Friday, 30 June 2017

How Much More Evidence Do We Need about Nurses’ Work Environments?

Ann-Marie Urban

Over three decades of research, monies, attention and recommendations highlight how the working conditions influence nurse turnover, retention, cost and more recently as highlighted in the recent virtual issue on nurses’ health. Gallagher and Pickler note the importance of healthy diets and stress management as part of improving nurses’ health, however, it is important to recognize the problematic work environment that continues to influence nurses’ health and their work. The realities of many work environments do not allow nurses to practise in a safe and caring way much of the time. Unfortunately, it requires nurses to be productive, expedite discharge, manage increasing complex patients and practise within a traditional hierarchical structure. Sadly, this disconnect has created nurses who are increasingly sick, stressed, bullied, burned out and morally fatigued.

What will the conditions be like in another decade? While nurses know that they work in the adverse conditions of acute care, they may not understand how they contribute to and are organized to meet institutional demands. Increasing patient acuity, budget constraints, a chronic shortage of staff, and overcrowding are routine in hospitals, yet no one discusses how this influences nurses’ work except when discussing nurses as stressed, fatigued or comprising patient care. Nurses are placed in situations where they lack the time, the resources and, in some cases, even the knowledge to care for patients. Because of these problems every year nurses suffer mental and physical injuries which are largely preventable. And sadly but not widely acknowledged, because the majority of nurses are women, this work is expected. Patriarchal underpinning and gendered assumptions situate nurses and their work in a quagmire of persistent problems with strategies focusing on nurses rather than on the system. While the nurse and nurses’ work have been widely studied, a focus on gender related to nurses’ physical and mental health is lacking. Understanding the realities and acknowledging the actualities of nurses’ work in hospitals are key to change. However, before a new reality will be realized, embedded assumptions about nurses and their work must be acknowledged by government, hospital managers and nurses. Similarly, nurses’ work must be understood within the context of the moving political and economic agendas. Further attention must be directed to the nurse’s work environment and how this influences patient care and the health of nurses.

Although efforts to improve the conditions in hospitals have been attempted, few strategies effectively support nurses’ health in their efforts towards patient care in the context of today’s hospitals. What has to change for hospital administrators, governments, professional associations, unions and researchers to notice and make changes? Is it not enough that nurses’ illness and injuries continue to be a problem, and that patient care is compromised? The existing traditional structure must be challenged to embark on another way. Supporting nurses’ health is vitally important for their overall well being for the care of patients.

A new structure would recognize nurses’ work by shifting their participation to a collaborative decision-making team. Different models of care delivery would move nurses to autonomous roles such as patient education, admission and discharge coordinators and patient advocates or to a model that incorporates an expanded role for nurses. Nurses and their work must also be understood within a broader sociopolitical context. Creating a collective awareness about the influencing powers could provide the space for discussion and possibilities for change. The gendered aspect of nursing must also be acknowledged as well as how nurses actively participate in maintaining their place in the hospital. Nurses, too, must realize other possibilities; they must realize that they do not have to become injured, stressed or leave the profession because of the patriarchal and political ruling. Untangling power will take time; however, if we begin to recognize and name it, nurses’ work has the potential to change.

Ann-Marie Urban, RN, RPN
Associate Professor
Faculty of Nursing, University of Regina,

Wednesday, 28 June 2017

Should residents in care homes have sex?

Roger Watson, Editor-in-Chief

My answer to the question that heads this entry is 'why not?' However, this entry covers an article from New Zealand by Cook et al. (2017) titled: 'Ethics, intimacy and sexuality in aged care' and published in JAN. The study on which the article is based aimed to: 'analyse the accounts of staff, family and residents to advance ethical insights into intimacy and sexuality in residential care.' Four  people, including a resident, were involved and interviewed.

With regard to the possibility of intimacy, the resident said: 'No. Couldn’t do anything here because if the door opened and somebody like [manager] walked in I’d be mortified. There are no locks on the door, as you notice. . .So there really is no privacy here at all . . .. I don’t feel like I’m home.' A care assistant expressed uncertainty about what to do with regard to sexuality: 'It [sexuality-related issues] does happen, I’ve seen it happen and nobody talks about it and, we’ve got to make a judgement call, which I have done on a few occasions. . ..and you just don’t know which is the right way . . ..'  The Registered Nurse was aware that some older people may be exploited but said: 'As long as they’re not being taken advantage of and I think for some it can open up new relationships, new caring. Again, when we talk about this everybody thinks of [penetrative] sex. . .but sometimes just to sit, cuddle, kiss, stroke, whatever, that’s more than enough for a lot of them.'

In conclusion, the authors said: 'The topic is complex: too often ageism shapes assumptions about older people’s entitlement to be intimate; where there is cognitive impairment, the debate about upholding the preferences of the “then” self or the well-being of the “now” self may result in conflict among decision-makers; proxy decision-makers may have limited knowledge of the resident’s lifetime of sexual preferences. Education and policies upholding rights may increase staff awareness beyond their own moral code. However, rigid policies may work against residents’ wellbeing. Instead, flexible responses that focus on person-centred wellbeing rather than a risk management approach are desirable.'

You can listen to this as a podcast


Cook, C., Schouten, V., Henrickson, M. and Mcdonald, S. (2017), Ethics, intimacy and sexuality in aged care. J Adv Nurs. doi:10.1111/jan.13361

Fatigue leads to nursing absence

Roger Watson, Editor-in-Chief

Fatigue and the work involved in nursing are closely related, but does fatigue lead to adverse outcomes for nurses? An article from the USA by Sagherian et al. (2017) titled: 'Acute fatigue predicts sickness absence in the workplace: A 1-year retrospective cohort study in pediatric nurses' and published in JAN came from a study that aimed to: 'examine the relationship between fatigue and sickness absence in nurses from a paediatric hospital over 12 months of follow-up. A secondary aim was to identify other work and personal factors that predict sickness absence.'

Forty children's nurses were involved and adminstered a measure of fatigue. Then they were followed up to check on their work patterns. The study showed that the extent of fatigue at the start of the study could predict sickness absence from work; nurses who were more fatigued were more likely to experience sickness absence. In conclusion, the authors say: 'Nursing management can monitor nurse fatigue and unit workloads to decrease this unfavourable outcome and consequently maintain safe practice environments.'

You can listen to this as a podcast


Sagherian, K., Unick, G. J., Zhu, S., Derickson, D., Hinds, P. S. and Geiger-Brown, J. (2017), Acute fatigue predicts sickness absence in the workplace: A 1-year retrospective cohort study in pediatric nurses. J Adv Nurs. doi:10.1111/jan.13357

Tuesday, 27 June 2017

Are nursing students angry people?

Roger Watson, Editor-in-Chief

The answer to the question is that they are more angry than other university students according to this article from Korea by Jun et al. (2017) titled: 'Comparing Anger, Anger Expression, Life Stress, and Social Support Between Korean Female Nursing and General University Students' and published in JAN which aimed to: 'compare anger, anger expression, life stress and social support among female students at a nursing university and a general university and to examine factors affecting anger in each group.'

Nearly 300 female university students, approximately divided into two equal groups of nursing students and other university students participated in the study which required them to complete a questionnaire on anger and sources of anger. The results showed that: '(n)ursing students’ anger scores were slightly higher than the scale’s median value but significantly higher than general students’ scores. Additionally, nursing students’ anger scores in this study were higher than those recorded by homeless people (who commonly reported alcohol problems and difficulty maintaining peer and familial relationships) using the same scale...' The reasons for the higher levels of anger in the nursing students was not clear but it may be the nature of their programme, as the authors explain: 'South Korean nursing students must complete large amounts of homework in each major course to satisfy nursing program certification standards set by the Korean Accreditation Board of Nursing Education.'

In conclusion the authors say: 'High levels of anger in health care providers may lead to poor mental health and reduced care quality. It is therefore particularly important to manage anger among nursing students' and '(a)nger expression and same-sex peer relationships affected nursing students’ anger...(t)herefore, nursing training programs should aim to reduce their students’ same-sex peer relationship stress and provide beneficial anger expression techniques.'

You can listen to this as a podcast


Jun, W. H. and Lee, G. (2017), Comparing Anger, Anger Expression, Life Stress, and Social Support Between Korean Female Nursing and General University Students. J Adv Nurs. doi:10.1111/jan.13354

Monday, 26 June 2017

Stress in newly qualified nurses

Roger Watson, Editor-in-Chief

Nurses are know to suffer stress and the period after qualification and entering clinical practice is an especially stressful period. This UK study by Halpin et al (2017) and published in JAN aimed to: 'investigate transition in newly qualified nurses through an exploration of their stressors and stress experiences during their first 12 months postqualifying.' The study was titled: 'A longitudinal, mixed methods investigation of newly qualified nurses’ workplace stressors and stress experiences during transition.'

Nearly 300 nurses completed a stress questoinnaire and were interviewed when they qualified and were followed up at 6 (over 100 nurses) and 12 months (over 80 nurses) after qualifying. While stress did not change significantly over the study, at each phase of the study 'workload' was the highest source of stress. Nurses reported being 'terrified' at the start; as one nurse said: 'When you first start obviously you are terrified because you are suddenly feeling responsible for everybody, all your patients. Just the overall feeling of the weight of responsibility, that stresses me.' They also did not like appearing not to know everything and one nurse said: 'It’s quite hard to say to some people, ‘sorry, I’m newly qualified’ because they just want answers then and there, so that’s added stress as well for me.'

In the words of the authors: 'Many of the stressors experienced by the participants had the potential to inhibit a successful transition. The results showed that the participants experienced a broad range of stressors throughout their first 12 months postqualifying resonating with the outcome of previous international studies...' In conclusion, the authors said: 'Planned, regular, constructive feedback from the (newly qualified nurse)’s manager would assist with personal development and the early identification of work-related stressors. Organization based training to improve effective and civil team-working together with a clear strategy to report and address incivility would also be beneficial. Healthcare experience prior to commencing nurse education appears to be a personal asset and is worthy of further research as it implies a change to pre-registration recruitment strategies should be considered.'

You can listen to this as a podcast


Halpin, Y., Terry, L. M. and Curzio, J. (2017), A longitudinal, mixed methods investigation of newly qualified nurses’ workplace stressors and stress experiences during transition. J Adv Nurs doi:10.1111/jan.13344

Friday, 16 June 2017

Addressing the needs of first-time fathers

Roger Watson, Editor-in-Chief

Childbirth is time when attention is, rightly, focused on the woman and the baby. But what about the father and, esepecially, first-time fathers? What are their needs and how can they be addressed? This is  the topic of an article from Singapore by Shorey et al. (2017) titled: 'First-time fathers’ postnatal experiences and support needs: A descriptive qualitative study' and published in JAN.

The study aimed to: 'explore first-time fathers’ postnatal experiences and support needs in the early postpartum period'. Fifteen first time fathers were interviewed  and, hardly unexpectedly, the researchers found: '1) No sense of reality to sense of responsibility, (2) Unprepared and challenged, (3) Support: needs, sources, experience and attitude and (4) Future help for fathers'. For example, one father said: 'One thing that we want to do (as a father) is to get more involved. But, another thing, maybe, from the hospital or from institutes, is telling us what we have to do. So, to be more aware, involve us more so that we will feel more important (laugh)'. The authors concluded: 'This study provides empirical evidence on the experiences and support needs of first-time multiracial fathers in Singapore. The fathers in this study underwent a series of emotional and personal challenges during their transition to fatherhood in the early postnatal period. They shared their support needs and the desire to be considered as an integral part of their family by Singapore healthcare professionals, especially nurses and midwives'.

You can listen to this as a podcast.


Shorey, S., Dennis, C.-L., Bridge, S., Chong, Y. S., Holroyd, E. and He, H.-G. (2017), First-time fathers’ postnatal experiences and support needs: A descriptive qualitative study. J Adv Nurs doi:10.1111/jan.13349

Wednesday, 7 June 2017

Are nurses fit to work?

Roger Watson, Editor-in-Chief

How fit are nurses compared with those they look after - the general population, and what happens to nurses' fitness when they work as nurses? That was the focus of a study from Australia by Perry et al. (2017) which aimed to: 'examine the quality of life of nurses and midwives in New South Wales, Australia and compare values with those of the Australian general population; to determine the influence of workforce, health and work life characteristics on quality of life and its effect on workforce intention to leave'. The outcome of this study is an article published in JAN titled: 'Health, workforce characteristics, quality of life and intention to leave: The ‘Fit for the Future’ survey of Australian nurses and midwives'.

Physical and mental health in over 4,500 nurses was studied over two years in New South Wales and compared with the general public and the characterstics of the nurses related to their fitness was examined. The results showed that nurses were more physically fit than the general public but less fit in terms of mental health. Nurses became less physically fit as they aged but reported better mental health. Nurses with poor mental health were more likely to want to leave their job.

The authors concuded: 'The study provides evidence for nursing/midwifery managers, researchers, decision-makers and policy-makers, and advocates for the development and implementation of targeted interventions for the nursing and midwifery workforce. Findings indicate potential benefit in terms of staff quality of life and workforce retention, for interventions focused not only on mental health, well-being, coping and resilience particularly but also on better sleep, pain reduction, smoking cessation and general health screening/health promotion.

You can listen to this as a podcast


Perry, L., Xu, X., Duffield, C., Gallagher, R., Nicholls, R. and Sibbritt, D. (2017), Health, workforce characteristics, quality of life and intention to leave: The ‘Fit for the Future’ survey of Australian nurses and midwives. J Adv Nurs. doi:10.1111/jan.13347

Tuesday, 6 June 2017

Can a nurse who smokes promote health?

Roger Watson, Editor-in-Chief

Does it matter if a nurse smokes? Will they be effective at health promotion? This was the subject of an article from Spain which was based on a study aiming to: 'explore the views of current and ex-smoker nurses on their role in supporting patients to stop smoking.' The article by Mijika et al (2017) was titled: 'Health professionals’ personal behaviours hindering health promotion: A study of nurses who smoke'.

The study used interviews with nurses who had or who still smoked in one hospital in Spain. The views of the nurses varied; one nurse who thought it made no difference said: 'I think that in terms of patients it (being a nurse who smokes) doesn’t have an impact (on the care provided to the patient), I mean . . . the patient knows, when you are at work you are a nurse...'. But another disagreed, saying: 'I think it does have an impact. I think it does. [. . .] For example, if a patient is trying to quit and has a lung cancer and a smoker nurse who smells of tobacco approaches him advocating for something that she’s doing wrong. . ., that has to provoke some kind of reaction in the patient.' Even in the face of patients ill from a smoking related disease, nurses were able to justify smoking: 'I have experienced situations like when you are taking care of a patient who is very ill, grasping for breath, with a lung cancer, the family very uptight, with...very bad...and I have got out and said “I’m going to smoke.” I mean situations that overwhelm you, that you can’t control with medication, that you can’t control...that affects your human nature, you know?'

The authors concluded: 'Nurses with an unhealthy behaviour such as smoking experience
internal processes that might have a negative impact when engaging in health promotion practice. Smoking nurses may be inhibited as health promoters without noticing it, and they may need help to
address the conflict that they experience between their professional responsibility and their smoking behaviour. If health promotion practices are to be enhanced, interventions that help these health professionals are necessary.'

You can listen to this as a podcast


Mujika, A., Arantzamendi, M., Lopez-Dicastillo, O. and Forbes, A. (2017), Health professionals’ personal behaviours hindering health promotion: A study of nurses who smoke. J Adv Nurs.  doi:10.1111/jan.13343

Monday, 5 June 2017

Response to commentary on Blake, Stanulewicz & McGill (2017) Predictors of physical activity and barriers to exercise in nursing and medical students

Response to commentary on Blake, Stanulewicz & McGill (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929

Holly Blake
Natalia Stanulewicz
Francesca McGill

On the May 10th 2017, JAN interactive published a commentary on Blake, Stanulewicz and McGill (2017) by Chappel et al. (2017). The authors of the commentary raised two main concerns regarding the study:(1) a possible misinterpretation of physical activity (PA) as solely “formal exercise” by the participants, and (2) a questionable extrapolation of the proposal for the need for PA interventions from student to staff nurse populations.

Regarding the first concern, the IPAQ-SF has been established as a reliable measure (e.g., Craig et al., 2003), that has been employed extensively across populations, cultural groups and demographics, and is extensively utilised worldwide. It was the preferred measure for use in this study due to its short format and ease of use, and has been described as ‘the most appropriate outcome measure for clinical and research use, as it has excellent reliability and moderate correlation with accelerometry’ (Silsbury et al, 2015).

We cannot report on exactly how participants interpreted the individual IPAQ-SF items in this online survey, although the measure includes items relating to walking, and vigorous or moderate intensity activities, and examples of activities were provided. Importantly, our participants were healthcare students, who receive education and training around health behaviours as part of their studies. At the institution where the data were collected, this includes both the distinction between types and levels of PA, and the relevance of work-related PA (including incidental activities) and their contribution to overall daily activity. Therefore, recognising there will be individual variation in the retention of learning, the overall potential for misinterpretation of PA and what it entails is likely to be low, or certainly lower in this sample than for other populations. For nurses, health promotion is a core aspect of their future professional role and as such is emphasised early in the first year of training.

We accept that PA may be either under, or over-reported using self-report measures, and that objective data is required to accurately measure PA levels. We do not dispute the potential for under-reporting of PA, although a systematic review of the validity of the IPAQ-SF including 23 studies, found that in almost all of the included studies, PA was actually overestimated using the IPAQ-SF by 36-173% (Lee et al, 2011).

Chappel and colleagues were concerned about extrapolating from student nurse to nurse populations, given the likelihood of higher PA in nurses within clinical settings. However, we remain convinced that our recommendations, based on our student sample and taken in context alongside the published literature, remain highly relevant to nurses as well as students of nursing.

First, workplace PA interventions can generate benefits in a range of occupational groups (see review by Anderson et al, 2009) including occupations incurring highly physical demands, such as home care workers (Pohjonen & Ranta, 2001). Physically demanding work does not necessarily have positive effects on physical fitness and so worksite PA intervention may offer additional benefits beyond work-related activities Further, we make no claim in our article that nurses and healthcare students are one and the same, although it is of clear relevance that all of the nursing students who completed our survey were registered on courses involving integrated clinical placements, and were regularly working alongside registered nurses in diverse clinical areas; therefore it follows that they may be exposed to similar work-related physical activities, and they were asked to report their activities with relation to clinical placements as well as university time.

Second, if high levels of work-related PA are observed in nurses (note: we do not know how this compares with students PA whilst on shifts), or if registered nurses self-report higher levels of PA than student nurses, we feel it would be unwise to focus only on the differences between the two populations in debating where to target PA intervention. The published evidence suggests that barriers to exercise reported by both groups can be similar, and that many nurses and students [a] do not meet government recommendations for daily PA, [b] are overweight or obese, and [c] report that their own health habits can impede their willingness to promote PA to patients. This sits clearly in line with the national call for health improvement of the health and medical force made in the 2010 Prime Minister’s Commission on the Future of Nursing and Midwifery in England, and the current government investment in health and well-being through the NHS Five Year Forward Plan.

With efforts to increase retention of nursing graduates, there is an increasing drive to instil healthy lifestyle behaviours in student nurses to ensure a healthy public health workforce for the future. This may help to establish patterns of healthy behaviours early on that will continue into the nursing career, and be promoted to patients and their families. Patterns of health behaviours that are established early on are likely to continue beyond registration and through the nursing career. Orr et al (2014) propose that PA positively correlates with motivation, well-being, coping and positive attitude, and that these attributes in turn impact on employability, retention and absence; they advocate that poor health and well-being of nurses may present risks around fitness to practice and may even breach the Nursing and Midwifery Council (NMC) Code of Conduct. These are all relevant factors for students and nurses, and for the transition between the two roles; and so it would be challenging to claim that these populations were unrelated.

Thus, we propose that health behaviours should be advocated and supported from student through to registered nurse rather than focusing solely on [i] either group, or [ii] the potential differences in PA between groups becoming determinants of whether it is timely to offer services, to which group, and to the exclusion of the other. Because of this we strongly disagree that it is premature to advocate PA intervention for nurses in the NHS workplace informed by findings from our sample, which sits alongside a wealth of published research evidence and national government-funded workplace intervention programmes.

Both nurses and nursing students consistently report low levels of PA, high levels of overweight and obesity, and barriers to healthy lifestyles influenced by common variables such as time pressure and shift work. We now need to move forwards in supporting healthcare professionals (of the current and next generation) to make healthy lifestyle choices. In workplace health practice, service commissioners do not necessarily distinguish between nurses and trainees who are not yet registered when it comes to promoting health – they all contribute to NHS healthcare through the profession of nursing, and can all access the same workplace physical activity interventions (see Nottingham University Hospitals NHS Trust as an exemplar of NHS well-being: Blake et al, 2013) and a ‘flagship’ trust in the UK Department of Health Five Year Forward Plan.

The ultimate goal of promoting PA to nurses or student nurses is broadly the same: to protect the physical and mental health of individuals, to reduce unnecessary burden to the NHS, and to support high quality patient care.

Dr Holly Blake
School of Health Sciences
University of Nottingham, UK

Natalia Stanulewicz
Department of Psychology
Durham University, UK

Francesca McGill, RN
Alder Hey Children’s Hospital
Liverpool, UK


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Silsbury Z, Goldsmith R, Rushton A. Systematic review of the measurement properties of self-report PA questionnaires in healthy adult populations. BMJ Open 2015;5:e008430. doi:10.1136/bmjopen-2015- 00843