Monday, 14 September 2020

Commentary on Darbyshire et al (2020)


Commentary on Darbyshire et al (2020) ‘The Culture Wars, nursing, and academic freedom’ Journal of Advanced Nursing doi:10.1111/jan.14507

William P Ball RN

PhD Student, School of Health and Social Care, Edinburgh Napier University, UK


I enjoyed reading the recent editorial by Darbyshire et al (2020) which calls us as Nurses to stand against what seems to be an increasingly polarised and reductive popular discourse around contentious issues. I share many of their concerns about academic freedom and the observation that Nurses collectively seem to be shying away from speaking truth to power.

As a Registered Nurse and Population Health researcher, I particularly agree that the Nursing profession will always be closely invested in: “women's health; child development; surgery; science and evidence; pathophysiology; ethics; social justice; health inequity; sexuality; and more”, which obliges our engagement with such issues, even in the face of potential social media-led backlashes.

I wonder whether the major reason for a lack of engagement from the profession is mainly based on an individualistic attitude of self-defence? The relative lack of engagement related to social justice and equity issues is particularly striking to me. Anecdotal interactions suggest such issues are perceived to be ‘too political’ by some outside and even some within the profession. I believe this reflects a history of passively and collectively allowing orthodoxy to go unchallenged – a presumed requirement to be politically neutral, rather than just a desire for self-preservation through avoiding controversy and the personal or professional repercussions which may follow.

As Bell (2020) writes concerning the role of nursing in anti-racism, we have: “a nursing culture that is not consciously situated in a broader socio-political context.” This results in a profession and systems of education which are ‘politically soft’ – promoting apolitical approaches whilst also failing to acknowledge our role in reinforcing systemic oppressions. The profession may be best placed to address the issues raised through conscious and reflective processes like decolonisation (Moorley et al, 2020) in practice, education and research.

The authors also appeal to the long-term public support and good-will shown towards Nurses, as reflected in polling data which regularly rates us as the most trustworthy profession (Reinhart, 2020). It may be possible to leverage this public support in the discussion of contentious issues, although the extent to which this trust is dependant upon misconceptions about Nurses and Nursing is not known. If Nursing voices become more prominent or overtly political, public perceptions are likely to change, perhaps eroding the image of trustworthiness.

This issue is perhaps best exemplified by the rhetoric around Nursing work presented to the public in mainstream and social media. There has been widespread public recognition of the important work undertaken by healthcare staff during the COVID-19 crisis. Nurses (and other professions) have variously been described as ‘Angels’ and ‘Heroes’, with an abundance of war-like metaphors. Whilst this language is well-intentioned and probably used instinctively it contributes to ‘mysticisation’ of Nurses and Nursing work. Such stereotypes have the potential to be damaging to the Nursing profession in the long-term and should be vigorously challenged (Stokes-Parish et al, 2020).


Darbyshire, P., Patrick, L., Williams, S., MacIntosh, N., Ion, R. (2020), The Culture Wars, nursing, and academic freedom. Journal of Advanced Nursing. doi:10.1111/jan.14507

Bell, B. (2020), White dominance in nursing education: A target for anti‐racist efforts. Nursing Inquiry. doi:10.1111/nin.12379

Moorley, C, Ferrante, J, Jennings, K, Dangerfield, A. (2020), Decolonizing care of Black, Asian and Minority Ethnic patients in the critical care environment: A practical guide. Nursing in Critical Care. 25: 324– 326.

Reinhart, R. J. (2020), Nurses continue to rate highest in honesty, ethics. Retrieved from‐continue‐rate‐highest‐honesty‐ethics.aspx

Stokes‐Parish, J., Elliott, R., Rolls, K. and Massey, D. (2020), Angels and Heroes: The Unintended Consequence of the Hero Narrative. Journal of Nursing Scholarship. doi:10.1111/jnu.12591


Editorial note: entries to JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief and may be subject to editing or removal by Wiley. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal.




Monday, 7 September 2020

Response to the commentary written by Carmen Tung

Paolo IOVINO (Corresponding author), MSN RN University of Rome Tor Vergata, Rome, Italy. Email: Tel: +39 3479392534. ORCID: 0000-0001-5952-881X

Maddalena DE MARIA, MSN RN University of Rome Tor Vergata, Rome, Italy. Email: ORCID: 0000-0003-0507-0158

Maria MATARESE, MSN RN University Campus Bio-Medico, Rome, Italy. Email: ORCID: 0000-0002-7923-914X

Ercole VELLONE, MSN RN University of Rome Tor Vergata, Rome, Italy. Email: ORCID: 0000-0003-4673-7473

Davide AUSILI, PhD, MSN, RN Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. Email: ORCID: 0000-0001-5212-6463

Barbara RIEGEL, PhD, RN, University of Pennsylvania, Philadelphia, United States. Email: ORCID: 0000-0002-0970-136X

We would like to thank Carmen Tung for her comments on our article “Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis”. We particularly appreciate the interest she has demonstrated in the self-care research.

Self-care is considered an important strategy for ensuring well-being and keeping control of illnesses. Individuals who benefit most from self-care are typically those affected by one or more chronic conditions. We agree with Tung that self-care maintenance (SCM) is an important step in taking care of oneself. This mostly happens because SCM is the first set of behaviors that are taught by healthcare providers and the least challenging to understand for chronically ill individuals when it is time to return home after hospitalization. Self-care is also performed by healthy individuals; this is particularly evident in the situation we are living in these days when, above and beyond the disastrous effects that COVID-19 is having on society, the pandemic is changing the way people take care of themselves. Handwashing and social distancing are two examples of basic self-care behaviours that, among many others, are put into practice to prevent infections in the community. Currently, our research team is investigating the impact of the COVID-19 outbreak on the self-care behaviors of people affected by multiple chronic conditions. We hope our study will offer healthcare providers important information about how to strengthen these behaviors that may reveal particularly vulnerable.

We also think that patients undergoing lung transplant, such as those referred to by Tung, could bring to light interesting dynamics regarding the self-care process. We agree with her that these individuals possess a high level of skill and long experience with regard to self-care. Post-transplant populations typically have a history of one or more chronic conditions prior to transplant. In our opinion, this has contributed to sharpening their knowledge and expertise related to self-care behaviours.

Problems with depression are, unfortunately, present in the post-transplant population; this has been observed by one of the authors, who is engaged in the clinical care of patients undergoing bone marrow transplantation. We particularly advocate herein the recommendation emphasized by Tung: a systematic screening of depression is vital in these fragile populations, especially because we have found that this mental health problem can negatively impair self-care behaviors. This relationship is rather worrisome because self-care includes medication adherence, which is important in maintaining immunosuppression and reducing the risk of organ rejection. Cukor et al. (2009) found that depression was the only significant predictor of low medication adherence in kidney transplant patients. Another study found that this mental health problem diminished in the short term after hematopoietic cell transplantation but then increased significantly over the following years (Kuba et al., 2017). This finding is important because screening for depression symptoms should not terminate at post-transplant discharge; rather, ideally it should be carried out as part of the early post-transplant check-ups and continue from there. Independently of the outcome, screening for depression should also be accompanied by self-care educational interventions.

In our study (Iovino et al., 2020), we found a small or even absent effect of depression on self-care monitoring and management. This was probably due to presence of caregivers, because in our sample, families were a constant presence for their loved ones. We envisage that this would also be the case for transplant patients. According to our clinical experience and evidence from research (Lonning et al., 2018), post transplantation carries a renewed desire to live a healthier life. In particular, patients who do not undergo transplants following cancer may perceive their past chronic illness as no longer a threat. The fact that the disease is finally eradicated brings new hope and motivation to take better care of themselves. We could also hypothesize that people perceive self-care monitoring and management behaviors as being more important than SCM as they ensure well-being and survival. For example, the high number of drugs post-transplant patients must take (e.g. immunosuppressors and corticosteroids) are linked to serious side effects that need to be recognized and detected promptly to avoid complications. This may induce patients to conduct more intense monitoring.

Regarding the study mentioned by Tung, we suggest that, when investigating self-care, she consider all three self-care dimensions (self-care maintenance, monitoring and management) in the analyses since self-care practices are highly intercorrelated (Riegel et al., 2012). By taking all of them into account, adjustment of each behaviour’s estimate is warranted. Also, we suggest measuring self-care self-efficacy. This variable, defined as the belief in one’s own abilities to perform self-care, is known to act as a mediator in the relation between self-care behaviours and outcomes (Vellone et al., 2016). Lastly, we would recommend considering other confounding factors, above and beyond caregiver support, such as cognitive status, age, social support, and quality of life to obtain results that are less likely to be biased.


Cukor, D., Rosenthal, D. S., Jindal, R. M., Brown, C. D. & Kimmel, P. L. 2009. Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int, 75, 1223-1229.

Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D. & Riegel, B. 2020. Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis. J Adv Nurs. , 76 (7), pp. 1668-1678.

Kuba, K., Esser, P., Mehnert, A., Johansen, C., Schwinn, A., Schirmer, L., Schulz-Kindermann, F., Kruse, M., Koch, U., Zander, A., Kroger, N., Gotze, H. & Scherwath, A. 2017. Depression and anxiety following hematopoietic stem cell transplantation: a prospective population-based study in Germany. Bone Marrow Transplant, 52, 1651-1657.

Lonning, K., Midtvedt, K., Heldal, K. & Andersen, M. H. 2018. Older kidney transplantation candidates' expectations of improvement in life and health following kidney transplantation: semistructured interviews with enlisted dialysis patients aged 65 years and older. BMJ Open, 8, e021275.

Riegel, B., Jaarsma, T. & Stromberg, A. 2012. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci, 35, 194-204.

Vellone, E., Pancani, L., Greco, A., Steca, P. & Riegel, B. 2016. Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model. Int J Nurs Stud, 60, 191-9.

Friday, 21 August 2020

The Effect of Depression on Self-Care Maintenance in Lung Transplant Recipients

The Effect of Depression on Self-Care Maintenance in Lung Transplant Recipients 

Carmen Tung

High Acuity Registered Nurse,
Vancouver General Hospital,
British Columbia, Canada

Commentary on Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D., & Riegel, B. (2020). Depression and self‐care in older adults with multiple chronic conditions: A multivariate analysis. Journal of Advanced Nursing, 76 (7), pp. 1668-1678.

Having worked with the lung transplant team at Vancouver General Hospital for most of my career, I wanted to integrate my clinical experiences with the recent literature on self-care maintenance (SCM) to recommend ways to improve our posttransplant education program.  To me, SCM is a vital first step to maintaining a patient’s quality of life.  When properly executed, SCM helps our transplant recipients reduce their risk for complications, decreases the rate of hospital readmission, and most importantly, enables these individuals to live richer lives than was possible prior to transplant.  The role of SCM has become particularly evident during the COVID-19 pandemic, where access to resources has been limited and patients have been managing more of their own care. 

Living with an organ transplant is a complex chronic condition, especially since many individuals find themselves trading one chronic disease for another.  At our site, patients require a lung transplant because they have underlying chronic obstructive pulmonary disease, interstitial lung disease, pulmonary hypertension, or cystic fibrosis.  After transplant, many unfortunately develop secondary chronic diseases, such as diabetes mellitus and Chronic Lung Allograft Dysfunction (CLAD).  While I agree with Iovino et al. (2020) that having multiple chronic conditions can make self-care difficult, I also believe that my population is unique because many of these patients have already practiced SCM for years prior to transplant.  As such, they bring with them a wealth of knowledge and experience.  What they require from health care providers is education, access to resources, and solutions to barriers so that they can engage in new SCM skills tailored for the posttransplant lifestyle. 

Using the definition proposed in Riegel et al. (2012), SCM includes the actions that preserve physical and emotional health.  In the context of lung transplantation, this includes smoking cessation, maintaining a healthy weight, engaging in healthy dietary and exercise habits, and most importantly, adhering to the antirejection medication regimen.  Based on my clinical experiences, depression is a major obstacle that limits SCM in the posttransplant population.  Similar findings are reported in the current literature.  Notably, Chu et al. (2020) found that up to 30% of transplant recipients experienced symptoms of major depressive disorder within two years of transplant.  When left untreated, depression can lead to medication nonadherence, which remains the biggest risk factor for CLAD, rehospitalization, and death (Costa et al., 2017).  I was thrilled to learn that the rigorous study published by Iovino et al. (2020), who conducted their investigation on individuals similar to my population, also came to the same conclusion and provided concrete suggestions to remedy this problem. 

Iovino et al. (2020) discovered that 65.6% of their patients with multiple chronic illnesses (N = 366) have mild to very severe depression, and even those who suffered from mild depression exhibited impaired SCM behaviours.  Based on these findings, Iovino et al. (2020) recommended systematic screening for depression in adults with multiple comorbidities and prioritizing the assessment of SCM behaviours.  We currently assess for depression prior to transplant, but not again unless a clinician detects symptoms during follow-up visits.  As such, I would like to conduct a similar study at our site to confirm that depression predominantly affects SCM.  If I discover similar findings, I would propose the use of a valid and reliable psychometric scale, such as the 9-Item Patient Health Questionnaire used by Iovino et al. (2020), to screen routinely for depression during posttransplant clinic visits, as well as during all hospital readmissions, especially if the reason for admission is medication nonadherence.  We currently test the blood serum level of the antirejection medication Tacrolimus at each posttransplant encounter.  This level is an established proxy for medication nonadherence and could serve as additional evidence that depression is linked to problems in this area of self-care (Chu et al., 2020).  Hopefully, with regular screening, we can detect depression early and provide interventions to help patients engage in conducive SCM behaviours.

I was surprised that Iovino et al. (2020) did not find an association between depression and the other two components of self-care.  In terms of self-care monitoring, the authors suggested that caregivers might have assisted patients with these tasks and thus masked the effects of depression.  I think this is a valid point and merits further investigation, especially since self-care monitoring is imperative to our population.  Specifically, a criterion for discharge is that our patients can monitor their vital signs, weight, spirometry, and blood glucose level daily without assistance from their support persons.  In terms of self-care management, we teach our patients how to recognize the signs and symptoms of infection and rejection, and how to respond to abnormal changes in any of their monitoring parameters.  Many of our interventions involve carrying out a predetermined action plan, such as self-administering insulin or notifying the transplant clinic of rapid weight gain.  It is crucial that our patients can perform these tasks independently, especially now during the COVID-19 pandemic.  To put things into perspective, geographically distant patients have been experiencing delays when trying to fly to our site.  For others, hospitalization poses a significant financial burden and these patients prefer to manage their health in the community.

In summary, Iovino et al. (2020) found that many individuals with multiple chronic conditions suffer from depression, and even those with mild symptoms showed deficits in SCM.  As such, the authors recommend routine depression screening.  In terms of my population, this translates to depression screening at posttransplant visits and upon hospital readmissions, and analyzing the results along with antirejection drug serum levels to detect for medication nonadherence.  In the future, I would like to investigate the relationship between depression and self-care monitoring and management while controlling for caregiver support.


Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D., & Riegel, B. (2020). Depression and self‐care in older adults with multiple chronic conditions: A multivariate analysis. Journal of Advanced Nursing, 76 (7), pp. 1668-1678.

Chu, M.C., Smith, P.J., Reynolds, J.M., Palmer, S.M., Snyder, L.D., Gray, A.L., & Blumenthal, J.A. (2020). Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients. International Journal of Psychiatry in Medicine, pp. 1-16.

Costa, J., Benvenuto, L.J. & Sonett, J.R. (2017). Long-term outcomes and management of lung transplant recipients. Best Practice & Research Clinical Anaesthesiology, 31 (2), pp. 285-297.

Riegel, B., Jaarsma, T., & Stromberg, A. (2012). A middle-range theory of self-care of chronic illness. Advances in Nursing Science, 35 (3), pp. 194–204.

Editorial note: entries to JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief and may be subject to editing or removal by Wiley. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal.

Friday, 7 August 2020

Monday, 3 August 2020

Effectiveness of executive function training on mental set shifting: one study reported across two papers or two trials with the same registration number?

Dear Editor
I write to highlight potential issues with the reporting of the randomised controlled trial by Chiu et al., (2018) that was published in the Journal of Advanced Nursing.

Our group have undertaken a series of reviews that have determined nursing trials compliance with ICMJE (De Angelis et al., 2004) requirement for prospective registration (Gray et al., 2017, 2019). Consistently, nursing has done poorly and has one of the lowest rates of trial registration of any clinical discipline (Gray, Brown, et al., 2019; Gray et al., 2017; Gray, Gray, et al., 2019). For example, In a review of the 151 nursing science trials published in 2017, just 17 (11%) were prospectively registered (Gray et al., 2019). The Journal of Advanced Nursing editorial team has taken the issue of prospective registration seriously and we are aware that they have put in place policies and procedures to ensure that the trials they publish are appropriately registered.

One of the practices that trial registration is intended to prevent is selective outcome reporting, where authors only publish a subset of the outcomes measured in order to inflate the magnitude of the treatment effect (Chan et al., 2004). In our previous reviews, we have not reconciled registration entries with published manuscripts to determine if there was any evidence of selective outcome reporting; this has been an acknowledged limitation of our methodology (Gray et al., 2019). We are in the process of completing our second yearly review of trial registration in nursing science (studies published in 2018) and have extended our methodology to address this deficit. Our review has identified a number of discrepancies between what authors have stated in the trial registry entry and reported in the published manuscript. We feel it is incumbent upon us to alert Journal editors about the discrepancies we have observed.

One of the trials included in our review was published in the Journal of Advanced Nursing and authored by Chiu et al., (2018). Several issues relate to this (Chiu et al., 2018) and another – seemingly related – trial by the same group (Kao et al., 2018), published in the International Journal of Nursing Studies (IJNS) and also included in our review. We have written to the IJNS separately about this paper.

Chiu et al., (2018) report a randomised controlled trial of 24 sessions of Executive Function Training on mental set shifting (determined using the Wisconsin Card Sorting Test) in healthy adults aged 65 years or older. The authors concluded that executive function training might be an effective preventative strategy in older adults. When we reconciled the manuscript with the registry entry (Chi-CTR-IOR-14005490), we noted that the authors were vague in their description of the intervention under investigation (described as cognitive training) and primary outcome (cognitive function). In our view, this apparent inconsistency warranted further investigation. We used the trial registration number to search (using Google) for any related publications (such as a trial protocol). A second paper was identified using the same trial registration number and published in BMC Geriatrics (Chan et al., 2019). In this paper, Chan et al., (2019) report the effect of 24 sessions of Interactive Cognitive-Motor Training on eye-hand coordination in older adults. According to the authors, there were no differences between the groups against the primary outcome at the end of the trial.  Our initial thought was that the authors were reporting a single trial across multiple papers (so-called salami-slicing) (Gray & Baker, 2016). This does not seem to be the case: the interventions described in the two papers seem entirely different. In the JAN paper, the authors state that that the Executive Function Training Group “…underwent process-based training using the Chinese version of the Rehacom computer training software (Hasomed GmbH, Magdeburg, Germany). Rehacom is a set of cognitive training software modules that have been proven effective by empirical research for improving the cognitive functions of older adults, including healthy older adults and patients with head injury, stroke and Alzheimer disease…” [sic] (Chiu et al., 2018). The interactive cognitive-motor training (ICMT) intervention in the BMC Geriatrics paper is described as follows “ICMT was performed on the Hot Plus interactive health service system. When using the system, the participants received information visually or acoustically and performed suitable physical responses based on their judgment. Through feedback, coordination between the brain and body can be improved to adjust responses” [sic] (Chan et al., 2019). Outcome measures in the two papers are also different. Mental set-shifting, working memory and inhibition were reported in the JAN paper (Chiu et al., 2018), and visual-motor integration, visual perception, motor coordination and cognitive function in the BMC Geriatrics manuscript (Chan et al., 2019). It seems that, apart from the trial registration number, the papers are reporting different studies. One possible explanation might therefore be that the authors reported the wrong registration number in one of the manuscripts. However, we checked the ethics committee reference number (201312037) which is the same in both papers. And both studies involved 62 participants. The demographic characteristics of the control groups in both papers are also essentially identical; mean age, MMSE score, gender, educational level is precisely the same (to two decimal places). However, the demographic profile of subjects in the experimental group subtly differs between the two studies.

The confusion deepens when a third – seemingly related paper – was reported in the IJNS is considered (Kao et al., 2018). The manuscript also reports a trial of interactive cognitive-motor training in 62 older adults. The primary outcome in this trial was gait performance. Although the Kao et al., (2018) trial has a different trial registration number (ChiCTR-IOR-17013812) to that reported in the Chan et al., (2019) paper (Chi-CTR-IOR-14005490), the demographic profile of participants in both papers match. We have written to the editors of the IJNS about our specific concerns with the paper they published.

In summary, we are unclear if the authors have reported a single trial of the same intervention that is reported across multiple papers. If this is the case the authors need to explain why the interventions are apparently different. Alternatively, the authors may have reported two separate trials and inadvertently used the same registration number. If this is the case, the authors need to explain why the demographic characteristics of control participants are identical in both studies. There may be a justification for the observed discrepancies that we have not considered.  We look forward to a response from the study authors.

Professor Richard Gray PhD
Research Focus Area Director
La Trobe University
Melbourne, VIC 3086