Tuesday, 26 May 2015

Artificial neural networks

Roger Watson, Editor-in-Chief

I have long had an interest in artificial neural networks (ANNs) but I must admit my interest was mainly in what they were, what they did and what possible use they could be. On a visit to Italy many months ago I met a research team at the University of Genoa who were using ANNs to study communication in emergency care.  I encouraged them to publish the work and worked very closely with them and that work is now published in JAN by Bagnasco et al. (2015) in their article titled: 'Applying artificial neural networks to predict communication risks in the emergency department'.

My understanding of ANNs has increased in the process and I am very happy to publish this paper so that others may also learn about them and see their potential in nursing research.  In the words of the authors: 'ANNs are mathematical models that try to imitate the functional processes of the human brain. ANNs involve non-linear relationships among different data sets that cannot always be fully identified through the use of conventional linear analyses. ANNs are extensively used in technology and science with applications in chemistry, physics, biology and medicine.'  I will not pretend that this concept or the operation of ANNs is easy to grasp; however, Bagnasco et al. explain it as clearly as anyone and central to the method, which is computer based, is the 'back propagation algorithm' which allows a system to 'learn' about the data that are being entered into it.

The present study used observational data of 840 nursing communication interactions and used the ANN to analyse which independent demographic variables predicted aspects of communication.  Age and seniority were important variables in increasing effective communication.  I hope that people will study this paper to lean more about ANNs and that we will see more applications of ANNs in nursing research and in the pages of JAN.

You can also listen to this entry as a podcast.


Bagnasco, Siri A, Aleo G, Rocco G, Sasso L (2015) Applying artificial neural networks to predict communication risks in the emergency department Journal of Advanced Nursing doi: 10.1111/jan.12691

Friday, 22 May 2015

Sex after childbirth

Roger Watson, Editor-in-Chief

Many myths surround the issue of sexual activity around childbirth - both pre- and post-natally. There cannot be a couple who are expecting a child or a woman who is imminently giving birth or has just given birth who does not wonder when they can resume sexual activity, especially but not exclusively, penetrative vaginal sexual intercourse.

This issue is addressed by O'Malley et al. (2015) in an article titled: 'Postpartum sexual health: a principle-based concept analysis' and published in JAN.  As the authors explain: 'Postpartum sexual health is a minimally understood concept, most often framed within physical/biological dimensions or as a ‘checklist’ task in postpartum information provision. This has the potential to leave women unprepared to manage transient or normative sexual health changes after childbirth. For meaningful discussions, clarity and understanding of postpartum sexual health is required.'

Using a wide variety of sources which were reviewed systematically the study uses a principle based concept analysis approach to investigate what is know about postpartum sex. They conclude that: 'Postpartum sexual health is conceptually immature with limited applicability in current midwifery practice.'  Midwives are in an excellent position to advise on postpartum sexual activity but, of course, new mothers (and fathers) may find it hard to ask and, equally, midwives may find the subject difficult to broach. Finally, in the words of the authors: 'Measurement tools for specifically
assessing and measuring postpartum sexual health were not identified in this analysis and there is a need to develop, test and validate such a tool. Finally, there is limited evidence on the topic from the perspective of midwife care providers and of that which was identified, midwives have apparent
limited knowledge in the area of postpartum sexual health and engage minimally in discussions with women on this topic in the postpartum period. This indicates an urgent need for education in this area, including curriculum considerations at undergraduate and postgraduate level, so that greater clinical understanding and appreciation for this important aspect of maternity care can be assured.'

You can listen to this entry as a podcast.


O’Malley D, Higgins A, Smith V (2015) Postpartum sexual health: a principle-based concept analysis Journal of Advanced Nursing doi: 10.1111/jan.12692

Wednesday, 20 May 2015

Dementia Awareness Week UK

Professor John Keady
Dementia and Ageing Research Team, University of Manchester

To mark Dementia Awareness Week, we asked Professor John Keady to select some papers on dementia from JAN.

John Keady
I have chosen six papers to discuss briefly in this blog, with five of the papers published in 2014 and one in 2015. The papers introduce the diversity of dementia as a topic area for research, practice, education and policy and are written by authors from academic institutions around the world. This breadth of active research interest represents the global effort and challenges posed by dementia and the various methodologies necessary to help generate prospective solutions.

The first paper is written by a team of four researchers in Sweden and led by Eva Karlsson, who is named as a PhD student (Karlsson et al. 2014). The primary aim of this paper is to explore how people with Alzheimer’s disease present their own life story and is informed by the contribution of nine participants - five women and four men (age-range 60-81) - all of whom were in the earlier stages of Alzheimer’s disease. Interviews were conducted in the participant’s own homes with the interviews lasting an average of one hour; care partners were reportedly present during this interview period to help provide any contextual/word-finding areas salient to completing the story. However, the focus of the research study and reported experiences was founded squarely on the storyteller, i.e. the person with Alzheimer’s disease. Following transcription, two of the research team led the paradigmatic analysis of the data which led to the generation of four core dimensions that tied together each life story: contentment; connectedness; self-reliance; and personal growth. Interestingly, the dimension of contentment includes a statement that: 'there were, in all stories, also signs of both grief and sadness deriving from emotionally stressful situations in the participant’s lives’ (Karlsson et al. 2014 p.2794). 

This theme of grief and loss is picked up in the second paper by Linauer and Harvath (2014) which undertook a concept analysis of 49 peer-reviewed papers that addressed pre-death grief in family carers of people with dementia. The first author is listed as a doctoral candidate in the USA and the authors included two sources from the popular media that focussed on dementia (a well known book, The Long Goodbye (2014), and the film Iris (2001)) to help frame the presented analysis within an everyday context. Following the study inclusion criteria, the article shared a total of 20 terms for pre-death grief that were contained within the 49 papers and this outlined the complexity in attaching a transparent meaning to the concept. To help provide clarity, the paper systematically compared the characteristics of ‘pre-death grief’, ‘anticipatory grief’ and ‘chronic sorrow’ and whilst the review suggests some ‘blurring’ between the three concepts, differences were also found in the context of family caregiving and dementia. The reporting of these differences enabled the authors to provide a definition of pre-death grief which spun around the caregiver’s ‘emotional and physical response to the perceived losses in a valued care recipient’ (p. 2203). The authors also suggested that pre-death grief can also contribute to caregiver burden, depression and maladaptive coping. 

In a study led by Wang et al. (2014), who is also identified as a PhD student but with an academic base in both China and Australia, the research team continued the focus on family caregiving and dementia. However, this time, the design comprised of an interview-based study which involved 23 participants recruited through geriatric clinics in three university-associated teaching hospitals in China. The sample was made-up of mainly women who had been caring at home for a person with dementia for an average of five years. At its heart, the study was interested in exploring issues that were faced by the participating carers where there was little, if any, expectation of external service support. Of the four themes that emerged from analysis, perhaps unsurprisingly, ‘untreated behavioural and psychological symptoms of dementia’ [the name of the first theme] emerged as a significant cause of family stress, distress and risk. Interestingly, the study participants suggested that beneficial changes would include better coordination between primary and specialist dementia services and that community nurses should have an integral role in this context. 

Papers four, five and six are all drawn from the nursing home setting home setting. Liu (2014) working from the Hong Kong Polytechnic University provides an insightful interview-based study that explored nursing assistant’s role in the identification, treatment and management of pain in a resident with dementia. Changes in a resident’s behaviour, for example through excessive walking or increased vocalisation, could be a sign that the person with dementia is in pain, and the study suggested that the knowledge held by nursing assistants was not always sought by the qualified staff to whom they were responsible. It was an inverse care relationship: the staff with the most familiarity and contact with residents with dementia were given the least autonomy and input into clinical decision-making. A study by Konno et al. (2014) conducted a best evidence review of non-pharmacological interventions for resistance-to-care behaviours of residents with dementia in a personal care context. Intervention studies conducted between 1990-2012 were included in the review and a total of 19 identified, ranging from the implementation of relaxing music at mealtimes to ability-focussed morning care. The evidence for such interventions was persuasive in most instances, but similar to several studies in this blog, the researchers located a number of different descriptive terms that related to the same phenomenon, for instance when looking at approaches to managing agitation. This made cross-comparison difficult. Konno et al. (2014) suggested that standardised terminology would help to build a better platform between researchers, caregivers and practice. The final choice of paper is by Willemse et al. (2015) where the lead researcher is a PhD student based at the VU University Amsterdam. It was selected as it contrasts nicely with the work of Konno et al. (2014) in that in the extensive national survey that sits at centre of this work (n=1093 nursing staff), it was reported that a person-centred workforce is a more effective one. In other words, it is important for nursing homes and managerial systems to create a positive work environment where staff well-being and decision-making is supported and integral to the culture of care. A simple but essential message as the nursing and dementia field moves forward.

Professor John Keady is Chair of Mental Health Nursing and Older People at The University of Manchester, UK where he holds a joint position with Greater Manchester West Mental Health NHS Foundation Trust. John is an invited Senior Fellow with the NIHR School for Social Care Research [2015-2019] and leads the inter-disciplinary Dementia and Ageing Research Team at The University of Manchester. John is a founder and co-editor of the bi-monthly Dementia: the international journal of social research and practice, published by Sage.

You may also like to read JAN's recent special section on dementia.


KARLSSON E., SÄVENSTEDT S., AXELSSON K. & ZINGMARK K. (2014) Stories about life narrated by people with Alzheimer’s disease. Journal of Advanced Nursing 70(12), 2791–2799. doi: 10.1111/jan.12429

KONNO R., KANG H.S. & MAKIMOTO K. (2014) A best-evidence review of intervention studies for minimizing resistance-to-care behaviours for older adults with dementia in nursing homes. Journal of Advanced Nursing 70(10), 2167–2180. doi: 10.1111/jan.12432

LINDAUER A. & HARVATH T.A. (2014) Pre-death grief in the context of dementia caregiving: a concept analysis. Journal of Advanced Nursing 70(10), 2196–2207. doi: 10.1111/jan.12411

LIU J.Y.W. (2014) Exploring nursing assistants’ roles in the process of pain management for cognitively impaired nursing home residents: a qualitative study. Journal of Advanced Nursing 70(5), 1065–1077. doi: 10.1111/jan.12259

WANG J., XIAO L.D., HE G.-P. & DE BELLIS A. (2014) Family caregiver challenges in dementia care in a country with undeveloped dementia services. Journal of Advanced Nursing 70(6), 1369–1380. doi: 10.1111/jan.12299

WILLEMSE B.M., DE JONGE J., SMIT D., VISSER Q., DEPLA M.F.I.A. & POT A.M. (2015) Staff’s person-centredness in dementia care in relation to job characteristics and job-related well-being: a cross-sectional survey in nursing homes. Journal of Advanced Nursing 71(2), 404–416. doi: 10.1111/jan.12505

Tuesday, 19 May 2015

Body-mind-spirit and depression

Roger Watson, Editor-in-Chief

A combined team from India and Hong Kong has investigated the use of a body-mind-spirit (BMS) intervention which 'highlights the components of Buddhism, recognition and acceptance of negative emotions, self-love techniques and gaining through pain' for people with depression.  The results are published by Rentala et al. (2105) in JAN in an article titled: 'Effectiveness of body–mind–spirit intervention on well-being, functional impairment and quality of life among depressive patients – a randomized controlled trial'.  

The aim of the project was: 'to examine the effectiveness of BMS intervention in improving outcomes (well-being, quality of life
and functional impairment) among the depressive patients.'  the BMS intervention was tested in a randomised controlled trial against treatment as usual (TAU).  The results showed that: 'Compared with the TAU group, the BMS group showed statistically significant decreases in depression and functional impairment'.

In the words of the authors: 'This is one of the few known studies on the subject which showed that BMS intervention implemented by a nurse was instrumental in bringing about significant changes among Indian depressive patients in terms of reduction in depressive and functional impairment scores, improvement in well-being and quality of life scores.'

You can also listen to this as a podcast.


Rentala S, Fong TCT, Nattala P, Chan CLW, Reddemma K (2015) Effectiveness of body–mind–spirit intervention on well-being, functional impairment and quality of life among depressive patients – a randomized controlled trial Journal of Advanced Nursing doi: 10.1111/jan.12677

Tuesday, 12 May 2015

Nurses: a force for change

Hester C. Klopper
President: Sigma Theta Tau International

Hester Klopper

In South Africa, my home country, we often say the only constant is change. In looking at the ICN’s theme for International Nurses Day 2015, Nurses a force for change, it seems that the sentiment of constant change is shared across the world. We have seen numerous changes in disease patterns over the past few decades. The non-communicable disease burden is heavier in low and middle income countries, and in several developing countries the quadruple burden of disease adds pressure to the already overloaded health systems. Changes in the healthcare environment seem to be daily with an increased focus on disease prevention and health promotion. Nurses as the largest group of health care professionals, are often the closest and most available to attend to patients, families and communities. Recently on a website I saw such a relevant quote: ‘A nurse is one who opens the eyes of a new-born and gently closes the eyes of a dying man, It is indeed a high blessing to be first and last to witness the beginning and end of life’ (www.nursebuff.com). Nurses are indeed the force for change. With the worldwide notion of providing equitable and accessible health care to all populations, nurses are playing the most critical role. Evidence indicated that the better qualified the nurse, the better the patient outcomes (Aiken et al. 2011). And results of our recent research studies indicate the better the quality of care a nurse provides, the more job satisfaction is experienced (Klopper et al. 2012, Coetzee et al. 2013).

With 19 million nurses globally we can indeed be the force for change. Change agent means the person who helps or facilitates in bringing about positive change. So how can nurses bring the change for the future? There are many ways we can bring about change, but let me focus on what I believe are the three most significant changes to be considered. First and foremost, if we want to bring about change we need to see the bigger picture … bigger in terms of the global and regional context (not just a focus on the local); seeing that nursing is part of the bigger system of healthcare, and therefore not just the focus on nursing, but the role nurses play in the healthcare system. Seeing the bigger picture will enable nurses to play a significant role in policy formulation, such as influencing the Post-2015 UN health agenda. Secondly, a change in the global workforce is needed. If we want to sustain a well-educated nursing workforce for the future, both the health and education systems need to take responsibility and collaborate. Proper workforce planning, in terms of competence, level (degree entry), skill mix and numbers are essential and needs a sound basis for planning. This will furthermore allow for more nurse-led care and advanced nurse roles, both associated with positive changes in the health care delivery system. A further aspect is to get the workforce to being productive. A productive workforce results in lower number of professional needed. This brings us to the third aspect in need of change – the work environment. The utmost importance of a positive work environment can no longer be underestimated. Adding more nurses to a toxic work environment will have no effect, opposed to adding nurses to a positive work environment that result in great benefits for the health care system. Important elements linked to the practice environment are good leadership, managerial support, respectable relationships amongst all members of the healthcare team but especially good relationships with doctors, nurses taking control over their own practice, and adequate resources – both human and equipment (Lake, et al, 2002). ‘ In concrete terms, this refers to adequate staffing and resources necessary to provide safe and timely patient care; and collaboration between nurses and physicians is critical for optimizing patient care’ (Jarrin et al. 2014).

As we celebrate International Nurses Day this month, I salute all the nurses of the world, be the change agents and continue to make a difference!


Aiken, L.H., Sloane, D.M., Clarke, S., Poshosyan, L., Cho, E, You, L., Finlayson, M., Kanai-Pak, M. Aungsuroch, Y. (2011). Importance of work environments on hospital outcomes in 9 countries. International Journal of Quality in Health Care, 23, 357-364.

Coetzee, S.K., Klopper, H.C., Ellis, S.M, Aiken, L.H. (2013). A tale of two systems—Nurse practice environment, wellbeing, perceived quality of care and patient safety in private and public hospitals in South Africa—A questionnaire survey. International Journal of Nursing Studies, 50, 162-173.

Jarrín, O., Flynn, L., Lake, E.T., Aiken, L.H. (2014). Home Health Agency Work Environments and Hospitalizations. Medical Care. 52: 877–883.

Klopper, HC; Coetzee, SK; Pretorius, R and Bester, P. (2012) Practice environment, job satisfaction, intention to leave and burnout of critical care nurses in South Africa. Journal of Nursing Management, 20:5 685-95.

Lake, E.T. (2002). Development of the Practice Environment Scale of the Nursing Work Index. Research in Nursing & Health, 25, 176-188.

Monday, 11 May 2015

International Nurses Day 2015 - NURSES: A FORCE FOR CHANGE

Roger Watson, Editor-in-Chief

This year's International Council of Nurses (ICN) theme for International Nurses Day is about effectiveness of nurses in terms of care and cost.  Intuition tells us that nurses are effective and cost-effective and we cite this in terms of readmission rates, pressure ulcers and infection rates, for example.  It seems obvious that, when nursing levels are sufficient to deliver nursing care, it is better than insufficient levels and that better qualified nurses are better then less qualified nurses where 'better' means better patient care and cost-savings.  However, as sound as intuition often is and that common sense would appear to dictate these things, intuition and common sense do not have much influence on budget holders who, in developed countries, spend vast amounts of money on hospital budgets, the largest proportion of which is always spent on the nursing workforce. They want evidence.

At JAN we take a great deal of interest in manuscripts related to any aspect of nursing workforce and this year have published two articles relevant to the ICN theme of care effective and cost effective.  As with all research, the evidence is ambiguous.  For example, in a systematic review titled:  Is there an economic case for investing in nursing care – what does the literature tell us? Twigg et al. (2015b) concluded: '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.' On the other hand, in a study of understaffed shifts on nurse-sensitive outcomes, Twigg et al. (2015a) showed that understaffing of wards had significant detrimental effects on: 'surgical wound infection, urinary tract infection, pressure injury, pneumonia, deep vein thrombosis, upper gastrointestinal bleed, sepsis and physiological metabolic derangement.' Clearly, these are different types of studies but in one - the single study - the effect of insufficient nursing is clear; however, the synthesized evidence is less clear. One thing is clear: more research is needed and that agreed outcomes and ways of measuring nursing care and staffing levels are necessary.

In the search for the evidence of cost-effectiveness we must not lose sight of the fact that it may not be there and may not be evident in all circumstances. For example, another study by Yang et al. (2105) titled: 'The impact of three nursing staffing models on nursing outcomes' and published in JAN showed unexpected relationships between staffing models and medication errors; models with 100% RNs as opposed to models with RNs and nurse aides led to more medication errors. The reason appeared to be that checking and administering as opposed to checking an allowing an nurse aide to administer was more error prone. It is a single study but also a lesson in not jumping to the wrong conclusion about nurse staffing levels.

As Editor-in-Chief of JAN, I am convinced that nursing is effective and cost-effective and I support the ICN slogan for this year's International Nurses Day. However, I think that globally we need to be more united and systematic in our efforts to study and report on the care effective and cost effective aspects of nursing. As a recent editorial by Fawcett et al. (2104) stated: Nursing today stands again at its Rubicon. Today’s 'gilded galley’ must be able to navigate the treacherous waters of failed accountability, broken trust and lost devotion. Though not all pervading, our professional gild has become tarnished and the vessel damaged. Picture a Roman galley moving through the waters of the Mediterranean with twin banks of oarsmen working together to pull the craft through the waves. The oarsmen work together, pulling in unity, almost as one. If nursing is to take its ‘gilded galley’ forward, it too needs unity and a common purpose to succeed. The pioneering nurses of the past can inspire us but it is today’s nurse leaders who must set the direction of travel and set course for better times. We have failed to direct the agenda and for too long we have been without a collective, visionary voice and an authoritative pride in our profession. We have looked in the mirror and we see a nursing profession that needs to take ownership of itself and take the lead, from grass roots front line nurses to those who are educators, researchers and policy makers.


Fawcett, T. N., Holloway, A. and Rhynas, S. (2014), If I have seen further it is by standing on the shoulders of giants: finding a voice, a positive future for nursing. Journal of Advanced Nursing. doi: 10.1111/jan.12556

Twigg D.E.Gelder L. & Myers H. (2015aThe impact of understaffed shifts on nurse-sensitive outcomesJournal of Advanced Nursing. doi: 10.1111/jan.12616

Twigg D.E.Myers H.Duffield C.Giles M. & Evans G. (2015bIs there an economic case for investing in nursing care – what does the literature tell us?Journal of Advanced Nursing 71(5), 975990. doi:10.1111/jan.12577

Yang P.-H.Hung C.-H. & Chen Y.-C. (2015The impact of three nursing staffing models on nursing outcomesJournal of Advanced Nursing doi: 10.1111/jan.12643