Thursday, 30 November 2017

VAW 2017: Gender pressures on the female and male genders in Pakistan

by Saima Eman

While we all know that gender-based violence affects women more than men, it strange to think that the male gender can be adversely affected by the negative stereotypes held by their female counterparts in many countries. South Asia can be a very good example in this regard and I will use the example of Pakistan to describe my point further.

What I observe is that it is not easy for men to accompany their spouse and children to family parks in the evening because that time is confined to ladies and children. In schools, men may not be allowed to go inside and communicate with teachers on a daily basis. One might say that this is a manifestation of patriarchy and a way things are in a patriarchal society such as Pakistan’s, however, this also has an impact on males too, or at least on some men. Since women in Pakistan feel uncomfortable in the presence of men other than their relatives, women in dual roles involving outside work and household tasks face a lot of pressure. That pressure is culture-driven, whereby women are expected to perform their household duties no matter whether they are working women or not. I would also call this pressure, an indirect form of self-bestowed pressure, which seems to stem from the unfounded, culturally instilled androphobia in Pakistani women. As a consequence, women feel overwhelmed with multiple tasks and responsibilities. Husbands are generally overprotective of their wives to the extent that ladies are not allowed to stand outside the house gate until the car or the taxi has arrived. Women from middle and higher classes are not seen walking to the markets outside the housing society. There is no safe public transport. The movement of women is quite restricted due to an unsafe environment. By unsafe, I am referring to the pollution of attitudes (male and female staring and ogling, hostile traffic) and the pollution generated by the smog.

The government institutions work in a haphazard way. When a man enters the women’s university, the security guards follow him as if he is a criminal. Female university students are perceived as the property of their parents and guardians. The parents pay their tuition fees. They cannot leave the university without their guardians. If a female student manages to escape the university within the university term, the parents or guardians hold the university, the teachers and the staff accountable. The guardianship gets transferred from parents to husbands following marriage.

Men who have experienced the friendliness of women in other countries (where they may have worked or studied), feel intimidated by the female members of Pakistani society because they give the man a stern or angry look as if he is any ordinary Pakistani (stereotyping him as a male villain or a chauvinistic person). Such a man avoids gatherings, which are dominated by ladies. Women domestic helpers are usually very defensive towards men because men are traditionally aggressive. Most men are perceived as aggressive with a domineering attitude, obsessed with sexual fulfilment, disrespectful towards women and their desires to the extent of honour killings in extreme cases. Therefore, suspicious glares from women towards men and androphobia is justified to a certain extent. Since men are also aware of the nature of Pakistani men in Pakistan, they assume an overly protective role towards their wives, mothers and sisters. For example, they would not sit with their female relatives in the male-dominated areas of a restaurant, hospital or market place. Due to the gendered societal response, an open-minded man would be uncomfortable being a male in Pakistan, while a female is overburdened with different roles. I can give my own example here. I have to do so many things on my own because my husband cannot accompany me everywhere due to his gender. For example, I have to miss delivering lectures at my workplace to accompany my child’s school trip to the zoo. I have to be late to work because I have to attend a practice assembly to motivate my son to speak before the audience (fathers not allowed). There is an hour’s distance between my child’s school and my workplace. My husband could easily help me out because he is 5 minutes from the school (at home) and he is not at work at the children’s school time. However, due to the school rules based on societal attitudes (females comfortable with females and males with males), the fathers are not allowed and as a female in Pakistan, I have to suffer.

The typical orthodox Pakistani culture does not accept friendliness of the opposite sexes. Those who go against the culture are termed as ‘liberal’, ‘modern’ in a negative way. Since the society segregates the male and the female genders, generally female members of upper middle class families are not seen walking on the roads, bicycling, and in roles defined as masculine by the society. The gender roles are still stereotyped into masculine (outside work) and feminine roles (inside household work). Even though many Pakistani women are going for higher education and careers in Pakistan, their primary role is still considered to revolve around the house and children, but men are not expected to work or help out at home. Therefore, when a female member from an upper middle class is seen in masculine roles, she is not protected from ugly stares of the men. Surprisingly, even in a female-dominated area, the female is perceived as a victim if a male enters that area. The underlying eastern societal perception is that the female gender is weak and unable to protect herself and survive without a man (brother, father, son or husband only). Therefore, the men (other than brother, father, son or husband) are perceived to be the perpetrators, the villains, and the women are perceived as victims no matter whether women are performing the masculine chores or even if a single man enters the female-dominated area.

The unhealthy expectations on behalf of the female gender about the male gender due to a stereotypical negative image of the male gender in Pakistan, the female gender is victimising the female gender through an increase in the female share of the burden. This is just one facet of gender discrimination. Even in household politics and workplace politics the female is both the perpetrator and the victim in Pakistan. The mother-in-law, sister-in-law, daughter-in-law politics occurs at home (primarily around kitchen control and division of the household tasks) whereby the female is a perpetrator and a victim. The mother-in-law complains to her son about her daughter-in-law; the daughter-in-law complains to her husband about the mother-in-law. The female domestic helpers gossip about daughter-in-law to mother-in-law and vice-versa. At workplace the female clerical staff as opposed to the male clerical staff disrespects the female teachers. The female bosses create problems for female subordinates and vice versa. The power politics occurs in the form of psychological bullying, taunts, harsh words, etc., and the physical torture occurs in the form of extra duties, work burden, extraordinary inspection and accountability.

I think that both genders are equally victimised in Pakistani society. The difference, however, could be in the form of overburden and restriction (of movement, and performing male-stereotyped roles) for the female gender and under-burden/restriction (in performing female-stereotyped roles) for the male gender.

Saima Eman
Lecturer in Psychology
Lahore College for Women University, Pakistan

PhD Commonwealth Scholar
University of Sheffield, UK

Khan Bahadur Visionaries Welfare

Twitter: @SaimaEman1


Wednesday, 29 November 2017

VAW 2017: Domestic Abuse and the Needs of Children – Untangling the Web

by Alison Higgins
In September 2017, the multi-agency response to children living with domestic abuse report was published. This resulted from a joint targeted area inspection programme, which began in September 2016. The findings in this report ‘consider the extent to which, in the six local authorities inspected, children’s social care, health professionals, the police and probation officers were effective in safeguarding children who live with domestic abuse. The report calls for a national public service initiative to raise awareness of domestic abuse and violence. It also calls for a greater focus on perpetrators and better strategies for the prevention of domestic abuse.

From my perspective as a commissioner of domestic and sexual abuse services in a local authority, this document is incredibly important and valuable. The inspectors, as well as visiting six local areas, have consulted focus groups of victims and survivors as well as sharing findings with stakeholders from national organisations such as Women’s Aid and SafeLives. Their overarching conclusion is that ‘while much good work is being done to protect children and victims, far too little is being done to prevent domestic abuse and repair the damage that it does’. This statement makes me want to shout ‘yippee’ from the rafters, not because I think it is a good state of affairs but that at last this is being recognised on a national level.

It feels to me that the volume of domestic abuse that services are presented with on a daily basis – ‘Domestic abuse is the most commonly cited factor when children are assessed by children’s social care services to determine whether they need support. In 2015-16, there were around 222,000 episodes where domestic violence was cited as a factor. This translates into around 28 new episodes every week in every local authority in the country’ – has meant that responses have become jaded and part of business as usual. Domestic abuse is almost normalised. Action is taken to address immediate issues but it is almost always focussed on short term crisis management. This means that not only is little being done to address the impact of domestic abuse on children but that ‘professionals sometimes failed to connect isolated incidents and build a picture that would lead to a different conclusion about the level of risk’. This short term view can make it harder for professionals to see the bigger picture and history of abuse within the family setting.

The report also highlights assumptions and ways of working in relation to domestic abuse that are letting down children and victims: 
  • Once the victim has left the abuser services often assume they are able to cease support. The report points out that ‘the end of an abusive relationship was considered [by agencies inspected] to reduce the risk to children, when in fact research tells us that separation can escalate risk’.
  • Perpetrators are not held to account for causing risk to children, instead it can be the victim who is held responsible: the report found ‘a pattern where professionals focused on the victim, which in all the cases we saw was the mother. In the best-case scenarios, this represented an understandable focus on the mother as a victim of crime and in need of protection. But, even in the best cases, there was often a lack of accountability or responsibility attributed to the perpetrator of the abuse. Furthermore, in a minority of cases, there was an inappropriate attribution of responsibility on the mother to protect her children.’  
  • Victims can be viewed as failing parents rather than shown empathy given the abuse they have suffered. The report highlighted one case where ‘a mother was in distress due to living with domestic abuse and this was having a clear impact on the well-being of her child. Her child was seen in her home by a health visitor, she was naked, with food around her face. The home conditions were observed to be messy and the mother was reported to have made another suicide attempt. The conditions the child was living in were recorded in isolation. There was no evidence in the record that the practitioner considered the impact of domestic abuse on the well-being of the mother, and subsequently, her ability to care properly for her child’. 
  • Understanding the impact of coercive control (now criminalised in law and recognised as the foundation of most domestic abuse) is lacking ‘because it confounds the usual interpretations of behaviour. Victims themselves can appear to be manipulative, secretive or contradictory in their words and actions. It takes skill and insight to identify that untruths or attempts to distract or mislead may be a coping strategy. Effective engagement with such victims relies on the skills, insight and experience of professionals and their ability to move beyond a ‘victim-blaming’ response.’
For me, this last point brings to mind a member of the Sheffield Domestic Abuse Service User Reference Group who relayed her experience of having taken her abusive partner back when her child was a baby, and then lying to the social worker when they came to her house to challenge her. She was a young, vulnerable woman at the time who felt that if she was honest, she would be blamed and her child would be taken away. She therefore felt it was better to lie. This was a course of action she later regretted, but I think we need to find a way of moving away from a narrative of labelling victims as ‘failing to protect’ – as she was when she was inevitably found out. What if the worker had said to her ‘I know it’s hard to get out of a relationship when there’s domestic abuse. I want to help you and empower you so that you can safeguard yourself and the baby’? The report suggests that working to build trust and supporting parents who are victims is ultimately the best way to support children living in domestic abuse situations even if removing children is unfortunately necessary sometimes.
The report recognises that domestic abuse is complex especially when substance misuse and mental health issues are also present. ‘Untangling this web and being consistent in identifying who needs to be held responsible, and for what, will always be challenges for professionals.’ But change is necessary, ‘the pattern of practice has served its time. We think the system is ready to evolve [because] … Domestic abuse is incredibly harmful to children and it poses an enormous cost to the public purse to deal with the repercussions. ’
In Sheffield, we are beginning a new project, ‘Strengthening Families’, which is intended to address these issues by working with families to improve longer term outcomes. We are developing interventions for perpetrators including fathers, expanding group support for mothers, commissioning therapeutic work with children – all to be coordinated by a team of multi-disciplinary key workers focussing on families affected by domestic abuse. We hope it will make a difference.

Alison Higgins has been the Strategic Commissioning Manager for Domestic and Sexual Abuse at Sheffield City Council since 2010. As well as being responsible for commissioning services for the city she coordinates Domestic Homicide Reviews, leads on the city’s strategy for Domestic and Sexual Abuse and is a co-chair of the Multi Agency Risk Assessment Conferences in Sheffield. Her background is in the voluntary sector. She worked at North Derbyshire Women’s Aid (now Derbyshire Domestic Abuse Services) for 15 years prior to working for Sheffield.

Tuesday, 28 November 2017

Response to Demetra Horotan, 'Coping with Parkinson's'

Mari Carmen Portillo. PhD, MSc, RN. Associate Professor, Faculty of Health Sciences, University of Southampton. UK.
M Victoria Navarta-Sánchez. PhD, MSc, RN. Lecturer, Faculty of Nursing, University of Navarre. Spain.
Regarding the commentary on our article (Navarta-Sánchez, 2017) we would like to show our appreciation to Demetra Horotan for her interest in the benefits of coping strategies for people with Parkinson's Disease (PD) and their family members. This is a fascinating area of research that needs further development especially if as nurses we want to make a difference in the lives of people with PD and their family members. We would also like to clarify and discuss the issues mentioned by Demetra Horotan in the commentary in JAN Interactive published on Monday, 20 November 2017.
Concerning the comment made about the use of the Chronic Care Model (CCM) we can confirm that the intervention design presented in the paper by Navarta-Sánchez et al. (2017) is based on the assumptions of the CCM because this model encourages an approach to support self-care, long-term monitoring, and the use of community and technology resources (Coleman et al., 2009). In particular, our intervention is focused on improving self-care through an enhanced process of coping with PD in people with the disease and their family carers. One specific strategy of this intervention among others (see Tables 5 and 6 in the above mentioned paper) is that nursing professionals could empower people with PD and family carers to develop more effective and sustainable coping skills in the community, which may improve their health, well-being and quality of life -- and this includes acceptance of the disease.
The assumption expressed in the commentary stating that reinforcing the acceptance of PD in both the patients and their family carers is an approach that appears to focus on a medical view is not accurate because recent research supports the need to work on the acceptance of the disease due to the concerns expressed by many people with PD and family carers and not to a medical view/preference.
Recently, a qualitative study (Kang & Ellis-Hill, 2015) and a review of relevant literature (Ambrosio et al., 2015) have come up with the same conclusion not only for PD but also for other long-term conditions. These studies highlight that the acceptance of the disease and its consequences is essential for people with PD and family carers to cope with the new situation, feel better and carry on with a meaningful life, and also evidence the difficulty that accepting the disease and the changes in their bodies and their lives involves for them (Kang & Ellis-Hill, 2015).
Furthermore, from a quantitative perspective some studies have shown significant statistical associations between the psychosocial adjustment to a chronic illness and the quality of life equally in people with PD and family carers (Suzukamo et al., 2006; Navarta-Sánchez et al., 2016) and the influence of coping skills in PD (Navarta-Sánchez et al., 2016) and other long-term conditions (Ambrosio et al., 2015). Therefore, this also supports the relevance of this approach if we want to contemplate patients’ and family’s wishes and needs and plan interventions accordingly.
In relation to the importance of using the Resilience Theory as a guiding framework in the design of the qualitative phase and the proposed intervention, we would like to point out two aspects:
  • The Resilience Theory provides an interesting positive point of view on people’s strengths needed to tackle adversity. However, this varies from the approach we presented in the paper based on the Chronic Care Model (Coleman et al., 2009) and the understanding of coping skills (Lazarus & Folkman, 1984). In our study we also aimed to identify negative coping skills used by family carers, like the tendency to focus their energies on the well-being of the patient exclusively to be able to reverse them. Also, our approach looked at other community and technology external resources, which could be used to encourage positive coping skills in people with PD and their family carers.
  • Contrary to the statement made in the commentary, without the Resilience Theory is possible to suggest strategies to strengthen family bonds. In fact, in our study we are highlighting strategies like the promotion of empathy to foster strong family ties and functional networks. In Table 5 of the paper we suggested that nurses may help patients and relatives to reflect on changes that each family member has experienced due to PD. Through the encouragement of these reflections, nurses could increase the empathy and reciprocal support in these families.
Regarding the criticism stating that in the paper little attention is given to the caregiver’s own health and handling of the chronic illness and that strategies should be aimed at reducing psychological burden, we would like to emphasize that:
  • Our intervention does contemplate the need for nurses to develop group sessions only with family carers. We consider that family carers have their own needs, some similar but others different to the patients’. Thus, although this requires an important effort of time and resources, it is necessary in order to deal with the health and well-being of family carers.
  • Finally, our intervention is part of a health promotion and prevention plan. For this reason, it is suggested that nurses should support the self-care in family carers in Primary Care Centres. Interventions focused on burden are necessary and relevant. However, here we are proposing an overarching prevention approach that could reduce the family carer’s distress also when it comes to personal and system burden. This is only possible through multifaceted-integrated interventions, which involve the use of community resources, and the adoption of healthy lifestyles and self-care skills among others.
Ambrosio, L., Senosiain García, J.M., Riverol Fernández, M., Anaut Bravo, S., Díaz de Cerio Ayesa, S., Ursúa Sesma, M.E., Caparrós Civera, N. & Portillo, M.C. (2015). Living with chronic illness in adults: a concept analysis. Journal of Clinical Nursing, 24, 2357-2367. DOI: 10.1111/jocn.12827.
Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the Chronic Care Model in the new millennium. Health affairs, 28 (1), 75-85.
Kang, M., & Ellis-Hill, C. (2015). How do people live life successfully with Parkinson’s disease? Journal of Clinical Nursing, 24, 2314-2322. DOI: 10.1111/jocn.12819.
Lazarus, R. & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer. ISBN: 0826141927.
Navarta-Sánchez, M. V., Senosiain García, J. M., Riverol, M., Ursúa Sesma, M. E., Díaz de Cerio Ayesa, S., Anaut Bravo, S.,… & Portillo M.C. (2016). Factors influencing psychosocial adjustment and quality of life in Parkinson patients and informal caregivers. Quality of Life Research, 25, 1959-1968. DOI: 10.1007/s11136-015-1220-3.
Navarta-Sánchez, M.V., Caparrós, N., Riverol, M., Díaz de Cerio, S., Ursúa, M.E., & Portillo, M.C. (2017). Core elements to understand and improve coping with Parkinson’s disease in patients and family carers: A focus group study. Journal of Advanced Nursing, 73, 2609-2621. DOI: 10.1111/jan.13335.
Suzukamo, Y., Ohbu, S., Kondo, T., Kohmoto, J. & Fukuhara, S. (2006). Psychosocial adjustment has a greater effect on health-related quality of life than on severity of disease in Parkinson’s disease. Movement Disorders, 21, 761-66. DOI: 10.1002/mds.20817.

VAW2017: Narrative and arts-based approaches to explore experiences of Gender-Based Violence

by Julie McGarry
Gender-based violence (GBV) may be described as a sensitive topic for a number of reasons. These include the emotive and challenging nature of the topic for all of those who are engaged in this area, including practitioners, clients and patients, researchers and research participants. However, arguably for those who are engaged with survivors of GBV in both practice and research environments, a sensitive approach to the process of enquiry is also required in order that experience does not become, in the words of Frank (2002) “an object to be measured and thus objectified” (p12). This involves a consideration of the approaches that may be used to capture the perspectives of individuals in their own words, rather than that which has been produced through the conduit of the ‘expert’ or researcher.

Relatively recently there has been a growing interest with regard to the possibilities of creative approaches to research and practice, including narratives across a range of subject areas. Fraser (2004) suggests for example [in a general sense and not directly related to GBV] that “with the greater acceptance of postmodern research methods, personal storytelling is now seen as a valid means of knowledge production” (p180). Fraser further suggests that narrative approaches have "much to offer" professions in practice [in Fraser’s example, social work] in terms of moving beyond a dialogue that is often structured around the perceived ‘expertise’ of the professional and a ‘problem focused’ approach to one which acknowledges context, interactions and ‘meaning making’. This approach arguably also has the potential to be relevant for those working with survivors of GBV. Whereby, as noted by researchers, there is often “limited understanding among professionals regarding why women may not be able to leave an abusive relationship (Lapierre, 2010) and the associated emphasis placed on mothers in terms of a ‘failure to protect’ children within the family (Hester, 2011)” (cited in McGarry & Watts, 2016). 

For individuals themselves, the use of narrative and creative approaches may perhaps also offer a means through which participants feel “empowered to share their experiences through their own accounts” (McGarry & Bowden, 2017). For those who have experienced GBV this can be pivotal to facilitating the conditions whereby voices that have all too often been silent have the opportunity to be heard. Moreover, personal experiences and the impact of GBV for survivors may be difficult to fully articulate through more traditional research methodologies. For example, Renold (2017), in her research with teen girls and sexual violence, highlights that “not all ‘felt effects’ can be articulated through words. Some experiences form part of an "unthought known" (Bollas, 1987) – that is, they can be felt corporeally, but are too painful to talk about” (p9). 

 The use of creative and narrative approaches are not without methodological and practical challenges, not least challenges from and to established evidential paradigms. However, there is also huge potential and this is worthy of further exploration and debate.


Bollas, C. (1987) The shadow of the object: psychoanalysis of the unthought known. New York NY: Columbia University Press, Free Association Books

Frank, A. (2002) At the will of the body: reflections on illness. New York: Houghton Mifflin Company

Fraser, H. (2004) Doing narrative research: analysing personal stories line by line. Qualitative Social Work. 3: 179-201

Hester, M. (2011) The Three Planet Model: Towards an Understanding of the Contradictions in Approaches to Women and Children’s Safety in Context of Domestic Violence. British Journal of Social Work. 41, 837 – 853

Lapierre, S. (2010) More Responsibilities, Less Control: Understanding the Challenges and Difficulties Involved in Mothering in the Context of Domestic Violence. British Journal of Social Work. 40, 1434 – 1451

McGarry, J & Bowden, D (2017) Unlocking stories: older women’s experiences of intimate partner violence told through creative expression Journal of Psychiatric and Mental Health Nursing.

McGarry J and Watts K (2016) Strengthening Interventions to Reduce Domestic Abuse (STRIDE) Project Report Executive Summary

Renold, E. (2017) ‘Feel what I feel’: making da(r)ta with teen girls for creative activisms on how sexual violence matters. Journal of Gender Studies.

Dr Julie McGarry 
Associate Professor, School of Health Sciences, University of Nottingham

Julie is an established researcher with expertise and professional background in the field of safeguarding (adults and children), gender-based violence and intimate partner violence/domestic violence and abuse with a focus towards survivors' experiences and the development of effective health/social care professionals' responses. Julie also has a well-established background in participant led research exploring effective approaches to domestic violence identification and management through co-production of arts based narrative projects with survivors of female genital mutilation (FGM) and domestic violence and abuse. Julie has initiated multi-agency collaborative scholarly partnerships on both international and national levels through leading the successful inception of the Integrated Domestic Violence and Abuse Research Group and Seminar Series within the Social Futures Centre of Excellence, Institute of Mental Health. Julie has published widely, disseminated her work through national and international conferences, and invited keynote speaker presentations. Recent co-production e-learning arts based resource 'Unlocking Stories: Older Women's Experiences of Domestic Violence and Abuse told through Creative Expression' can be accessed here:

Monday, 27 November 2017

Coercive Control Relationships Hurt Women’s Health

by Lisa Fontes, PhD
Isolated. Degraded. Manipulated. Threatened. Stalked. And sometimes subject to physical and sexual violence. It’s no wonder some women’s relationships are making them sick. Coercive control is a strategy some people use to dominate their intimate partners—mostly men over women.1 It’s not just bossiness—it’s domination. Over time, women who are treated this way lose their autonomy, self-esteem and sense of well-being. Between the direct acts of control and possibly violence, a woman lives in fear of doing anything that might anger her partner. The distress is ongoing, even during periods that seem calmer. Some abusers also deliberately weaken their partners physically, restricting their access to food, interfering with their sleep and medical care, obligating unwanted pregnancies, pushing them to use alcohol or drugs, and beating or sexually assaulting them.

Here are examples of ways a controlling partner can directly interfere with a woman’s health:
  • Gita’s husband would not let her go anywhere unaccompanied. He insisted on sitting in on her medical appointments, explaining to the clinic staff that this was “cultural.”
  • Over a period of years, Cindy’s boyfriend whittled away at her self-esteem so much that she hated to have anyone look at her—she could barely stand to see herself in the mirror. He obligated her to work out constantly and restricted her intake of food. He was never satisfied with her appearance, and insulted her body all the time, threatening to leave her for someone “hotter."     
  • Shanique’s husband cancelled her counselling appointment, saying she was disloyal for wanting to tell others about their private matters.
  • When Grace, 16, attended a routine medical appointment, her provider noticed that her breasts were bruised. Grace said her boyfriend did it, and that it was “nothing.” The provider was alarmed but didn’t quite know what else to ask to determine if Grace was safe.
  • The medical staff noticed that Carmen had to check with her boyfriend about “everything”— which exams they’d give her, where she should pick up her prescriptions, what medicines she could take, and referrals to other providers. They heard her explaining to him on her phone, from the waiting room, that she really was delayed at the doctor’s and would be home soon, apparently begging him to trust her before she finally snapped a photo to prove where she was. She looked worried.
  • Sally, a nurse, found it “natural” to take care of her boyfriend, Sam, who constantly needed emotional support, rides, and money. She began missing shifts at work and stopped seeing friends and family as she responded to his frequent demands for help. Her co-workers noticed that she had lost weight and looked anxious, and seemed to constantly be calling or texting him, and reassuring him.
Living with chronic fear induces physical changes. Women who are victims2 of coercive control frequently experience medical problems, including heart trouble, non-specific head, back and stomach pains, and difficulties with sleeping and eating. Often, patients don’t realize their relationship is the cause of their ailments. Of course, being controlled by their partner can also contribute to people’s psychological symptoms such as depression, anxiety, substance abuse and suicidality. Providers sometimes prescribe medication, tests, and referrals to specialists for a problem that has its roots in the person’s intimate relationship.

Physical violence and coercive control reinforce each other. Even minor acts of physical violence make it easier to control a partner and intensify the effects of insults and threats. Similarly, people who feel entrapped and isolated become more afraid of physical blows. Once people are firmly under their partners’ control, occasional insults, slaps and pushes may be enough to keep them acting submissive.

“Sex on demand” is a common rule in coercive control relationships. An abuser may accuse a victim who tries to decline sex of being unfaithful or not loving him enough, or simply push her until she gives in. If he uses physical force to obtain sex even once, she knows she has no real choice; all future sex is coerced.

The line between violence and safety can be especially blurry during sex. If an abuser insists on sexual activities that his partner has said she does not want, or treats her roughly and she objects, or gets her drunk or high so she will do things she does not want, he is victimizing her. Often, a woman gives her partner the benefit of the doubt if the painful actions occur during sex. She decides to define his actions as passion rather than violence; in this way, enabling the relationship to continue without a risky confrontation.

Often people who use coercive control against their partners go out of their way to be charming and helpful to others. The person being controlled struggles to keep up appearances—afraid to tell others what is really going on in the relationship. She may blame herself. If only she could “be better,” she thinks, maybe her partner wouldn’t degrade or hurt her. If she tries to end the relationship or demands changes, the threats escalate. Domestic violence advocates can help women develop safety plans, even if they choose to remain in the relationship. And with the new U.K. laws against coercive and controlling behaviour, law enforcement help may be available.
For more information about Coercive Control and how to help people who are caught in such a relationship, check out the book, Invisible Chains: Overcoming Coercive Control in Your Intimate Relationship.
1 Coercive control can occur in same sex relationships, and occasionally women exert coercive control over men.
2 I am using the word “victim” here, but please feel free to substitute “target” or “survivor” if you prefer. 



Immigrant Muslim Couples and Domestic Violence


Lisa Aronson Fontes, PhD’s most recent book is: Invisible Chains: Overcoming Coercive Control in Your Intimate Relationship. She is a Senior Lecturer at the University of Massachusetts Amherst. With a doctorate in psychology, she writes and conducts trainings around the world on topics related to culture, child maltreatment and violence against women. Her blog at Psychology Today is called Invisible Chains.

Saturday, 25 November 2017

Why do nurses leave?

Roger Watson, Editor-in-Chief

Registered Nurses (RNs) leaving their job and the profession is a significant issue worldwide. Generally, there is a shortage of RNs and this contributes to it. The more we know about the causes, then the better we can deal with the problem.

This is the subject of an article from New Zealand by Willoughby et al (2017) titled: 'Factors predicting registered nurses’ intentions to leave their organisation and profession? A job demands-resources framework' and published in JAN which aimed to: 'develop a comprehensive model of nursing turnover intention by examining the effects of job demands, job resources, personal demands and personal resources on burnout and work engagement and subsequently on the intention to leave the organization and profession'. Data were collected over two years from nearly 3000 nurses and the results modelled to examine what caused nurses to want to leave.

It was not surprising that burnout incrased the intention to leave and, alternatively, the more engaged nurses felt in their jobs lowered the intention to leave but also the more challenged they were by the job. The extent to which nursing interfered with life increased the intention to leave. Aggressive patients also increased the likelihood to leave.

The authors conclude: 'The results suggest that dealing with death and suffering is not something that turns RNs away from their profession: quite the contrary. What alienates them is a greater exposure to  aggressive or troublesome patients' and ' is important for nursing schools to identify and recruit individuals with a strong desire to offer patient-centred care and then provide appropriate training to enhance their confidence in taking on challenging tasks in their work'.

You can listen to this as a podcast


Moloney, W., Boxall, P., Parsons, M. and Cheung, G. (2017), Factors predicting registered nurses’ intentions to leave their organisation and profession? A job demands-resources framework. J Adv Nurs. doi:10.1111/jan.13497

Violence Against Women 2017

by Parveen Ali

Violence against women (VAW) is a reality that affects the lives of millions of girls and women in various countries around the world. It affects women in every sphere of life and intersects culture, religion, social class, income or educational background. VAW is defined as any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life’ (General Assembly Resolution 48/104 Declaration on the Elimination of Violence against Women, 1993). It happens in public as well as private space and can take the form of physical, psychological and sexual abuse. It affects girls and women of all ages, in the form of female infanticide, female genital mutilation, child marriage, grooming, trafficking, forced marriage, honour killing, domestic violence and intimate partner violence.

General awareness of gender-based violence (GBV) and VAW has increased over time due to the continuous efforts of practitioners, activists, researchers and health and social care professionals. Much has been done to develop and improve laws and their enforcements, though a lot more still needs to be done.

One of the important rights of any individual is the right to education. VAW can occur in the sphere of education and can affect girls’ and women’s (and sometimes men’s) ability to pursue education that can help them develop their personal and professional potential. 25 November is celebrated as the International Day for the Elimination of Violence against Women and 10 December is celebrated as Human Rights Day. A campaign called ‘16 Days of Activism against Gender-Based Violence’ is an annual event that connects these two important dates and reminds us that violence against women as a human rights issue. The campaign was originated by the first Women's Global Leadership Institute in 1991 and is coordinated by the Centre for Women's Global Leadership in Rutgers, New Jersey, USA. However, this is now an annual event in which practitioners, professionals, academics, researchers and students from many parts of the world come together to demand the elimination of every form of gender-based violence.

Other important dates that take place during the 16 Days Campaign are International Women’s Rights Defenders Day on 29 November, World AIDS Day on 1 December, and the Anniversary of the massacre at École Polytechnique in Montreal, Canada, when 28 people, including 14 women, were murdered by an attacker who claimed he was "fighting feminism" and called his female victims "a bunch of feminists" whom he blamed for ruining his life. For this year, the United Nations’ theme for the 16 days campaign is Leave No One Behind: End Violence against Women and Girls. Another theme for this year is ‘Together We Can End GBV in Education’.

Nurses and midwives and other healthcare professionals are an important part of healthcare system and can contribute immensely in identification, recognition and prevention of gender-based violence. To be able to perform their role effectively, they need to be confident and competent in their ability to explore the ways in which they can help to minimize gender-based violence and its impact on individuals and families.

Building on our efforts to raise understanding of the issue and to contribute to the body of knowledge, to highlight role of nurses and healthcare professionals and to play our part in ‘16 days of activism’, JAN has decided to run a series of JAN interactive entries from 25 November - 10 December 2017, in addition to the launch of a special issue of JAN on violence against women. I am privileged to contribute to this activity. During the 16 days, through a series of blog posts, we will explore various issues related to VAW. Expert healthcare professionals, researchers and academics from various disciplines and settings will share their views about aspects of VAW. We will explore diverse issues in relation to gender-based violence, intimate partner violence, its aspects (physical, sexual, psychological) and its impact. We will look at the issue of sexual and street violence and its impact on individuals, families and communities. I look forward to the coming 16 days and hope that my colleagues will be able to contribute to these activities by sharing their views. Please read and comment on the blogs and share these widely to your colleagues.

Parveen Ali
University of Sheffield
Editorial Board member, JAN

Wednesday, 22 November 2017

Sleep, burnout and performance

Roger Watson, Editor-in-Chief

Nursing is notoriously hard work and it is also, for many nurses, shift-work with late evening and night working being common. In addition, it is emotional work and it leads to burnout. But does this affect job performance? This was the subject of an article from Italy titled: 'Can sleep quality and burnout affect the job performance of shift-work nurses? A cross sectional study' by Giorgi et al (2017) and published in JAN.

The study on which the article was based aimed to: 'investigate any possible relationship between sleep disorders, burnout and job performance in a shift-work population of nurses.' Involving over 300 nurses in seven Italian hospitals, the participants were given three questionnaires to complete: one on sleep, one on burnout and one on job performance. The results showed that poor sleep and burnout were related and that females were more affected in this regard. Particular settings - for example psychiatry - and working long shifts led to burnout and there was an effect of burnout on work performance.

The authors conclude: 'Specific characteristics of shift-work nurses can directly affect sleep quality and burnout and indirectly job performance' and '(s)leep quality appears to be worse in women than in men', therefore, '(t)his evidence offers healthcare administrators opportunities to intervene with measures to promote nurse’s health, well-being and safety.'

You can listen to this as a podcast


Giorgi F, Mattei A, Notamicola I, Petrucci C, Lancia L (2017) Can sleep quality and burnout affect the job performance of shift-work nurses? A cross sectional study Journal of Advancd Nursing DOI: 10.1111/jan.13484

Commentary: Collaboration in Canadian Health Care

Ken Cabrera

This is in response to the article entitled: Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system by Clausen et al. (2017). As a graduate student pursuing my nurse practitioner degree, I found this study to be fascinating, meaningful and significant.

For years now, Quebec has been undergoing sweeping health care reforms aimed at integrating health care and social services at various structural levels to improve the overall quality and delivery of care (Vedel et al., 2011). The reorganization of primary care, the integration of primary and secondary care at the clinical level, and developing effective governance and change management have been identified as three of most important challenges facing Quebec health care. Moreover, the implementation of nurse practitioners at the primary care level has been identified by the Quebec government as a key initiative to strengthening the delivery and quality of primary care (Vedel et al., 2011). The ability of the nurse practitioner to provide cost-effective, high quality care as indicated by positive patient-outcomes is well-documented (Martin-Misener et al, 2015).

The article refers to today’s rapidly changing climate, the complexity of challenges and the daunting task of meeting these challenges while striving to maintain safety and quality of care. In response to these challenges, key factors have been identified to facilitate change and transform care delivery: collaborative healthcare management structures and leadership. As a result, several health care systems in Canada are instituting co-leadership and co-management models- the benefits of which have been documented (e.g. greater unity, co-responsibility, interdependence, mutual obligation, preservation of the individuality of the partner).

Clausen’s substantive theory of ‘intentional partnering’ could not be more relevant considering the current state of affairs. The recognition of the nurse practitioner as an indispensable resource and their ever-expanding presence at various levels of the health care system coincides with this shift towards collaborative management in health care delivery systems. To meet this end, the successful transformation of health care can only be achieved within a context that is firmly grounded in collaborative leadership. Understanding and embracing ‘Intentional partnering’ which involves moving through a three-cog system of ‘accepting mutual necessity’, ‘daring to risk (together)’ and constructing a shared responsibility is the key to unlocking the power of the nurse practitioner and physician co-leadership dyad.

The findings of this study clearly illuminate for us as physicians and nurses alike that we share a common goal, and despite our allegiance to our own professional agendas - we are better together. Not only can we meet our own professional objectives through respectful co-leading and collaboration, but as a united team, we can achieve immeasurably more resulting in benefits for everyone. I believe only by working collaboratively can we meet the challenges of the future. 

The knowledge generated from this study by Clausen et al. has extended our understanding of nurse-physician dyadic relationships to new depths. Furthermore, it has provided us with a theoretical framework out of which we have a systematic approach to foster inter-professional collaboration. I believe, this seminal study represents a monumental contribution to the nursing profession and nursing leadership with enormous implications for the future of all Canadians.

Ken Cabrera
Graduate student, Primary Care Nurse Practitioner Program
McGill University
Quebec, Canada


Clausen C., Lavoie-Tremblay M., Purden M., Lamothe L., Ezer H. Mcvey L. (2017) Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system. Journal of Advanced Nursing 73(9), 2156–2166

Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., Bryant-Lukosius, D., Kaasalainen, S., Marshall, D. A. & Charbonneau-Smith, R. 2015. Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review. BMJ open, 5, e007167.

Vedel, I., Monette, M., Beland, F., Monette, J. & Bergman, H. 2011. Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada. International journal of integrated care, 11.


Monday, 20 November 2017

On Nursing Burnout, Staff Shortages and Travel Nurses

Kaitlyn Williams, RN

I am writing with regards to the journal article titled “Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time lagged study” (2016) by Sheila Boamah PhD(c) RN MN, Emily Read PhD RN, and Heather Laschinger PhD RN FAAN FCAHS. Burnout in the nursing field is a national issue. Healthcare is such a demanding field to be in. Boamah draws specific attention to the fact that short staffing and the lack of structural empowerment in the work environment are some of the most common reasons nurses experience dissatisfaction among their job. I was once one of the ones on the verge of nursing burnout within a year of my nursing career, and this author describes all of the emotions and frustrations that I experienced during a time when I thought I was the only one experiencing it.

It is so very unfortunate that some nurses feel unappreciated for the extra work that they offer. I cannot honestly say that our clinical supervisors and manager have ever made it feel like doing extra was an expectation. They are always so grateful for the help and understand that we are giving up our time off. The clinical supervisors are always checking in with the nurses to see if they need anything, assess the status of new admission, and are willing to help in any way that they can.

While most facilities are experiencing staffing shortages, the nurses are experiencing a higher workload and an increased patient to nurse ratio. We welcomed a new nurse to our night shift family and after talking to her for a while about why she left her old facility she explained that it was because of staffing. While they were losing staff members, the people higher in administration felt it was appropriate to increase their patient to nurse ratios from 6:1 on night shift to 8:1. She felt that it was not safe for her or the patients and was not willing to take the chance.

Facilities are experiencing high turnover rates within their departments. On my unit especially there are many nurses that plan to continue to get their nurse practitioner license. I think that is a wonderful thing for them to continue and applaud their decisions. However, after speaking to some about why they chose that pathway it was alarming to hear how many were “just tired” of bedside nursing. Our night shift staff experienced the effects of short staffing almost every night. We were offered monetary incentives as well as gift certificates if we were willing to pick up an extra shift to help. The majority of the night shift staff picked up extra shifts for weeks until we were approved to bring in travel nurses. One of our more experienced clinical supervisors made the comment that she has only seen travelers brought in to the unit one other time in her 19 years there.

Travel nurses are a wonderful resource to have and provide a sense of relief to the ones that have been working extra to help staffing needs. Jan Cottingham, in the Arkansas Business article “Health Care Demands Push Growth of NLR’s Travel Nurse”, explains that the concept of travel nursing came about as a “short-term solution” for staffing shortages in the 1980s. The effects of staffing shortages are being felt nationwide still today. If the hospital’s budget permits it, travel nursing contracts should be initiated more often instead of allowing the staff to work beyond mental and physical fatigue each week.

This article made me reflect on the past year in my nursing career. As I was reading each section I found myself relating to the situations and circumstances described. It is so common for nursing staff to experience these frustrations. I never thought it would happen to me so soon in my career. Through this article I realized that I am lucky to be a part of the team that I have. We are being reminded that we have to take care of ourselves, too. We cannot allow our patients to be the ones to deal with the repercussions of our fatigue.

Boamah S.A., Read E.A. & Spence Laschinger H.K. (2017) Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time-lagged study. Journal of Advanced Nursing 73(5), 11821195.

Cottingham, J. (2017) Health Care Demands Push Growth of NLR's Travel Nurse. Arkansas Business. [Online]. Available from:

Commentary: Coping with Parkinson’s

Commentary on: Navarta-Sánchez MVCaparrós NRiverol Fernández MDíaz De Cerio Ayesa SUrsúa Sesma MEPortillo MC. (2017) Core elements to understand and improve coping with Parkinson's disease in patients and family carers: A focus group study. Journal of Advanced Nursing. 73, 2609-2621.

Demetra Horotan
On reading the study conducted by Navarta-Sanchez et al. (2017) two issues warrant mention. First, the methodology used for proposed intervention was based on the Chronic Care Model (Coleman et al., 2009), which is a framework for improving chronic illness care at both the individual and population level. However, in this study, the researchers focused on the idea that nurses should take charge of redirecting the coping process related to Parkinson’s Disease when it is inadequate. Furthermore, they stress the importance of reinforcing the “acceptance” of this disease in both the patients and their family carers (Navarta-Sanchez, 2017). This approach appears to focus on a medical view of the patients and their families. Considering using the Resilience Theory (Zauszniewski, Bekhet & Suresky, 2009) as a guiding framework would have been more appropriate in addressing the idea of “acceptance of disease as one of the most important steps” (Navarro-Sanchez, 2017). Creating opportunities to change perspectives, creating positive, constructive strategies and strengthening family bonds can be accomplished through fostering resilience (Zauszniewski, Bekhet & Suresky, 2009). Considering this approach in their study would have reinforced the individual and family strengths as opposed to focusing on a healthcare providers’ perception of what is deficient and what needs “acceptance” (Gottlieb, 2014).

Second, the intervention suggested in this study was a combination of ten topics where “all components interact and are necessary and relevant to improve coping with Parkinson’s Disease” (Navarro-Sanchez, 2017). Even though the intervention addresses the process of coping with Parkinson’s Disease, it’s generalization to both the patient and the caregivers is questionable. From the “relatives focus group”, Peter (one of the carers in the study) expresses the desperate need for caregiver support. However, in the discussion section, the researchers refer to redirecting coping skills for improving patient and carers’ well-being and quality of life. Little attention is given to caregivers' own health and handling of the chronic illness. Previous research has demonstrated that caregivers’ decrease in well-being and perceived burden is directly related to patients’ functional status, thus strategies should be aimed at reducing psychological burden associated with caregiving and not just at “redirecting” the process of coping (Grunfeld et al, 2004).

Overall this study has expressed the importance of the meaning of coping with Parkinson’s Disease and its relevance for clinical nursing practice, related both to patients and their caregivers. While it acknowledges the need for resources in helping nurses integrate the intervention proposed, its feasibility and relevance to nursing practice could be challenged.

Demetra Horotan,

McGill University, Ingram School of Nursing
Montreal, Canada


Navarta-Sánchez MVCaparrós NRiverol Fernández MDíaz De Cerio Ayesa SUrsúa Sesma MEPortillo MC. (2017) Core elements to understand and improve coping with Parkinson's disease in patients and family carers: A focus group study. Journal of Advanced Nursing. 73, 2609-2621.
Coleman, K., Austin, B., Brach, C., & Wagner, E. (2009). Evidence on the Chronic Care Model
in the new millennium. Health Affairs, 28, 75-85.

Gottlieb, L. N. (2014). Strengths-Based NursingAJN American Journal of Nursing114(8), 24-33.

Grunfeld, E., Coyle, D., Whelan, T., Clinch, J., Reyno, L., Earle, C., & … Glossop, R. (2004). Family caregiver burden:results of a longitudinal study of breast cancer patients and their principlecaregivers. CMAJ: Canadian Medical Associaltion Journal, 170, 1795-1801.

Zauszniewski, J., Bekhet, A., & Suresky, M. (2009). Effects on resilience of women family caregivers of adults withserious mental illness: the role of positive cognitions. Archives of Psychiatric Nursing, 23, 412-422.

Response to Commentary on Douglas T, Redley B, Ottmann G. The need to know: The information needs of parents of infants with an intellectual disability—a qualitative study.

Response to Commentary on Douglas T, Redley B, Ottmann G. The need to know: The information needs of parents of infants with an intellectual disability—a qualitative study. Journal of Advanced Nursing 2017; 73:2600–2608

Tracy Douglas

Bernice Redley
Goetz Ottmann

The commentary by Ms Kudzman on on Douglas, Redley & Ottmann  (2017) highlights some important points for how the findings of our research can be translated into practice.  The parent participants in our research identified information-seeking was a significant part of them establishing their role as the parent of an infant with an intellectual disability; but this was not well supported by the health professionals they encountered.  As reported in our earlier paper outlining the broader study findings (Douglas, Redley & Ottman 2016), information needs were one of three themes describing the support needs of parents caring for a child with an intellectual disability in the first year of life.  In this subsequent paper, we reported sub-analyses that conceptualised parents’ identified information needs into three knowledge types based on patterns that emerged in analyses of parents’ narratives.  Such findings can provide a framework to assist health professionals to begin to support parents to access the information they require at the ideal time.

Ms Kudzman quite rightly points out the need for information to be tailored to the individual needs of each family and their child.  Our research findings provide guidance for clinicians to do this.  The theme “Information about the infant’s specific needs” (Douglas, Redley & Ottmann 2017) captures this requirement for individualisation.  However, in addition, our research found parents also needed “Information about their infant’s condition”, often as a prerequisite to being able to engage in meaningful information-seeking specific to their individual needs and circumstances.  When placed into the context of the broader study findings (Douglas, Redley & Ottmann 2016), the need for information about the child’s condition was closely linked to parents’ emotional needs, particularly early in the parent journey.  Our findings suggest that providing general information about their child’s condition, whatever it may be, is needed in the first instance for reassurance, so parents can begin to assimilate what has happened, before they can identify the specific knowledge they may need to better understand what this means for their child and family.  Understanding common patterns in the types of information parents may need, and when this may occur, can provide health professionals with a starting point to engage with parents about the care of their child, and lay the foundations to appropriately tailor and individualise subsequent care and information.

It is not the claim of this qualitative descriptive study to explain every circumstance, but to use the data to identify common patterns that may be transferable to other situations.  Qualitative descriptive research aims to understand and describe in everyday language the experiences of the research participants (Sullivan-Bolyai, Bova & Harper 2005).  The strength of this methodology lies in its facilitation of new and rich insights into the experiences of the participants, and its tenet to present this data in a way that remains true to participants’ perspectives (Sandelowski 2000).  It has further been argued that qualitative description lends itself to the identification of factors that can improve the utilisation of health services because the findings are based on the perspectives of the people who use those services (Sullivan-Bolyai, Bova & Harper 2005).  Consistent with the qualitative descriptive methodology, our research findings stay close to the data, telling parents’ stories as told by them.  The identification of common patterns and themes across the range of parents suggests there are some needs that are shared regardless of the specific conditions or circumstances (Douglas, Redley & Ottmann 2016), and these are potentially transferable to other parents of children with a wide range of disabilities, as captured in the participant group.

Further, every parent involved in our research self-selected based on the invitation for parents of children with intellectual disabilities to participate.  The requirement for participation was that the parents knew there were signs that the infant had an intellectual disability and that parents could share their stories about seeking support for this during the first year of the child’s life (Douglas, Redley & Ottmann 2016).  The voluntary participation of parents whose infant had been diagnosed with cerebral palsy in no way implies that all people with cerebral palsy have an intellectual disability.  Rather, the inclusion of these parents, as well as the parent whose child did not have a diagnosis at all, supports our research finding that there are some common support and information needs across a range of parent circumstances (Douglas, Redley & Ottmann 2016).  In fact, a maximum variation sample that aims to capture a wide range of experiences is important to identify common patterns across the diversity of conditions experienced by the families health professionals care for in the course of their work, and these patterns are even more significant given they have emerged from a heterogeneous cohort (Palinkas et al. 2015).  Identification of these common needs across this varied sample can assist health professionals to understand the general patterns in the types of supports they need to provide when caring for a wide range of parents and their infants who may have a range of conditions leading to intellectual disability.  This is particularly important because, as demonstrated in our research, failure to meet these needs can have a direct impact on how well parents are able to coordinate the care their infants require, which in turn can impact on the infant’s health and developmental outcomes (Douglas, Redley & Ottmann 2017; Intellectual Disability Rights Service 2009).

Every parent in our research described the challenges they experienced trying to access accurate and reliable information about their child’s condition, their child’s unique needs and the supports and services available to them.  In response to this, the important role of health professionals both directly providing information and recommending quality information sources (Douglas, Redley & Ottmann 2017) enables parents to access the information they require when they require it.  The articulation of the three types of knowledge provide a starting point to assist health professionals who are often unknowledgeable about disability, to understand how they can better support the nuanced, information-seeking of parents so they are empowered to take charge of their own child’s care as they desire.

Tracy Douglas & Bernice Redley, School of Nursing and Midwifery
Dr Goetz Ottmann, School of Health and Social Development
Deakin University
221 Burwood Highway
Burwood, Victoria 3125 Australia



Douglas T, Redley B & Ottmann G (2016) The first year: the support needs of parents caring for a child with an intellectual disabilityJournal of Advanced Nursing 72(11), 2738-2749.  doi: 10.1111/jan.1305

Douglas, T, Redley, B & Ottmann, G (2017) The need to know: The information needs of parents of infants with an intellectual disability: a qualitative studyJournal of Advanced Nursing 73(11), 2600-2608. https://doi .org/10.1111/jan.13321

Intellectual Disability Rights Service (2009) Introduction to intellectual disability.  Retrieved from on 7 November 2017.

Palinkas L, Horwitz S, Green C, Widsom J, Duan N & Hoagwood K (2015) Purposeful sampling for qualitative data collection and analysis in mixed method implementation researchAdministration and Policy in Mental Health and Mental Health Services Research 42(5), 533-544. doi: 10.1007/s10488-013-0528-y

Sandelowski M (2000) Whatever happened to qualitative description? Research in Nursing & Health 23(4), 334-340.

Sullivan-Bolyai S, Bova C & Harper D (2005) Developing and refining interventions in persons with health disparities: the use of qualitative descriptionNursing Outlook 53(3), 127-133.

Sunday, 19 November 2017

Burnout in midwives

Roger Watson, Editor-in-Chief

Midwifery is a caring profession and caring professionals are prone to burnout. Burnout leads to indifference to those in your care and a feeling that your job is not worth it and that nobody cares for you. The ultimate problem is that it leads to psychological morbidity and to absence from work.

This article from Australia titled: 'Personal, professional and workplace factors that contribute to burnout in Australian midwives' by Fenwick et al (2017) and published in JAN is based on a study that aimed to: 'identify personal, professional and workplace factors that contribute to burnout in midwives'. A survey of over 1000 midwives using a burnout questionnaire showed that nearly half of the midwives were suffering from severe burnout. Midwives were more burned out in some states of Australia than others; for example, burnout was highest in Victoria and lowest in South Australia. A caseload model of care was associated with lowest burnout and also those less happy at work were more burned out.

The authors conclude: 'Understanding the factors contributing to burnout will enable healthcare organizations to reduce costs associated with staff attrition, reduce human costs in regard to the health and well-being of midwives and most importantly, improve the health and safety of women and their newborns. Flexible, activity-based work patterns afforded in midwifery caseload models should be the norm.

You can listen to this as a podcast


Fenwick, J., Lubomski, A., Creedy, D. K. and Sidebotham, M. (2017), Personal, professional and workplace factors that contribute to burnout in Australian midwives. J Adv Nurs. doi:10.1111/jan.13491

Thursday, 16 November 2017

Violence Against Women: JAN Special Section

Violence against women (VAW) refers to ‘any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life’ (United Nations Declaration on the Elimination of Violence against Women 1993). VAW is associated with significant morbidity and mortality of victims and, therefore, the role of health care professionals becomes much more important. Available evidence suggests that one in three women worldwide are subjected to physical or sexual violence at some point in their lives (Garcia-Moreno et al. 2005). In most cases, the perpetrator is someone known to the woman, such as an intimate partner, ex-partner, husband, boyfriend or a family member. While men can of course also experience violence, in most cases the perpetrator is usually a stranger. In addition, the extent and impact of the injuries appears to be much more intense for women than men. VAW can take many different forms including female infanticide, female genital mutilation, child marriage, grooming, trafficking, forced marriage, honour killing, domestic violence and abuse (DVA), and intimate partner violence (IPV).

As the role of nurses, midwives and other health care professionals is very important with regards to identification and prevention of domestic violence, it is important that the issue is highlighted in nursing scholarly and academic arena. Therefore, this year, JAN is highlighting the issue of VAW by contributing to the United Nations campaign of ‘16 days of activism’ which will start on International Day for the Elimination of Violence against Women (25 November 2017) and ends on Human Rights Day (10 December 2017). We will run a series of JAN interactive entries each day and have launched a special section on gender-based violence. We had a fantastic response to the call for papers, four of which were excellent enough to be included in the special section. The topics of these range from exploring validity of a risk assessment tool (Messing et al., 2017), to examination of breast feeding practices, domestic violence and its relationship with displacement, and abused women experiences of accessing support from primary care nurses. 
Major natural or man-made disasters can contribute to increased vulnerability of displaced individuals. One of the articles (Soland et al. 2017) uses a descriptive correlational design to explore physical, psychological and sexual violence among internally displaced adolescent girls following the 2010 Haiti earthquake. While findings suggest similar risk of physical and sexual abuse pre- and post-earthquake, there is a need to ensure appropriate preventive measures are in place to protect vulnerable adolescent girls and others.

Messing, Campbell & Snider (2017) assessed the predictive validity of the DA-5, a shortened version of the Danger Assessment, an intimate partner violence risk assessment, assault using sensitivity, specificity and ROC curve analysis techniques. The tool was identified as accurate as the original version. 

Another paper included in the special section reported a cross-sectional study to explore the impact of domestic violence on breastfeeding practices of mothers (Finnbogadottir & Thies-Lagergren, 2017). However, it is good to know that domestic violence did not influence mothers’ determination to breastfeed their children. Breastfeeding practices as well as the rate didn’t differ in women with or without a history of domestic violence. However, symptoms of depression influenced duration of exclusive breastfeeding as those with fewer symptoms of depression were more likely to exclusively breastfeed than those with several symptoms of depression. The study emphasised the need to identify and support women with symptoms of depression to enhance their mental health and wellbeing. 

Based on a qualitative case study, another paper reported abused women’s experiences of an identification and referral intervention and to discuss the implications for nurses, specifically those working in primary and community care (Bradbury-Jones, Clark and Taylor, 2017). The study highlighted the role of nurses in identification of domestic violence, referral of abused women to appropriate services, and safety planning. 

All these papers provide important insight into the complex issue of domestic violence from various perspectives. We need to continue with the effort of exploring and developing practices, challenging stereotypes, and developing strategies to provide quality care to those experiencing abuse. We as nurses have a unique role to play in this regard as we not only provide care to victims but, at times, it may be the perpetrator who is the recipient of care. Therefore, nurses really need to understand the complex nature of the issue of domestic violence and also need to be aware of their own emotional reactions to situations that they can come across. Such efforts will help them develop a clear understanding of their role and responsibilities with regards to provision of appropriate care to those affected by domestic violence. 

Parveen Ali
University of Sheffield
Editorial Board member, JAN