Wednesday, 20 January 2016

Keeping older nurses in the workforce

Roger Watson, Editor-in-Chief

Older nurses have a great deal to contribute to nursing but the physical and psychological stress of the job and caring responsibilities for older relatives and generally being 'burned out' after years in the profession mean that many leave.  Being primarily a female profession, also, many leave when they have children and seek to return later in life but it is not always easy.  This represents a considerable waste of the resources that have been invested in education and training.

A study from New Zealand by Clendon and Walker (2016) titled: 'The juxtaposition of ageing and nursing: the challenges and enablers  of continuing to work in the latter stages of a nursing career' and published in JAN aims to: 'To identify why some nurses cope well with continuing to work as they
age and others struggle.'  The study surveyed over 3000 nurses and held focus groups with nearly 50 nurses aged over 50 years.

In New Zealand it is reckoned that half of the current nursing workforce will be lost in the next 10-15 years.  The authors reckon that this is an international phenomenon.  Those of us working in nursing education know how student attrition can be high and that many nursing students do not enter the nursing workforce.  Also, there are significant problems keeping nurses in the health services.  The nurses reported the physical stresses associated with nursing and how they were less able to carry out their jobs due to physical limitations.  They also reported guilt associated with this in that they were not able to do their job properly.  Some felt limited in their job prospects due simply to their age - possibly indicating ageism - and also the struggle to keep up with professional development requirements.  On the other hand, older nurses did report that they had developed resilience and some said that they made efforts to keep fit and eat healthy foods to remain fit for their job.  They also said that they found that being afforded flexibility in their jobs was a factor that made remaining in the jib easier and this reflects some work with which I was involved nearly a decade ago in the UK and also published in JAN (Andrews et al. 2006).

The authors conclude: 'The juxtaposition of ageing and nursing demonstrates nurses who continue to work while they age face a range of challenges associated with the ageing process but develop effective coping strategies that help build their resilience in the workplace. Workplaces can support nurses to managethe challenges of ageing by addressing ageism, assessing their organisational approach to older workers and providing a supportive environment where nurses of all ages can flourish.'

You can listen to this as a podcast.


Andrews J, Watson R, Manthorpe J (2006) Employment transitions for older nurses: a qualitative study
Journal of Advanced Nursing 51, 298-306 

Clendon J, Walker L (2106) The juxtaposition of ageing and nursing: the challenges and enablers of continuing to work in the latter stages of a nursing career Journal of Advanced Nursing doi: 10.1111/jan.12896

Monday, 18 January 2016

Time to listen: do we ‘care’?

Sue Dean, Claire Williams, Mark Balnaves*

Nurse education has undergone many changes over the last few decades with the transition from apprentice-type training to university education. This has profoundly altered the way teaching and learning happens. When nurse training occurred entirely within hospitals, nurses learnt by doing and this was supplemented by theoretical learning mainly in the form of lectures provided by medical practitioners using medical textbooks (nurses had not developed their own disciplinary evidence- based resources.)  After the transition, nurses’ theoretical knowledge was integrated with clinical skills development within the university, (increasingly with evidence-based resources developed by nurses), and their clinical experience within the hospitals. They were introduced to clinical skills in on-campus laboratories where they used dummies, practised on each other and role-played. For OSCAs (objective, structured, clinical assessments), people were employed to come in and act as patients and students were assessed on their interpersonal communication skills alongside their clinical skills.

As university enrolments increased, clinical opportunities narrowed due to the competition for places, funding cuts to universities demanded less resource-intensive methods of learning and teaching, and the fear of litigation led educators to favour low-risk learning environments. This was the context within which universities began to use simulated technology, mannequins, both low and high fidelity, for nurse education.

There is growing evidence that nurses are often failing to communicate in an empathic and compassionate way (Bensing et al. 2013, Francis, 2010). For example, health complaints related to communication have risen in recent times and have now overtaken complaints related to clinical issues (Australian Commission on Safety and Quality in Health Care 2011).The increasing use of high fidelity mannequins to instruct our nursing students may be contributing to the problem. It has been mooted that in the future simulation laboratories using the high technology might well replace clinical experience entirely (Jeffries 2009). While simulation technology is now being questioned in the aviation and medical arenas, there is little debate in nursing (Gilpin 2015).The pedagogical evidence for the use of simulated technology in nurse education is scarce, particularly in the area of interpersonal skill development,  and the fact that medical simulation technology is a major growth market, in an industry estimated to be worth over $2 billion globally  by 2019  is salient. The financial commitments that hospitals, universities and other training facilitates are investing in the technology guarantee an ongoing market for investors and, as investments reports highlight, tie the institutions to the technology (Markets and Markets 2014).

We have known since the early 1970’s that empathic arousal precedes and motivates helping (Hoffman 1979). Machine patients do not and cannot provide what is essential for the development of empathy: communal orientation, vulnerability, unanticipated reactions and actions, spontaneity, recognition of differences and the uniqueness of the individual, and commitment to conversation and interpretation. The emerging worlds of computer simulation reveal that we can, in fact, de-humanise people and remove empathy by mimicking human interaction at a surface level and not including dialogue at the base level (Bastian et al. 2013).

Whilst there undoubtedly are benefits from the use of high fidelity mannequins in nurse education, we need to interrogate their use rigorously and ensure that the important interpersonal dimension of nursing is not lost.

* the authors have published an editorial Dean, S., Williams, C. and Balnaves, M. (2016) Living dolls and nurses without empathy Journal of Advanced Nursing doi: 10.1111/jan.12891

Australian Commission on Safety and Quality in Health Care. (2011). Patient-centred care: Improving quality and safety through partnerships with patients and consumers. Sydney: ACSQHC.
Bensing, J., Rimondini, M., & Visser, A. (2013). What patients want. Patient Education and Counseling, 90, 287-290.
Francis, R. (2010). Robert Francis Inquiry Report into Mid-Staffordshire NHS Foundation Trust. The Stationery Office: London.
Gilpin, K. (2015, June 25th 2015). The benefits of Advanced Physiology Modeling to Simulation. Paper presented at the SimGhosts, Clinical skills development service, Brisbane.
Hoffman, M. L. (1979). Development of moral thought, feeling, and behavior. American Psychologist, 34(10), 958-966. doi: 10.1037/0003-066X.34.10.958
Jeffries, P. R. (2009). Guest editorial: Dreams for the future for clinical simulation. Nursing Education Perspectives, 30, 71-71.
Markets and Markets 2014. Healthcare/Medical Simulation Market by product (Patient Simulator, Surgical Simulator, Web-based simulation, Simulations Software, Dental Simulator, Eye Simulator), End-User (Academics, Hospitals, Military) & By Services - Global Forecast to 2019.

Saturday, 9 January 2016

Becoming a competent nurse

Roger Watson, Editor-in-Chief

Are nurses ready to 'hit the ground running' when they graduate or does competence continue to develop once they enter clinical practice?  I have long suspected the latter and that was certainly my own experience in the transition from student to staff nurse.  If that is the case then it means that nurses are not fully prepared for practice when they graduate but that they develop after they start working.  Hopefully, they have a set of competencies that enable safe practice in most environments but as they specialise and settle down in one particular area of practice, they continue to learn.  This all seems very logical but it is hard to demonstrate and has recently been demonstrated in an Australian study by Lima et al. (2015) titled: 'Development of competence in the first year of graduate nursing practice: a longitudinal study' and published in JAN.  The study aimed to 'determine the extent to which competence develops in the first year of nursing practice' and this was carried out working with children.  The study is unique because, as identified by the authors: 'there have been few studies that have used a standardized tool to determine the development of professional nursing competence in the first year of practice'. I have to admit a special interest in this article due to my own work - some published in JAN - on competence which was cited in the article (Redfern et al. 2002, Watson et al. 2002, Chen & Watson 2011).

The study used the 73-item Nurse Competence Scale and administered it to 47 nurses entering practice with children at 3, 6 and 12 months after entry.  Using some very sophisticated statistical analysis involving mixed effects modelling - which takes into account baseline differences, missing data and time - the outcome of the study, in the words of the authors was that: 'Graduate nurses showed significant gains in competence in the first 6 months of transition from nursing students to Registered Nurses.'  There were gains after 6 months which were not statistically significant.  As the authors conclude: 'It is important to recognize the degree of competence of newly Registered Nurses and beyond. There must be support and professional development opportunities in place to facilitate ongoing development of competence, ensuring the safety of both the newly Registered Nurses and the patients for whom they care during this period of transition.'

Listen to this as a podcast.


Chen Y, Watson R (2011) A review of clinical competence assessment in nursing Nurse Education Today 31, 832–836

Lima S, Newall F, Jordan HL, Hamilton B, Kinney S (2015) Development of competence in the first year of graduate nursing practice: a longitudinal study Journal of Advanced Nursing doi: 10.1111/jan.12874

Redfern S, Norman I, Calman L, Watson R, Murrells T.(2002) Assessing competence to practise in nursing: a review of the literature Research Papers in Education 17, 51–77

Watson R, Stimpson A, Topping A, Porock D (2002) Clinical competence assessment in nursing: a systematic review of the literature Journal of Advanced Nursing 39, 421–431

Breast milk feeding among working women

Roger Watson, Editor-in-Chief

Breast feeding can be problematic for many women and especially those returning to work.  Given the benefits of breast milk feeding to babies, in countries where a large proportion of women work in their reproductive years this, as these authors indicate, can become a public health issue.

In this study from Malaysia by Sulaiman et al. (2016) titled: 'The enablers and barriers to continue breast milk feeding in women returning to work' and published in JAN, the 'enablers and barriers working women experience in continuing breast milk feeding after they return to work postpartum in urban Malaysia' were described.  Using interviews and diaries, 40 women with children younger than two years were involved.

Three types of women were identified: ‘Passionate’, ‘Ambivalent’ and ‘Equivalent’ where the 'Passionate' women were passionate about breast feeding and managed to sustain it into their return to work; the 'Ambivalent' were unable to sustain exclusive feeding with breast milk; and the 'Equivalent' introduced formula feeding before going back to work.  Clearly, breast milk is best and the opportunities to feed breast milk to babies by working mothers should be optimised.  The authors conclude: 'Interventions in the workplace may be useful for most women; however, for those who have decided to formula feed their infants it may not have an impact in creating a mother-friendly environment. Changing or introducing a policy, therefore may be of relevance in influencing some women. To implement or create change in the workplace, using various strategies may help to reach a wider spectrum of women who have different ways of how they interpret the circumstances around them.'

Listen to this as a podcast.


Sulaiman Z, Liamputtong P, Amir LH (2016) The enablers and barriers to continue breast milk feeding in women returning to work Journal of Advanced Nursing doi: 10.1111/jan.12884