on’ and what results is a very measured, polite and well-referenced piece.

Clearly, by labelling these rounds one and two respectively I am hoping that further correspondence and articles will arise, perhaps not from the original ‘protagonists’ but from others with a view on the relative contributions of Nightingale and Seacole to modern nursing and healthcare.Whatever one’s view – and JAN is neutral in this debate – the influence of Mary Seacole is undeniable. I was in Edgbaston in Birmingham recently, taking a taxi past Birmingham City University, and noticed another Seacole Building; few universities where nursing is taught are without one. The Seacole ‘lobby’ and the move in the UK, for example, to have a statue erected in her honour, are well organised and influential. I am not aware of a similar ‘lobby’ for Florence Nightingale; perhaps her place in the history of nursing is assured.

If you wish to contribute to the debate then please check our author guidelines for how to contribute to JAN interactive.


McDonald L (2013) Florence Nightingale and MarySeacole on nursing and health Journal of Advanced Nursing 70, 1436-1444

Staring-Derks C, Staring J, Anionwu E (2014) MarySeacole: global nurse extrodinaire Journal of Advanced Nursing doi: 10.1111/jan.12559

Tuesday, 11 November 2014

Nurses' overtime and patient care

Roger Watson, Editor-in-Chief

Nursing work is hard enough with physical and psychological demands and long and often unsocial hours. Nursing shortages and often poor salaries mean that overtime working is often a feature of many nurses' lives. It appears that there is little rigorous research into the extent to which working overtime influences patient care, according to a recent paper from Canada by Lobo et al. (2014) titled Integrative review: an evaluation of the methods used to explore the relationship between overtime and patient outcomes.

The paper reports on nine articles related to how nursing overtime affects patient outcomes. As with many such studies, the review showed methodological weaknesses in the area related to defining overtime and working out what effect confounding variables had on the measurement of outcomes. The findings of the studies, therefore, need to be interpreted cautiously. Nevertheless, there was some evidence to show that nurses' overtime was related to such things as infection rates, deaths from pneumonia and medication errors.

If there is any truth in these findings, these phenomena are surely worth investigating further; if upheld, they would certainly strengthen the argument for a better resourced nursing workforce. In the words of the authors: 'additional funding and attention needs to be directed at this topic area to mitigate the negative patient outcomes that may be a result of the use of nursing overtime.'

Lobo v, Fisher A, Peachey G, Ploeg J, Akhtar-Danesh N (2014) Integrative review: an evaluation of the methods used to explore the relationship between overtime and patient outcomes Journal of Advanced Nursing doi: 10.1111/jan.12523

Wednesday, 5 November 2014

Response to Commentary: Is there a spiritual life outside religion?

Katia G. Reinert, PhD, CRNP, FNP-BC, PHCNS-BC

Response to Bert Garssen's Commentary on Reinert K.G. & Koenig H.G. (2013) Re-examining definitions of spirituality in nursing research. Journal of Advanced Nursing 69 (12), 2622–2634. doi: 10.1111/jan.12152

Thank you for a thoughtful response to our article (Reinert & Koenig 2013). While we understand the concern voiced in the response, we would like to restate what we proposed and why. We proposed that reducing spirituality to religion (not for clinical practice but for the purposes of research) is critical, since it is difficult if not impossible to measure spirituality as a distinctive construct except by measuring religion.

We agree and fully support the notion that spirituality can be broadened beyond religion to be inclusive for clinical purposes, but for conducting research, there is too much overlap with mental health constructs due to the way spirituality is currently being measured in nursing research, as we described in the article.

Our main point is that the results of research examining spirituality and mental health is virtually impossible to interpret due to the tautology in relationships between constructs being measured. Only by measuring spirituality by religion can we retain the distinctiveness of the concept.

Katia G. Reinert, PhD, CRNP, FNP-BC, PHCNS-BC
Johns Hopkins University School of Nursing
Baltimore, MD


Reinert K.G. & Koenig H.G. (2013) Re-examining definitions of spirituality in nursing research. Journal of Advanced Nursing 69 (12), 2622–2634. doi: 10.1111/jan.12152

Tuesday, 4 November 2014

Commentary: Is there a spiritual life outside religion?

Bert Garssen, PhD
Helen Dowling Institute, Center for Psycho-oncology

Commentary on Reinert K.G. & Koenig H.G. (2013) Re-examining definitions of spirituality in nursing research. Journal of Advanced Nursing 69 (12), 2622–2634. doi: 10.1111/jan.12152

Spirituality questionnaires that contain items referring to spiritual well-being or mental health should not be used to investigate the causal relationship between spirituality and mental health. This concern was expressed before (Migdal & MacDonald 2013) and has been repeated in a recent article in JAN (Reinert & Koenig 2013). Reinert & Koenig (2013) object to using mental health concepts in the definition of spirituality, though in my view their use in spirituality scales seems most problematic.

Reinert & Koenig (2013) plead for a further reduction of the concept by restricting spirituality to religiosity. One of the reasons for preferring this restriction is that many definitions of spirituality have become very broad and include mental health concepts. I agree, if this would refer to terms like well-being and enjoyment. However, I consider terms like “the experience of meaningfulness or purpose in life” of a different category. According to Reinert & Koenig (2013), these terms refer to the core mental symptoms of the DSM-IV diagnosis of major depression. “Worthlessness”, they say, “is one of the nine cardinal symptoms”. However, worthlessness is not simply a lack of meaningfulness or purpose in life. One may experience life in general as meaningful and yet - at least temporarily – experience anxiety or depression. This indicates that there is a distinction between the two concepts. So, in my view there is no decisive reason for the advice of the authors “...that spirituality in research is better served if defined in the context of religious involvement” (Reinert & Koenig 2013).

What to think of people who consider themselves spiritual but not religious, if we would accept the opinion of Reinert & Koenig? Their number cannot be neglected. Zinnbauer et al. (1997) selected people from different churches, New Age groups, students, nursing professionals, and nursing home residents in Pennsylvania and Ohio, and found that 19% defined themselves as spiritual, but not religious. The same number was found in a more recent study among the Dutch general population (Berghuijs et al. 2013).

In fact, there is no decisive logical argument to decide which definition should be accepted, and Reinert & Koenig (2013) also indicate that how one defines spirituality is a matter of personal preference; dependent upon the background and religiosity of the researcher. Nevertheless, I would like to propose some arguments against reducing spirituality to religion. First, non-religious spiritual people describe experiences and attitudes that are also mentioned by religious people, and which both groups find very important in their lives. According to the persons themselves and according to scientists, these are spiritual experiences and attitudes. If so, how can the existence of a non-religious form of spirituality be denied? Experiences that seem essential for both religious people and for non-religious people who consider themselves spiritual are: feeling part of a larger whole, detaching oneself from daily routines and rising above oneself, letting go of the ego focus, experiencing awe for and connectedness with nature (‘God’s creation’ in religious terms), and feeling a deep connection to other people (the congregation or ‘God’s people’ for religious people).

Second, Reinert & Koenig (2013) argue that a definition in religious terms would yield a clearer concept, but even within and among religious traditions is a wide variety in beliefs, experiences, and attitudes. In addition, there presently are definitions of spirituality that are consistent, have not arisen from personal preference, and can be used across international borders, as Reinert & Koenig (2013) prefer. Conceptual analyses (Reed 1992, Chiu et al. 2004) have shown that connectedness is an essential element of spirituality. In nursing research, spirituality is also often defined in terms of connectedness. Reed defined spirituality on the basis of conceptual, empirical, and clinical nursing literature as “the propensity to make meaning through a sense of relatedness to dimensions that transcend the self in such a way that empowers and does not devalue the individual. This relatedness may be experienced intrapersonally (as a connectedness within oneself), interpersonally (in the context of others and the natural environment) and transpersonally (referring to a sense of relatedness to the unseen, God, or power greater than the self and ordinary source)” (Reed 1992, p. 350). Connectedness with oneself is expressed by aspects such as authenticity, inner harmony/ inner peace, consciousness, self-knowledge, and experiencing and searching for meaning in life. Connectedness with others and with nature is related to compassion, caring, gratitude, and wonder. Connectedness with the transcendent includes connectedness with something or someone beyond the human level, such as the universe, transcendent reality, a higher power or God. I am, of course, aware of several other definitions of spirituality. My only aim was to briefly indicate the possibility of presenting a coherent, accepted and usable definition of spirituality that is not (strictly) framed in religious terms.

To summarize, I welcome the warning of Reinert & Koenig (2013) to ban elements of mental health from definitions and operationalizations of spirituality. However, I do not agree with their suggestion that a definition in religious terms would advance the scientific development in this area.

Bert Garssen, PhD
Helen Dowling Institute, Center for Psycho-oncology
The Netherlands

The author of the original article has responded to this commentary.


Berghuijs J, Pieper J, and Bakker C (2013) Being 'spiritual' and being 'religious' in Europe: Diverging life orientations, Journal of Contemporary Religion, 28 (1), 15-32.

Chiu L, Emblen JD, van Hofwegen L, Sawatzky R, and Meyerhoff H (2004) An integrative review of the concept of spirituality in the health sciences, Western Journal of Nursing Research, 26, 405-428.

Migdal L and MacDonald DA (2013) Clarifying the Relation Between Spirituality and Well-Being, Journal of Nervous and Mental Disease, 201, 274-280.

Reed P (1992) An emerging paradigm for the investigation of spirituality in nursing, Research in Nursing & Health, 15, 349-357.

Reinert KG and Koenig HG (2013) Re-examining definitions of spirituality in nursing research, Journal of Advanced Nursing, 69 (12), 2622–2634 doi 10/1111/jan.

Zinnbauer BJ, Pargament KI, Cole B, Rye MS, Butter EM, Belavich TG et al. (1997) Religion and spirituality: Unfuzzying the fuzzy, Journal for the Scientific Study of Religion, 36 (4): 549-564.