Sunday, 15 December 2019

Turnover prevention among newly qualified nurses

Roger Watson, Editor-in-Chief

Nursing turnover, especially in the early days in clinical practice, is of intense interest as this is a period when many nurses are lost to the profession. The aim of this study from The Netherlands by Hoeve et al. (2019) and published in JAN was to gain: 'insight in the most crucial organizational job stressors for novice nurses’ professional commitment and whether the job stressors are mediated through negative emotions.'

Eighteen newly qualified nurses provided nearly 600 diary entries related to their time in practice and this was combined with measures on emotions and commitment. The results showed that: 'lack of support from colleagues, negative experiences with patients and confrontations with existential events were most strongly negatively related to professional commitment through negative emotions.'

The authors concluded: ' anticipation of growing nursing shortages, it is essential to prevent turnover of novice nurses. Therefore, nurses need a supportive work environment for coping with the most crucial organizational job stressors to enhance professional commitment. In particular, support in the clinical environment is crucial because not feeling supported by colleagues, negative experiences with patients, encountering existential events and conflicting job demands proved to be critical to professional commitment. Retaining novice nurses by creating a supportive work environment for the nursing workforce can be considered a major challenge for nurse managers, organizational management and policy makers.'

You can listen to this as a podcast


Hoeve, Y.T., Brouwer, J. and Kunnen, S. (2019), Turnover prevention: The direct and indirect association between organizational job stressors, negative emotions and professional commitment in novice nurses. J Adv Nurs. Accepted Author Manuscript. doi:10.1111/jan.14281

Sunday, 8 December 2019

Is urinary urgency in older women associated with falls?

Roger Watson, Editor-in-Chief

There is good reason to suspect that having to go to the toilet frequently by older women may be associated with falls. These older women are possibly more likely to be frail and, in addition to frequent visits to the toilet during the day - which can be exhausting in itself - having to go at night adds additional danger.

This study from South Korea by Park et al (2019) titled: Association Between Urinary Urgency and Falls Among rural dwelling Older Wome and published in JAN aimed to: 'examine the association between urinary urgency and falls in older women living in rural areas in South Korea.' The study included nearly 250 women aged over 65. The frequency of falls and the factors associated with them were examined. Just over 30% of the women had experienced a fall in the past year and a range of hazards such as slippery floors was associated with this. Also, urinary frequency and osteoporosis were associated with falls.

The authors concluded: 'The current study found that urinary urgency was associated with falls among older women living in Korean rural areas. The sense of a strong urge to void often makes older women with urinary urgency rush to the bathroom and places them at a high risk of falls.' Among other recommendations: 'The findings also have implications for policymakers with regard to designing safer indoor and outdoor environments for older women living in rural areas, such as by amending building codes for elder-friendly environments or by providing funds for remodeling their residence spaces or neighbourhood.'

You can listen to this as a podcast.


Park, J., Lee, K. and Lee, K. (2019), Association Between Urinary Urgency and Falls Among rural dwelling Older Women. J Adv Nurs. doi:10.1111/jan.14284

Friday, 29 November 2019

Sarcoma Clinical Nurse Specialist and former patient reunite after a decade in support of new charity awareness campaign

November 26th marked the launch of Sarcoma UK’s new comprehensive report ‘The Loneliest Cancer’ which reveals how this little-known disease has a devastating impact on patients and their families.

Over 5,300 people are diagnosed with sarcoma in the UK every year. This is a tenth of those found with breast cancer, meaning that those diagnosed with sarcoma might never meet someone who shares the same type as them – in many ways, sarcoma is the loneliest cancer. Sarcomas are tumours that develop in the cells of either the body’s soft tissue or bones and they can appear in almost any part of the body.

As part of the campaign activity, sarcoma Clinical Nurse Specialist Helen Stradling and a former patient she treated over ten years ago, Liam Harrison, came together to raise awareness of this complex and commonly misunderstood cancer.

Helen spent many years practising at Nuffield Orthopaedic Centre, and in 2005 became the first sarcoma specialist nurse in Oxford. She first became involved with Sarcoma UK in 2010, and for the past three years has been on the frontline of support and awareness by helping to man Sarcoma UK’s national Support Line, which, since its establishment in February 2016, has taken 5,500 calls and emails from 1500 people. Back in 2006, Helen treated the then 20-year-old Liam Harrison. Liam had been playing football when he suffered a hip injury. When the pain did not subside, Liam went to hospital where an x-ray suggested something more sinister. Further tests revealed that he had chondrosarcoma - the most common type of bone sarcoma. Helen remembers being in the room with Liam and his mother when he received his diagnosis. “Up until I was told I had a sarcoma, I’d never heard of it,” said Liam. “At first, I couldn’t believe it was happening to me”. Within two weeks, his damaged hip joint was removed and replaced with a prosthetic. Happily, his relatively early diagnosis, together with a steely determination, ensured Liam made a full recovery and he is now living in Spain, where he is working as a teacher.

Over ten years on, Helen and Liam joined forces to raise awareness of sarcoma and the launch of the new charity report. Helen spent the day participating in a series of radio interviews and speaking to journalists to help flag up symptoms, treatment routes and support services, and was joined for one interview by Liam. The charity’s campaign also aimed to increase healthcare professionals’ understanding of the cancer via a series of free Sarcoma Diagnostic Toolkits.  The guides contain simple yet effective tools outlining clinical presentations, investigations for adults and children, as well as guidance on how to refer patients to their nearest Sarcoma Specialist Centre for diagnosis and treatment – they can be downloaded at.

Richard Davidson, Chief Executive of Sarcoma UK comments; “Appallingly, this destructive cancer has maintained a low profile until now, even though lives are still being lost or devastated by amputations and invasive treatments. 15 people each day in the UK receive the shattering news that they have sarcoma, yet according to a YouGov poll, 75% of people “do not know what sarcoma is”. With greater awareness, diagnosis could be quicker and with increased funding for pioneering research, survival rates could be improved.  I’m really grateful to both Helen and Liam for helping to spread the word.”

Sarcoma UK Support Line Specialists are here for every person affected by sarcoma. Monday to Friday, 10am - 3pm. Phone: 0808 801 0401 or email.

Wednesday, 27 November 2019

Depressive symptom management interventions may have significantly positive effects on low-income mothers.

With great interest, we read the article by Kim K et al. entitled “The effects of depressive symptom management interventions on low-income mothers: A systematic review and meta-analysis.” published in the June 2019 issue of Journal of Advanced Nursing (Kim & Lee, 2019). The authors performed a meta-analysis to evaluate the effects of depressive symptom management interventions (DSMIs) for low-income mothers. The study is of profound academic importance, and there are some points we would like to address.

Regarding the outcome of the effect of interventions on the depressive symptoms of low-income mothers, the heterogeneity according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011) is I2=58% (P=0.01), which means the heterogeneity of the pooled data is considerable and the results are possibly not robust and reliable. Therefore, to get a reliable result, following the guidance of the guideline (Higgins & Green, 2011), we performed sensitivity analysis with REVMAN software (version 5.3 for Windows. Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration). After excluding one study by Chan et al. (Chan, Whitford, Conroy, Gibney, & Hollywood, 2011), the heterogeneity significantly decreased (I2=32%, P=0.17), and the P value for the overall effect is 0.003 (as shown in Fig. 1). This, however, indicates that compared to usual care with verbal or written material used for education, DSMIs have significantly positive effect on the depressive symptoms of low-income mothers. This is different from the conclusion the authors drew regarding this point.

In addition, funnel plots of the outcomes should be presented to evaluate the publication bias of current review, according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011).

We appreciate the authors` contribution in providing a meta-analysis to investigate the effects of DSMIs on low-income mothers. Based on the current evidence, DSMIs do have significantly positive effects on the depressive symptoms of low-income mothers. Future research is warranted to further confirm this finding.

Meixing Zhong1,2 , Hui Chen2Aihua Zhou3Yaling Zheng2*

1  Mental Health Clinic, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
2   Department of Hospital Infection Control, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
3   Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi,China  

*Corresponding author: Yaling Zheng

  Department of Hospital Infection Control, First Affiliated Hospital of Gannan
 Medical University, Ganzhou, Jiangxi, China

Tel: +86 0797-8689051

E-mail address:

Meixing Zhong is an associate professor in Mental Health Clinic and Department of Hospital Infection Control at the First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China.

Hui Chen and Yaling Zheng are senior nurses in Department of Hospital Infection Control at the First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China.

Aihua Zhou is a senior nurse in Department of Neurosurgery at the First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China.



Declaration of Conflicting Interests

No conflict of interest has been declared by the authors.

Funding statement.

  This work was supported by The Open Project of Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, China [XN201814].

This work was supported by The Open Project of Key Laboratory of Prevention and Treatment of
Cardiovascular and Cerebrovascular Diseases of Ministry of Education, China [XN201814].

Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Chan, W. S., Whitford, D. L., Conroy, R., Gibney, D., & Hollywood, B. (2011). A multidisciplinary primary care team consultation in a socio-economically deprived community: an exploratory randomised controlled trial. BMC Health Serv Res, 11, 15. doi: 10.1186/1472-6963-11-15
Higgins, Julian PT, & Green, Sally. (2011). Cochrane handbook for systematic reviews of interventions (Vol. 4): John Wiley & Sons.
Kim, K., & Lee, Y. (2019). The effects of depressive symptom management interventions on low-income mothers: A systematic review and meta-analysis. J Adv Nurs, 75(6), 1173-1187. doi: 10.1111/jan.13912

Figure legend
Fig. 1 Effect size of depressive symptom intervention after sensitivity analysis.

Tuesday, 26 November 2019

Wear Orange to show solidarity

Catherine Best & Dr Parveen Ali

In 2009 the United Nations declared:

‘Violence against women and girls is one of the most widespread, persistent and devastating human rights violations in our world today remains largely unreported due to the impunity, silence, stigma and shame surrounding it’.

The UN Sustainable Development Goals and in particular number 5 Gender Equality, recognises the essential foundation through which a peaceful, prosperous and viable society can live, work and grow and yet women and girls continue to be ostracised and both physically and sexually abused across the globe. There is no place for this in a civilised, gender equal world.

25th November is therefore dedicated as the International Day for the Elimination of Violence against Women. This day should be emblazoned on the hearts and minds of all those who believe that violence against women is wrong. Every year this day aims to increase awareness about women’s rights and violence against women in all its forms. This year the focus will be on increasing awareness about rape and its impact. 25th November also marks the start of ‘16 days of activism’, which will end on 10th December 2019 on Human Rights Day.

Rape is only one type of abuse and sadly every day women and girls experience multiple forms. Violence against women happens at home, in the streets, in offices, in peacetime and in war. It takes many forms, including physical, psychological and sexual abuse. It affects women and girls 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. Violence against women is associated with grave physical, emotional and mental health consequences. It not only impacts the lives of women victims of violence but also has a negative impact on children and families.

Gender-related killing of women and girls remains a major problem across regions, in countries both rich and poor. In 2017, this study affirms, the number of women killed by ‘intimate partners or family members’ accounted for 58% of all women homicide victims globally, and disappointingly, little headway has been made in preventing this most heinous of crimes. Within the UK deaths as a result of domestic violence have reached an all-time high in the last 5 years.

In the past few decades, much has been done to highlight this issue and to attract the attention of policy makers and practitioners at National and International level. As a result, many countries, around the world, have developed laws that aim to end violence against women, though the implementation of such laws remains challenging. There is undeniably a need to challenge and change societal and cultural norms, which do not condemn violence against women and to mobilise people in every walk of life to play their part in its prevention.
Campaigns across the UK have sought to raise awareness of the impact of domestic abuse, including those run by Refuge, Women’s Aid, White Ribbon UK and Neighbourhood Watch.

Disappointingly however, more still needs to be done before the world can start becoming a slightly better place for girls and women, where they don’t have to fight for their rights and where they are not abused and killed just because of their gender.

Economic issues are affecting provision of all kind of services, including services for women affected by violence. In the UK, for example, cuts to funding has meant many specialist domestic violence services have experienced financial issues and many refuges have closed. At the same time many perpetrators of domestic abuse are walking free as a result of the impact of funding cuts on police services. While, the Government seeks to bring perpetrators to justice through the Domestic Abuse Bill, a lot still needs to be done to improve the lives of those affected by it and to protect others from experiencing it. There needs to be a sustainable funding strategy for violence against women services, so the women and children are able to access the safety and support they deserve.

Within healthcare many nurses, midwives and other healthcare professionals witness the impact of domestic abuse every day though they are not always effectively prepared to respond to the needs of these women. There is a requirement therefore to increase the knowledge and skills of all healthcare professionals, so they can provide effective support and appropriate care.

There are also various learning opportunities available. The number is increasing frequently and can be used to support revalidation. For example, the Royal College of Nursing provides resources that enable nurses to gain a better understanding of how to support affected women and their children. Further resources  include an interactive boardgame that aims to facilitate acquisition of knowledge through discussion and reflection… and why not sign up to an online, free course offered on the platform of FutureLearn. This course can help you confidently support those in need of your help.

All these learning materials present a wonderful opportunity to develop new knowledge and understanding in a world where sadly domestic abuse remains a significant concern, not just Nationally but Globally. Ultimately, it cannot be right that women and girls suffer at the hands of others simply for being well… women and girls. Can it?

Catherine best is Chair RCN Yorkshire and Humber Regional Board

Dr Parveen Ali, Senior Lecturer, University of Sheffield

Thursday, 17 October 2019

Voluntary stopping of eating and drinking is a rare but nevertheless relevant phenomenon in long-term care

Sabrina Stängle*, MSc, RN
Wissenschaftliche Mitarbeiterin
ZHAW Zürcher Hochschule für Angewandte Wissenschaften Institut für Pflege, Departement Gesundheit Technikumstrasse 81, Postfach CH - 8401 Winterthur Tel. +41 58 934 4144

Voluntary stopping of eating and drinking (VSED) is a way to end life prematurely. People who choose this path are able to make decisions, are able to eat and drink and are neither cognitively impaired nor suffer from mental illness. They decide to follow this path in order to end unbearable suffering that cannot be alleviated despite medical progress. Aware of the phenomenon, VSED was included as a controversially discussed option in 2018, when the guideline of the Swiss Academy of Medical Sciences "Dealing with Dying and Death" was updated. The guideline is trend-setting for health professionals. However, it was unclear what relevance VSED has in Switzerland. For this reason, the objectives of this study were to assess the incidence of VSED in long-term care and to gain insights into the attitudes of long-term care nurses about the VSED. Heads of Swiss nursing homes (535; 34%) took part in an online survey on this subject. The results could show that almost every second institution among the participants has already accompanied a VSED case. Moreover, among all persons who died in Swiss nursing homes in 2016, 1.7% are due to VSED. Participants' overall views on the VSED are very positive, whereas it is assumed that it is a phenomenon of old age. Professionals still lack sufficient knowledge about this phenomenon, which could be clarified through training.

* Forthcoming article: Stängle S, Schnepp W, Büche D, Fringer A (2019) Long-term care nurses´ attitudes and the incidence of voluntary stopping of eating and drinking: a cross-sectional study Journal of Advanced Nursing (in press)

Saturday, 5 October 2019

The colour of your skin may influence your pain relief

Roger Watson, Editor-in-Chief

The colour of your skin may influence the extent to which you obtain pain relief from a health professional. This is reported in a systematic review by Aronowitz et al (2019) from the USA titled: 'Mixed Studies Review of Factors Influencing Receipt of Pain Treatment by Injured Black Patients'.

The study aimed to: 'explore the factors that influence provider pain treatment decision making and the receipt of pain management by injured Black patients in the United States'. Twenty studies were found which met the criteria of the study and the main results were: 'that healthcare provider characteristics, racial myths about pain sensitization, and assumed criminality all impact provider treatment decision making and the receipt of pain treatment by injured Black patients'.

The authors concluded: 'Racial disparities in pain treatment are clearly unjust and can understandably sow mistrust in healthcare providers among individuals in communities harmed by these disparities, which can lead to an avoidance of care. The results of this review provide important areas for further study, including how intentionality of injury may impact provider-perceived patient trustworthiness and the receipt of pain treatment by injured patients. The assumed criminality of certain populations, particularly people of color, can negatively impact the way people are treated by law enforcement, potential employers, healthcare providers, and the general public. How the assumed criminality of certain patients by providers may impact the quality of care that these patients receive has not been thoroughly explored, but is vital to address healthcare disparities.

You can listen to this as a podcast


Aronowitz, S. V., Mcdonald, C. C., Stevens, R. C. and Richmond, T. S. (2019), Mixed Studies Review of Factors Influencing Receipt of Pain Treatment by Injured Black Patients. J Adv Nurs. doi:10.1111/jan.14215

Friday, 13 September 2019

Celebrating Women : Women and Ethical Employment

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board 

In contemporary society much is spoken about the travesty of unethical employment. In the destructive life of a mardi gras bead, David Redmon cites the hidden dangers associated with the colourful beads, mostly associated with mardi gras. Combined with the risks posed to human health, linked to poor working conditions, exposure to neurotoxic chemicals such as lead poisoning, as well as the impact on the global environment this trinket, has a lot to answer for. Many of these workers are children whose lives are controlled not by what time they need to get up for school, but by the number of beads they can make and the wages they can earn to feed their families.

Historically women and children have borne the brunt of patriarchal intentions made all the more intolerable by the cruel vagaries of Victorian England and the often-unendurable conditions in which women and children lived, worked and died. Such conditions such as those associated with the plight of the matchstick girls, the Cradley Heath Women Chain makers and the New Jersey radium girls are recorded in the annals of history as a stark reminder of the importance of ensuring ethical employment is high on the agenda of all governments.

Such accounts continue to tell the stories of the many actions undertaken by women that would see them challenge the paternalistic world in which they lived and worked and for many ultimately win. This is perhaps no more evident than the matchstick girls strike of 1888 when 141 women and girls came on strike following a resounding call to action. The narrative of those who worked in the Radium Industry a poison which significantly contributed to the early deaths of many women who worked within its walls, caused teeth to fall out, jaws to necrose and flesh to ulcerate. And to the Cradley Heath Chain makers whose miserable wages and impoverished lives led to the strike of 1910 when women downed tools as a result of the starvation wages and strict regimes imposed.

In Victorian England nursing was also considered sweated labour, but was it really necessary that ‘to help a million sick, you must kill a few nurses’? For nurses too were subject to the horrors of employment and with blood poisoning from sewer gas, TB and other infectious diseases, including cholera and typhoid, rife in the hospital setting, along with many others, nurses paid the ultimate price; they were dying as a result of caring for the sick.

Today, the World Health Organisation’s response to workplace wellbeing is clear, that the health of the worker should be protected, whilst the World Employment Confederation presents a strong business case for ethical employment.

In their quest to ensure fair work for all, the government of Wales has released a Code of Practice , which seeks to ensure good employment practices for the millions of workers at every stage of the supply chain. Although the Welsh Government has moved forward with a code of ethics, there is still much work to be done before this is enshrined in legislation

The NHS too is playing its part.  All healthcare practitioners have a role to play in ensuring ethical employment and reducing the risks associated with the environment. In 2018 Great Ormond Street Hospital launched ‘the gloves are off campaign’ the aim of which is to reduce the associated risks of dermatitis, due to overuse, improve hand hygiene compliance and improve the environmental impact as well as reduce the risk of hospital acquired infections.

Nursing continues to remain a gendered specific profession. We may no longer be killing nurses, with blood poisoning from sewer gas, TB and other infectious diseases but are we not killing their passion, spirit and willingness to nurse.

All of these scenarios have one thing in common; they are all associated with product development and service delivery. It is the responsibility of each and every organisation involved in the supply chain to ensure ethical employment practices are adhered to. We have a long way to go.

Different times, same issues

Aligning Safe Staffing with Patient Safety: Is this Two Sides of the Same Coin?

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the second of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

Research undertaken by Dr Linda Aiken and others has identified a strong link between, nursing skill mix and improved patient outcomes:

‘We find a nursing skill mix in hospitals with a higher proportion of professional nurses is associated with significantly lower mortality, higher patient ratings of their care and fewer adverse care outcomes’ (Aiken et al. 2016).

Nursing research has also identified an increased risk of patient mortality, during hospital admissions when nurse staffing levels are reduced and there is a reliance upon nursing support staff to cover the shortfall.

The Royal College of Nursing (RCN) report Nursing on the Brink makes their position clear:

‘Having the right number of registered nurses and nursing support staff with the right knowledge, skills and experience in the right place at the right time is critical to the delivery of safe and effective care for patients and clients’.

With Westminster demonstrating a lack of accountability in ensuring safe nurse staffing levels, many see this as a flagrant lack of commitment to a nursing workforce that is teetering on the edge. The RCN is calling on parliament, not only to ensure accountability for staffing becomes the domain of the Secretary of State for Health and Social Care but also that accountability for the health and care workforce is firmly enshrined in English law.

Encouragingly legislation has been passed in both Wales and Scotland, which goes some way to making safe staffing a reality, but What about England? What about Northern Ireland? Nurses who take the fight to the doorstep of Westminster, must be prepared to be in this for the long haul, for history demonstrates that what we do today, requires patience, resilience and a sense of determination to succeed. This understanding however, should not dampen the spirits of any nurse who finds themselves working in understaffed clinical areas, for every great achievement must begin by taking the very first step. In the meantime, while we campaign for safe staffing levels to be enshrined in English law, what can nurses do to reduce the significant challenge to maintaining patient safety?

Find your voice and speak up 
It is not simply the role of nurses to speak up, but all healthcare professionals. Freedom to speak up was introduced following a 2015 review into whistleblowing practices within the NHS, the aim of which was to create a culture shift in the way in which safety issues are addressed ultimately reducing the need to ‘whistle blow’.

Disappointingly the continued culture of blame in the NHS fails to consider the consequences of poor staffing levels, inadequate skill mix and continued lack of investment. With the RCN demonstrating the impact of the loss of the nursing bursary and the cumulative effect of 40,000 nursing vacancies in England alone, nurses are being increasingly challenged in their attempts to ensure the delivery of safe and effective care. And when mistakes do happen, the impact can be devastating, not only for patients, carers and families but also for those healthcare professionals involved. Creating a just culture in healthcare settings is as important as ensuring safe staffing is enshrined in legislation. Nurses should not fear the stigma of blame when things go wrong; instead they should be encouraged to speak up in order to reduce the associated impact and for valuable lessons to be learned. It is however important to note, that a just culture does not absolve nurses of their accountability to deliver safe and effective patient care, simply that a fair and honest approach is taken.

The significant shortage of nurses is now considered to be affecting patient care and threatening lives. One way in which nurses can find their voice is by contributing to the 100 voices campaign. By sharing experiences, reflections and actions, nurses can contribute not only to the educating of others but also in ensuring lessons learned are encased in policy and health care reform. 

Pursue Learning Opportunities When Jeremy Hunt the then Secretary of State for Health declared in the report Building a Knowledge enabled NHS for the Future that:

‘The world’s fifth largest organisation needs to become the world’s largest learning organisation’. 

he was absolutely right.

However, when crisis after crisis continues to plague the NHS, as evidenced in the recent Whorlton Hall abuse scandal it is a strong reminder of the polemic approach that governments take when responding to any crisis.

Improving patient safety through education and training is recognised as an essential requirement and in recent weeks the government has gone some way to improving funding for continuous professional development for nurses, but this is only skimming the surface. More commitment is needed to ensure the future of nursing is guaranteed, throughout all sectors and in all specialties. A lack of funding for pre-registration nurse education has been cited as a reason for the reduction in the number of students entering nurse training. If the government is to be congratulated for their commitment to ensuring high quality patient care, then investment in the nursing workforce is crucial.

Demonstrate Strong Leadership
Strong leadership in nursing is considered one of the most important aspects of ensuring safe and effective care. All nurses have the capacity to lead; crucially however nurses must also have the ability to reflect and act in dynamic situations, not only to ensure that patient safety is maintained but that risks are identified quickly and service delivery transformed.

Nurses have a unique role to play in encouraging other nurses to speak up when they have concerns. All nurses have both a duty of candour and a responsibility for ensuring continued patient care and this cannot be achieved by nurses who are afraid to speak up and act. Supporting individual nurses with a degree of compassion and understanding when things do go wrong can make the difference between someone returning to work or not, staying in the profession or leaving or in some severe cases even prevent nurses from taking their own life. Errors in general occur as a result of bad systems, not bad people. Whether you agree with this or not is a matter of personal belief, however what is clear is that mistakes occur as a result of a very complex chain of design, systems, inadequate training and human factors.

In today’s turbulent healthcare climate, the responsibilities placed on nurses, is overwhelming. Nurses are no longer able to guarantee the delivery of safe and effective care, perhaps we never could, but we can continue to raise awareness of the impact that poor staffing, poor levels of skill mix and a lack of appropriate education and training can have on patient care. To do this may instil a sense of hope that things can be different.

Wednesday, 11 September 2019

Promoting a safe and just culture in nursing: Aligning Human Factors with the Courage to Speak Up

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the first of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

The theme "Patient Safety: a global health priority", with the rather apt slogan “Speak up for patient safety” is a call to action for all healthcare workers across the world to help reduce the 134 million adverse events, which results in 2.6 million deaths each year globally.
Ensuring patient safety is an essential role of all healthcare organisations and arguably all health care professionals; this role, being enshrined within both the UK Nursing and Midwifery Council and General Medical Council Codes.

Human Factors
Within healthcare in recent years, the term human factors has been synonymous with patient safety. In an attempt to make sense of the causes, the facts and the myths associated with near misses, healthcare failings and individual responsibilities, the study of human factors has sought to identify problems and generate effective solutions in order to reduce the risks associated with maintaining patient safety.

In accordance with the World Health Organisation, human factors examines the correlation between humans and the processes and systems with which they interrelate, the aim of which is to improve efficiency, creativity, productivity and job satisfaction, whilst seeking to reduce the risk of errors. Investigating adverse incidents within the healthcare setting, often identifies a failure to apply these basic principles.

Contemporary organisations, particularly the aviation industry has recognised human factors as being an important element of safety; this recognition now evident within the NHS. The Clinical Human Factors Group (CHFG) highlights the seriousness of the iatrogenic consequences of accidents and incidents borne out through error. Disturbingly statistical data highlighted by the CHFG makes for stark reading; most of all the cost to human life insurmountable. But it doesn’t have to be this way? Improving safety through speaking up is both an ethical and financial imperative, and organisations should be responsible for encouraging employees to speak up and share their concerns.

For many healthcare professionals their first introduction to human factors may be as a result of an incident in which a patient was harmed, as a result of potential failings. It should not be this way. By gaining an insight into the complexity associated with human factors through educational tools including the well-publicised videos ‘Just a routine operation’ and ‘Gina’s Story’, many healthcare workers can learn about the devastating effect experienced by many. Many more stories, such as these no doubt exist.

These real-life events have in some way occurred as a result of clinical error and a lack of professional judgement, perhaps something that any one of us could be subject to, if exposed to the right situation. We just need to be in the wrong place at the wrong time, for catastrophe to happen.

The Swiss Cheese Model
One theory, of how such incidents occur was proposed by James reason in 1978; known as the Swiss Cheese Model. This model can help to identify potential hazards, demonstrate how incidents occur and help to illuminate or clarify potential causes in accident investigation. When all the holes line up, anything is possible. Inadequate staffing levels for example, could be a contributory factor in helping to align those holes, another perhaps inadequate skill mix. Agency staff can be a buffer to reducing the risk, or can be a mitigating factor, but buffers should no longer be acceptable. Other factors such as skill set and skill mix, attitude, beliefs and values, all play their part, the willingness to challenge senior staff and as nurses make your voice heard could be argued is a significant factor, and is particularly evident in the Elaine Bromiley tragedy as shared in the video ‘Just a routine operation’. Promoting a positive safety culture in which all staff feel able to speak up may also be a positive step in reducing risk.

Developing a safety culture
Developing a safety culture in which all staff, irrespective of roles and responsibilities feel empowered to raise concerns is an essential element of any healthcare organisation seeking to reduce patient harm, and not simply the NHS. From domestic staff to consultant and all roles in-between, staff must be aware of the importance of raising the alarm, when they think something may be wrong or when it has gone wrong. Disappointingly staff working within healthcare settings continue to be overwhelmed by the challenge of speaking up, so eloquently discussed by Professor Mannion in his article ‘Speaking Up in Health Care: The Canary in the Mine?’ that they fail to do it. So, despite the introduction of Freedom to Speak up Guardians created as a response to the Francis report; a lack of confidence in speaking up remains evident.

The World Health Organisation has produced a multitude of technical reports, a link which can be found here. These reports describe the nature and impact of harm, and provide some potential solutions and rational steps to take in order to help improve patient safety.

Sunday, 18 August 2019

Which parents are more likely to call an ambulance unnecessarily for a sick child?

Roger Watson, Editor-in-Chief

Having a sick child is stressful for parents and there is always the issue of whether or not to summon help, sometimes from the ambulance service. Not every instance of parents calling an ambulance is necessary, but which parents are most likely to make unnecessary calls? This as the subject of a study by Ueki et al. (2019) from Japan titled: 'Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross‐sectional study' and published in JAN. The aim of the study was to: 'examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily' and over 170 parents who had visited the emergency department of a hospital were questioned.

The results showed that 'parents who did not use resources to obtain information regarding their child’s illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances. The authors concluded: 'Publicizing available resources regarding child health information, social health care activities to raise parents’ health literacy and explanations in accordance with parents’ uncertainty, especially when faced with new symptoms in their child, might reduce unnecessary ambulance use.'

You can listen to this as a podcast

Ueki, S. , Komai, K. , Ohashi, K. , Fujita, Y. , Kitao, M. and Fujiwara, C. (2019), Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross‐sectional study. J Adv Nurs. doi:10.1111/jan.14161

Tuesday, 6 August 2019

Declarations of political belief are not necessary or desirable in academic journals

Niall McCrae and Jonathan Portes
King’s College London

Brexit, the withdrawal of the UK from the European Union, has caused ripples throughout academe and in the literature of health professions. Our article ‘Attitudes to Brexit: a survey of nursing and midwifery students’ (McCrae & Portes, 2018) is a unique contribution to the lively and sometimes rancorous discourse. However, its publication in JAN irked Clifton and Banks (2019), who argue that editorials should not be contaminated with original research data.

On a point of principle, Clifton and Banks express their surprise at ‘a full-blown empirical research paper masquerading as an editorial’. This would be fair criticism if a study bypassed the peer-review system, but it did not. The manuscript was initially reviewed and the editor-in-chief decided not to publish in the submitted form, suggesting instead that we restructure it as an editorial on a matter of much interest to nurses in the UK and Europe.  And while we did not claim any conclusive results, our methods and findings, and the limitations of our study, were presented clearly and rigorously. 
Remarkably, Clifton and Banks, after asserting that it is inappropriate to include empirical research within an editorial, decided to bolster their own editorial by conducting fresh empirical research.  ‘We then conducted a very quick and crude scope of the JAN archives for the last five years, to determine how many empirical research articles are classified as editorials.’ Yet accuracy in reporting the results appears to elude them: ‘The answer is very few.’ We’re not asking for an F-test here, but some numbers would help.

Clifton and Banks then switch tack to allege that our article ‘lacks balance’, despite stating that the topic is immaterial to their argument, and their acknowledgment that the ‘point of any editorial is to present an opinion, often controversial’.  They criticise our lack of declaration of political interest at the foot of our article.  Of course, any financial interests or support should be declared; every journal requires this. If we’d had any funding for this research, we would have said so.

But politics are different. We are not aware of any healthcare, humanities or social science journal that requires authors to declare their beliefs. It would be appropriate for a writer to state as a potential conflict of interest a formal role as advisor to a political party, for example, but that does not apply to either of us.

The political transparency for editorials demanded by Clifton and Banks is neither necessary nor desirable.  If an editorial is politically influenced, this will be apparent in what is written. The implication of their argument is that if we wrote an editorial on why Brexit is good or bad for the National Health Service, then we should declare our attitude to Brexit. This is circular reasoning.

Clifton and Banks suggest that editorial submissions be reviewed by more than one editor. This may be a constructive idea, but the purpose of double review should not be to monitor opinion. Clifton and Banks state: -
‘The history of nursing in the UK is underscored with a series of cabals, hidden networks and vested interests. If we want a candid and modern profession, we need more transparency and openness in all aspects of the profession, including academic publishing.’
All professions and institutions are prone to group-think, but this is a very odd charge to levy against us. We suggest that Clifton and Banks have chosen the wrong target for their warning against undue influence. While being colleagues at King’s College London, we are hardly co-conspirators on either nursing (a field in which Portes has no expertise) or on Brexit, where our views - to put it mildly - are very different (as a publication search would show).  But we are both committed to scholarly debate and investigating complex phenomena in our disciplines.

A requirement for declaring political views would not be enforceable (and should not be). Voting is a private exercise in wielding the pencil in the polling booth. This does not prohibit people from divulging their political beliefs, and there is plenty of open discussion among nurses. But nobody should be forced into stating their likes and dislikes. Would an author stating membership of a populist or communist party be fairly considered for publication, and if the article were published, would this have adverse consequences for that author’s career?  A standard for political declarations might reinforce orthodoxy and quell dissent. 

Our critics informed readers of their own political stances: Clifton ‘voted remain in the 2016 referendum’ and Banks ‘was a longstanding member of the UK Labour Party’. In their efforts to practice what they preach, they unwittingly leave readers with an unanswered question. How did Banks vote in the referendum? We hope that he does not have anything to hide!


Clifton A, Banks D (2019): When is an editorial not an editorial: when it is empirical research! Journal of Advanced Nursing doi: 10.1111/jan.14160

McCrae N, Portes J (2018): Attitudes to Brexit: a survey of nursing and midwifery students.  Journal of Advanced Nursing, 75, 1-9

Sunday, 14 July 2019

Trial registration in nursing: room for improvement

Roger Watson, Editor-in-Chief

Since the advent of the AllTrials campaign, the registration of clinical trials has improved. Ideally, trials should be registered, with a published protocol, prior to their start date and certainly before publication. Since the start of 2019 JAN insists the all trials which it publishes - in fact all studies of patient interventions as defined by the WHO (Noyes 2018) - are registered prospectively and demonstrably. If they are  not, they will be rejected.

I am very grateful to Professor Richard Gray from LaTrobe University in Melbourne, Australia who, along with colleagues (2017, 2019), has been monitoring the situation in nursing. He has also been, specifically, monitoring the situation in JAN and has published reviews for 2017 and 2018. The most recent contribution, published in JAN is: 'A review of prospective registration of trials published in nursing science journals in 2017'. This study aimed to: 'determine the proportion of trials published in nursing science journals in 2017 that were prospectively registered'. The results of the study are summarised by the authors as follows: 'Of 151 randomized controlled trials published in nursing science journals in 2017, 17 (11%) were prospectively registered. Thirty-six (24%) trials were retrospectively and 93 (62%) not registered. We could not determine the registration status of five (3%) trials. The registration number was included in the abstract of two prospectively and eight retrospectively registered studies. Compared with the rest of the world, trial registration rates were significantly lower in Asian countries'. I am happy to say that JAN - at 18th place in the 'league table' - comes out well; but we could do better.

The authors conclude: 'Funding bodies, study sponsors, journal editors and trialists all have an important role to play in improving prospective trial registration. We intend to repeat this review with trials published in 2018 (and again in subsequent years). It is our hope is that by headlining the number of trials in the disciple that are prospectively registered we raise awareness among colleagues and as a result, improving the quality of future nursing science'.

You can listen to this as a podcast


Gray, R. , Gray, G. and Brown, E. (2019), A review of prospective registration of trials published in nursing science journals in 2017. J Adv Nurs. doi:10.1111/jan.14131

Gray, R. , Brown, E. and Gray, G. (2019), A review of prospective trial registration in the Journal of Advanced Nursing in 2018. J Adv Nurs. doi:10.1111/jan.14090

Gray, R. , Badnapurkar, A. and Thomas, D. (2017), Reporting of clinical trials in nursing journals: how are we doing?. J Adv Nurs, 73: 2782-2784. doi:10.1111/jan.13149

Noyes, J. (2018), Which studies should be registered on a clinical trials registry?. J Adv Nurs, 74: 2479-2479. doi:10.1111/jan.13696