Tuesday, 14 April 2020

Creating a Culture of Authentic Learning within Nurse Education

Catherine Best
Email: catherine.best23@gmail.com


Higher education environments encourage learning through a plethora of systems and structures; such structures define what is taught and how, and therefore ultimately determine the type of knowledge gained (Snowden and Halsall, 2014). Meeting the needs of 21st Century learners however, presents educators with a significant challenge (Iucu and Marin, 2014). For today’s learners are more likely to be motivated by learning new concepts and skills, and being prepared to work in a variety of situations relevant to their professional lives; a process considered external to academia (Iucu and Marin, 2014).

Within contemporary nurse education, in order to correct this problem, adopting a more constructivism approach to learning has been encouraged (Ellis, 2016). This approach enabling learners to effectively engage in knowledge discovery by the ‘working through’ of problems that arise within practice (Ellis, 2016). A process it could be argued encourages authentic learning.

The idea of authentic learning, has emerged as a result of the disconnect that has occurred between real life experience and education and the concern raised as to how this can be remedied Karakaş-Özür and Duman (2019). Within this concept is the importance of an authentic learning strategy, the aim of which is to bring real world themes and learners together. Furthermore, adopting an authentic approach to learning has the potential to motivate learners, with an emphasis now being placed on the importance of self-directed (van Rensburg and Botma 2015) and self-determined or heutagogical learning (Kenyon and Hase, 2013).

Heutagogy, emphasises the importance of how learners prefer to learn, rather than on what is being taught (Kenyon and Hase, 2013). This position affirms Halsall et al. (2016) offers a paradigm for scholarship that harnesses and effectively supports the dynamic and complex notion of self-determined learning; providing an approach to education congruent with the demands of modern-day society.

Self-directed learners are able to identify personal learning needs, develop and implement a structured approach to learning and ultimately become adept in monitoring own progress (van Rensburg and Botma, 2015). Furthermore, self-determined learners are considered to be highly autonomous, the emphasis being on learner capacity and capability; the goal of which is to equip learners for the complexities of latter-day work (Blaschke, 2012).

One way in which nurses can channel professional learning is through reflective practice and portfolio development a key requirement of revalidation (NMC, 2015).

Reflexivity v Reflective Practice

In his work on transformative and reflexive learning, Arvanitis, (2017) argues that modern-day educationalists need to develop a more epistemological approach to learning, one which is based on ‘professional knowing and action’ requiring educationalists to develop a greater reflexive approach.

Definitions abound as to the meaning of reflexivity and is often synonymously used with the term, reflective practice, creating what Archer (2010) calls ‘fuzzy borders’. Reflexivity defined by Archer (2010) is the ability to consider self in relation to social and cultural contexts and vice versa; reflexive internal actions considered the means by which the individual can contemplate their next steps, which in turn has the capacity to allow new knowledge and practices to emerge. Situated within nursing practice reflexivity it could be argued is the process whereby nurses seek to locate themselves within their own professional experiences, and are thus able to effectively learn from them.

Furthermore, today’s business leaders and educational organisations want the inception of educational policies that have the capacity to support the ‘development of broad transferrable skills and knowledge’ and in so doing create a deeper level of learning (Goldman and Pellegrino, 2015).

According to Graham and Johns, (2019) intellectual discourse extols the importance of reflection as being a learning strategy, by which professional practice can be improved. Such strategies they argue, emphasise the importance of reflective practice. Through such strategies, reflection can be considered a purposeful learning tool enabling the practitioner to look beyond their experience and in so doing gain useful insight into the way in which things can be done better using directed future development (Graham and Johns 2019).

Furthermore, reflective practice argues Chinn and Kramer, (2018) is a process that leads to an understanding about the rationale of one’s own actions and in so doing has the potential to improve one’s practice and ‘contribute to personal growth’.

It could be argued therefore that reflection with its emphasis on real life experiences and ‘guided future development’ is indeed a true expression of authentic learning.


Situated within modern-day educational systems is a diverse range of educational theories, curricula design, education programmes and teaching strategies (Crawford, 2019). In order to effectively research these increasingly complex issues requires an equally diverse range of methodologies that have the capacity to contribute to such research (Crawford, 2019). This may present a particular challenge to educationalists as they continue to weather the storm of student expectations, university policies and government expectations.

Kelsey and Hayes (2015) in their work on reflective practice, postulate words of encouragement. In order to meet the expanding demands placed upon nurse education, the increasing expectations of learners and the growing needs of an expanding global society, nurse educationalists who understand the importance of learners ‘learning how to learn’ have the potential, through their actions, to build a workforce that takes responsibility for its development and in so doing can change the future of nurse education for the better.


Archer, M.S. (2010). Introduction: The reflexive re-turn. In Archer, M.S. ed. Conversations about reflexivity. London: Routledge, pp. 1-14.

Arvanitis, E. (2017) Preservice teacher education: Towards a transformative and reflexive learning Global Studies of Childhood pp. 1–17.

Blaschke, L.M. (2012) Heutagogy and Lifelong Learning: A Review of Heutagogical Practice and Self-Determined Learning. http://www.irrodl.org/index.php/irrodl/article/view/1076/2087 Accessed 23 March 2018.

Chinn, P.L. and Kramer, M.K. (2018) Knowledge Development in Nursing. Theory and Process. 10th ed. St Louis, Missouri: Elsevier.

Crawford, R. (2019) Using Interpretative Phenomenological Analysis in music education research: An authentic analysis system for investigating authentic learning and teaching practice. International Journal of Music Education 37(3) pp. 454–475

Ellis, D.M. (2016) The role of nurse educators' self-perception and beliefs in the use of learner-centered teaching in the classroom. Nurse Education in Practice, 16 pp.66-70. http://dx. doi.org/10.1016/j.nepr.2015.08.011.

Goldman, S. and Pellegrino, J. (2015) Research on learning and instruction: Implications for curriculum, instruction, and assessment. Policy Insights from the Behavioral and Brain Sciences, 2(1), 33–41.

Graham, M.M. and Johns, C. (2019) Becoming student kind: A nurse educator′s reflexive narrative inquiry. Nurse Education in Practice, 39 pp. 111-116

Halsall, J.P. Powell, J.L. and Snowden M. (2016) Determined learning approach: Implications of heutagogy society based learning. Cogent Social Sciences 2 (1) pp. 1-11

Iucu R.B. and Marin, E. (2014) Authentic Learning in Adult Education. Procedia - Social and Behavioral Sciences, 142 pp. 410-415.

Karakaş-Özür, N. and Duman, N. (2019) The Trends in Authentic Learning Studies and the Role of Authentic Learning in Geography Education International Education Studies, 12 (12) pp. 28-42

Kelsey, C. and Hayes, S (2015) Frameworks and Models Problematising Reflective Practice. Nurse Education in Practice 15 (6), 393-396.

Kenyon C and Hase, S (2013) Heutagogy Fundamentals. In: Hase, S and Kenyon C. (editors). Self-determined Learning. Heutagogy in action. London: Bloomsbury, 7-38.

Nursing and Midwifery Council (2015) Revalidation How to revalidate with the NMC Requirements for renewing your registration. London: NMC.

Snowden, M and Halsall, J. (2014) Community Development: A Shift in Thinking Towards Heutagogy. International Journal of Multi-Disciplinary Comparative Studies 1 (3), pp. 81­91

Van Rensburg, G.H. and Botma, Y. (2015) Bridging the gap between self-directed learning of nurse educators and effective student support. Curationis 38 (2), pp.1-7 http://www.curationis.org.za doi:10.4102/curationis.v38i2.1503

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.

Information about the COVID-19 pandemic in northern Italy: the experience of the A&E in Alessandria, Piedmont.

T.Bolgeo1  M-Bertolotti2 M.Betti3  A.Roveta4 A.Maconi5

1. Head of the Research Unit of the Health Professions RN, MSc, PhD ( stud) Infrastructure Research, Training and Innovation Hospital A.O. SS Antonio and Biagio Alessandria, Italy, EU.
2. Epidemiology biologist Clinical Trial Centre Infrastructure Research, Training and Innovation A.O. SS Antonio and Biagio Alessandria – Italy, EU.
3. PhD Clinical Study Coordinator Clinical Trial Centre Infrastructure Research, Training and Innovation AO SS. Antonio and Biagio Alessandria – Italy, EU.
4. Biologist Infrastructure Research, Training and Innovation A.O. SS Antonio and Biagio of Alessandria – Italy, EU.
5. Responsible manager Infrastructure Research, Training and Innovation A.O. SS Antonio and Biagio of Alessandria – Italy, EU.

On 22 February, the first COVID-19 case was diagnosed in Piedmont. The total number of deaths involving COVID-19 in Piedmont as of 7 April 2020 was 1417 (267 Alessandria; 72 Asti, 96 Biella, 100 Cuneo, 145 Novara, 572 Turin, 73 Vercelli, 68 Verbano-Cusio-Ossola, 24 resident from other regions but died in Piedmont).

COVID-19 recovery trend in Piedmont: in recovery 834, recovered 732. There are currently 423 patients in intensive care. The number of diagnostic swabs performed so far are 51,311 of which 28,236 gave negative results. The Italian crude mortality average is 4 per 10,000. In Piedmont it is lower (3 per 10,000).

On 27 February 2020, the Ministry of Health issued a document prepared by the Superior Council of Health which gave guidance on the criteria for subjecting people to examination for the SARS-CoV-2 infection (Shah & Farrow, 2020). The document indicated the use of swaps only for symptomatic cases, stating that the test in the absence of symptoms does not appear to be supported by scientific rationality, and does not provide indicative information for clinical purposes, indeed it can be misleading. According to the Superior Council of Health, the literature data reports a share of false negatives in the first phase of the disease in excess of 15%.

Since the beginning of the epidemic, public health measures put in place to contain infection (suspected patient isolation, contact tracing) have been instigated on ‘suspicion of infection’, before testing and the availability of the results to prevent the timing of diagnostic analysis and false results from impacting on the spread of the infection data.

The Hospital Company "SS. Antonio and Biagio and Cesare Arrigo" of Alessandria, part of the Health System of the Piedmont Region, has been recognized as a reference Hub Hospital, home to the II level DEA, within the hospital network related to the South East Piedmont Area that includes the provinces of Asti and Alessandria, with a reference population of about 650,000 inhabitants.

Alessandria hospital works in close contact with the Piedmont Region Crisis Unit, to promptly reorganise the users services and rapidly adapt them to the evolving situation. A COVID-19 emergency management business crisis unit has been set up to meet twice a day to take operational decisions that are important to contain and manage the COVID-19 emergency in both the short and long term.(Remuzzi & Remuzzi, 2020)

Reception places have been created for suspected COVID-19 cases where triage is carried out. Inpatient wards have been redefined into COVID-19 and non COVID-19 wards. All scheduled non-urgent outpatient services have been suspended. For non-deferable visits, patients are pre-triaged in front of each clinic. Pre-triage involves a short interview and in cases of cough, cold or fever the patient is handed a surgical mask.

Oncology and haematological therapies, including clinics, remained active. These include: Blood and biopsy testing at the Gardella Testing Point, TAO testing, Post-surgical medications, Check-ups and post-discharge evaluation, Scheduled visits and check-ups for pregnant women, Dialysis, Direct distribution of drugs in hospitals and dedicated clinics. Blood donations; Visits for expiring driving licence renewal and visits and administration of drugs for various disciplines.

In addition, on the recommendation of the DPCM of 8 March 2020, patient carers are prohibited from staying in the waiting rooms of emergency departments (DEA/A&E). Only one person per patient is permitted to visit at a time - who does not have respiratory symptoms (cold, cough, etc.) or fever. Before entering the room, they are asked to use the gel placed at the entrance of the inpatient rooms. Visitors are advised to avoid contact with potentially contaminated surfaces and furnishings (furniture, handles, bed straps, etc.).

Following the guidance provided by the Crisis Unit, the Directorate General regulates the way relatives, visitors and carers enter as follows:

· Two check points managed by the nursing service have been set up, where body temperature is detected for both employees and visitors and patients and antiseptic hand gel is provided.

· In order to cope with the emergency, doctors (11), nurses (30), other professional operators (32).

· Emergency facilities have been implemented and training courses have been activated for their proper use (Figure 1).

· The Psychology professionals of Alessandria Hospital have activated a psychological emergency service for citizens and health professionals subjected to extraordinary stress due to coronavirus and its consequences on the individual and on relations with the community.

· In addition, within Alessandria Hospital we operate an Innovation Training Research Infrastructure (IRFI) that promotes, organises and coordinates the research and training activities of operators, according to the models highlighted by publications.

· The IRFI consists of the following areas: Clinical Trial Centre - Grant Office, Documentation Centre - Biomedical Library, Communication and Scientific Disclosure, Administrative Coordination, Training, UVT-HTA Units, Research Unit for Health Professions.

· Each sector works with professionals on a daily basis to manage the COVID-19 emergency in collaboration with the crisis unit.

· Hospitals have been identified for COVID patients and other hospitals that accept patients discharged from other centres, but not yet fully recovered.

Figure 1



https://www.coronavirus.gov .

Remuzzi, A., & Remuzzi, G. (2020). COVID-19 and Italy: what next? Lancet, 395(10231), 1225-1228. doi: 10.1016/s0140-6736(20)30627-9

Shah, S. G. S., & Farrow, A. (2020). A commentary on "World Health Organization declares global emergency: A review of the 2019 novel Coronavirus (COVID-19)". Int J Surg, 76, 128-129. doi: 10.1016/j.ijsu.2020.03.001

National Institute for the Infectious Diseases “L. Spallanzani”, IRCCS. Recommendations for COVID-19 clinical management

Emanuele Nicastri, Nicola Petrosillo, Tommaso Ascoli Bartoli, Luciana Lepore, Annalisa Mondi, Fabrizio Palmieri, Gianpiero D'Offizi, Luisa Marchioni, Silvia Murachelli, Giuseppe Ippolito, Andrea Antinori, for the INMI COVID-19 Treatment Group (ICOTREG) Infect Dis Rep. 2020 Feb 25; 12(1): 8543. Published online 2020 Mar 16. doi: 10.4081/idr. 2020.8543

Rapid response to COVID-19 outbreak in Northern Italy: how to convert a classic infectious disease ward into a COVID-19 response centre E. Asperges, S. Novati, A. Muzzi, S. Biscarini, M. Sciarra, M. Lupi, M. Sambo, I. Gallazzi, M. Peverini, P. Lago, F. Mojoli, S. Perlini, R. Bruno, COVID-19 IRCCS San Matteo Pavia Task Force J Hosp Infect. 2020 Mar 20 doi: 10.1016/j.jhin. 2020.03.020 [Epub ahead of print]

Sunday, 12 April 2020

Covid-19 and the nursing response

Roger Watson, Editor-in-Chief

Covid-19 is infecting thousands of people, including nurses and doctors, and killing some of these. The crisis has shown that the United Kingdom National Health Service (NHS) may not have enough nurses to cope. Also, nursing students are being badly affected by this as their nursing education is going to be affected for several months and this will affect their ability to qualify and practice as nurses.

Rumours have spread that many retired nurses will be brought back into practice and that these will not be safe to practice in the health service. Another rumour is that final year nursing students will be ‘fast-tracked’ to qualification and will, also, not be safe to practice. Strictly speaking neither of these is true. I wish to clarify what the situation is.

In the United Kingdom, nursing is regulated by the Nursing and Midwifery Council (NMC). When nurses qualify, they must have passed their final year university examinations and have spent at least 50% of their programme in clinical practice. Then they become Registered Nurses. This means that their names are recorded on the Nursing Register held by the NMC. Nurses who are already registered must continue to meet high standards of practice and continuing education or they can be removed from the register.

In the present crisis the NMC has taken two actions:

Returning retired nurses to the wards
The NMC has created a Covid-19 temporary register and only nurses who have retired within the past three years will be eligible to join this register. These nurses will not have to pay to join this register, but they will have to meet all the standards expected by the NMC. These nurses will only be on the register for as long as they are needed to help with the Covid-19 crisis. Having only left practice in the past three years and, mostly being very experienced, they should quickly fit in an regain their skills. They will have to get up to date with some recent legislation affecting the NHS such as data protection and safeguarding. They will also have to be up to date on observation skills for patients and resuscitation.  These will include ‘early warning’ so that they can spot patients whose condition is likely to get worse and who will need intensive care.

Nursing student education and training
For nursing students the NMC has instructed universities to suspend clinical practice for first year nursing students. They will make up for this in the next two years of their university programme. If first year nursing students wish to work on the wards to help with the Covid-19 crisis then they may do so at their own risk. The time they spend on the wards will not count towards their nursing education and registration.

All other students will spend 80% of their time in clinical practice and 20% in education. At the time of writing, with universities closed to students, the education will be delivered online. Universities will be given more flexibility over where final year nursing students practice in their final six months to make sure that they are able to qualify safely.

The role of Universities
To make all this happen, universities are central to the process. They have had to make enormous changes to the way they deliver education to all students, including nursing students. Students, like nursing students and medical students who must spend time with patients, pose an extra challenge. University nursing departments are already making huge changes to their programmes and timetables to make these new arrangements work. They are also working out how to support nursing students working on the wards in hospitals. University nursing departments are responsible, along with the NHS, in making sure that those nurses being admitted to the Covid-19 temporary register are properly prepared to look after patients safely.

The present situation has shown how important nurses are in the NHS and at this time. The NMC, the NHS and the universities are working closely to ensure that the number of nurses will increase, that nursing students will be able to register and that patients will be looked after safely.

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, 10 April 2020

Problems with current UK government lockdown policy

Kevin Corbett, UK
Independent Research Consultant

David Crowe, Canada


1. There might be a real increase in cases but there is form of categorization occurring in the NHS where deaths with the non-specific symptoms of SARS-CoV-2 (the presumed viral agent)(Covid19 is the disease) are being attributed to SARS-CoV-2 without serological or laboratory (tissue culture) confirmation. Are autopsies being undertaken on all the deceased? SARS-CoV-2/Covid19 is not like Ebola or the Hantavirus and has not been categorized by the Government as a ‘Highly Contagious Infectious Disease’ (HCID). This peculiar categorization of non-specific cases being due to SARS-CoV-2 will act to confound the epidemiological picture by inflating the actual numbers of illness due to SARS-CoV-2.

2. This picture of people with a ‘new’ condition is relatively smaller in the context of annual winter deaths from flu and pneumonia (which in no way discounts the awfulness of any of these deaths). For example, see the Government’s statistics from the flu epidemic 2018/19 (attached). In 2018/19 there were 1,692 deaths attributed to flu and many more for pneumoniae. By comparison, what is being described by the Government and all of the media as an ‘epidemic’ or a ‘pandemic’ fails to reach the proportions of last year’s flu epidemic where 1,692 people died (according to the Government) with many more deaths attributed to pneumoniae. Therefore in 2018/19 we could expect around 25,000-30,000 deaths from flu/pneumonia without the same ‘pandemic’ label. This lack of any relative comparison with 2018/19 by either the government or the media isolates the current events from those which occurred last year, and thereby solidifies in the public psyche the frightening idea that a huge epidemic is now happening.

3. The tests for Covid19 are not yet calibrated to different populations like those without symptoms. ‘Died after testing positive for Covid19’ (what we hear daily in the media) is not the same as ‘died due to Covid19’ which is an evidence-based statement of disease causation. Tests are giving false positive and false negative readings, where people’s symptoms are being falsely attributed to Covid19 and where those without any symptoms are being falsely told they have Covid19. Test manufacturer data sheets warn about this fact of medical test technology and public health authorities in different jurisdictions are charged with advising on the calibration of these tests for the different populations in which they are to be used. This explains why only hospital patients are being tested and why there is a delay in rolling out tests (e.g. antibody tests) to the wider population which has understandably become extremely worried about Covid19 through Government messages. The lack of calibration of these tests will add to the number of Covid19 positives, further bolstering a perception of a disease out of control.

4. The NHS has consistently and continually been telling sick people via NHS 111 - as well as in high profile advertising in billboards, TV and radio etc. - to self-isolate and not to attend their usual health services when they have a set of generic non-Covid19 specific symptoms. This list of symptoms can apply to literally hundreds of different diseases and illnesses. Who doesn’t have a cough or runny nose living in our heavily polluted capital? This reduction and now virtual closure of primary care GP services in London has been gaining momentum since February. This may have been effective in causing people to let their illnesses/symptoms advance and thus when they finally show up at A&E they are in a much worse and fulminating condition. The Government advice therefore may be helping to create some of the dire clinical status that is being experienced in A&E departments with patients presenting in acute respiratory distress syndrome (ARDS).

5. Healthcare practice in hospital to lessen the perceived risk of Covid19 transmission via aerosolized contaminants discounts treating hypoxia in patients presenting with cough and fever with non-invasive ventilation (NIV) based on some limited evidence of Covid19 existing on surfaces, in favour of intubation and ventilation (possibly irrespective of clinical need), which may also help to explain the reported increased use of the existing critical care capacity. This situation is further exacerbated by the lack of personal protective equipment (PPE) and the necessary hardware, like ventilators, and workforce such as suitably trained critical care nurses and doctors, all of which have been negatively impacted in the last 12 years by Government austerity policies.

6. The current lockdown picture can be clouded by the ‘fog of war’ (meaning: the uncertainty in our current situation of lockdown due to a perceived threat to the public health). Healthcare staff will see cases as more serious through the ‘lens’ of a positive SARS-CoV-2 test and given the widespread awareness that there is something ‘out there’ that is officially perceived as ‘dangerous’ to everyone. Every presenting clinical picture in a patient will be attributed to the agency of SARS-CoV-2 when a test result is returned as positive. This will act to further inflate the statistics on Covid19 deaths and further bolster the perception of an epidemic which is getting out of control.

7. Many patients are being enrolled in clinical trials of antiviral, rheumatoid arthritis and malaria drugs around the world, although no drugs have been tested on more than a handful of SARS-CoV-2 patients, if any. This may be encouraged by doctors who are desperate to find a ‘silver bullet’, and obviously by pharmaceutical companies who are racing to get drugs approved for Covid19. However, it is not clear that it is possible to obtain informed consent from elderly patients with pre-existing health conditions, particularly those on ventilators, who may not realize that the probability of benefits is unknown, and the probability of side effects is very real. Furthermore, the trials will almost certainly not be double-blinded, randomized, placebo-controlled trials, so the data will be of limited use.

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.

Coronavirus outbreak: A turning point in nursing education

1. Assistant professor of nursing, Department of Nursing, Necmettin Erbakan University, Konya, Turkey.

2. Professor of nursing, Department of Nursing, Necmettin Erbakan University, Konya, Turkey.


We are a faculty member of nursing and are writing to you to raise the issue of current nursing education and put forward some solutions for this issue. The epidemic of the Coronavirus in the world in 2020 was a shock to educational systems in some countries in the world which cause a cessation in education. During this period the managers, faculties, and students fully comprehend the importance of distance education and the necessity of incorporating information technology in the educational curriculum. There is a popular fable about a penguin colony quoted by Kotter and Rath­geber in 2006. This penguin colony lived on an iceberg in Antarctica area for several years. But when they identified the problematic symptom of the iceberg, they eventually realized that the environment had changed and it is a need to modify and change how they lived (Murray, 2018).

The current health care system is dynamic and rapidly changing in line with modern technological breakthroughs. To keep pace with these trends, the nursing profession has to be vigilant and incorporate appropriate technologies, especially in educational settings (Nwozichi, Marcial, Farotimi, Escabarte, & Madu, 2019). The nurses of 2025 will most certainly work in a very different environment than what we work today and these trends require a shift in how we educate future generations for the nursing profession (Risling, 2017). We have to stop educating tomorrow’s nurses for yesterday’s jobs; now and tomorrow we are in an unceasing change; thus, con­tinuous adaptation is needed. We have to fully realize that tomorrow’s grad­uates will require a special arts background and have to contribute to soci­ety much more meaningfully by therapeutic re­lationship and creativity and give the mechanized responsibilities to the robots. If we continue to teach as we have done now, we will have to face and struggle with infrastructure shortage and global crises such as war, weather prolusion, and infectious diseases such as Coronavirus (Murray, 2018). So, curricular revisions are required to educate nurses to meet the challenges of the 21st-century (Tellez, 2012), (Darvish, Bahramnezhad, Keyhanian, & Navidhamidi, 2014), (Hunter, McGonigle, & Hebda, 2013) (Ainsley & Brown, 2009Krau, 2015).

These issues are not insurmountable provided that appropriate measures are adopted. Undoubtedly, the most effective way to iron out them is faculty engagement. To have faculty involved in this process adequately, managers should allocate a substantial amount of time, energy and resources to release time and compensate for those who participate in curricular revision. The faculty should receive training to become familiarized to effectively review the curricula (Tellez, 2012) (TOPAZ et al., 2016). Furthermore, they should try to create an atmosphere to promote students’ positive caring attitude and a love of learning for being informed and staying up-to-date on strategies to improve professional practice (Ainsley & Brown, 2009).

In addition to faculty engagement, preparing the atmosphere of the clinical setting cannot be denied. For the clinical setting, it is recommended that information technology become a requirement for all nurses to improve the quality of care. Creating some roles such as Chief Nursing Information Officers or other types of field informatics specialists at organizational or country levels is a good approach. For successful implementation, increasing awareness of information technology relevance and the representation of it at leadership, organizational, and policy levels is a prerequisite. One solution for acceptance is creating a clear relationship between nursing data and health outcomes and improved decision making by nurses in systems (TOPAZ et al., 2016).

Another challenge facing the integration of information technology in nursing education is the lack of support from administration and government. It is therefore recommended that governments should provide sufficient support for the integration of information technology in the various nursing institutions (Nwozichi et al., 2019). Deans of nursing programs were encouraged to create opportunities for faculty to develop the skills and knowledge necessary to teach nursing informatics, to provide the resources for infrastructure (Tellez, 2012). Creating more funding opportunities for information technology research at a government and other levels is highly recommended and existing research funding institutions should allocate information technology specific funds (TOPAZ et al., 2016). Increase multi-disciplinary collaboration and combine resources at the international level, among various nursing organizations, and integrate collaborative and multidisciplinary approaches is a foundation in this trend (Tellez, 2012) (Madsen, Cummings, & M., 2015) (Button, Harrington, & Belan, 2014).

In conclusion, we should assign a high priority to incorporate information technology into the nursing curriculum. A combination of different solutions such as faculty engagement, preparing the clinical atmosphere, and management support would definitely produce more desirable results. As the situation is serious, I request you to highlight it through your journal so that the authorities are sensitized towards it and do the needful. Thank you for allowing us to express our opinion.


Ainsley, B., & Brown, A. (2009). The impact of informatics on nursing education: a review of the literature. J Contin Educ Nurs, 40(5), 228-232. doi: 10.3928/00220124-20090422-02

Button, D., Harrington, A., & Belan, I. (2014). E-learning & information communication technology (ICT) in nursing education: A review of the literature. Nurse Educ Today, 34(10), 1311-1323. doi: 10.1016/j.nedt.2013.05.002

Darvish, A., Bahramnezhad, F., Keyhanian, S., & Navidhamidi, M. (2014). The role of nursing informatics on promoting quality of health care and the need for appropriate education. Glob J Health Sci, 6(6), 11-18. doi: 10.5539/gjhs.v6n6p11

Hunter, K., McGonigle, D., & Hebda, T. (2013). The integration of informatics content in baccalaureate and graduate nursing education: a status report. Nurse Educ, 38(3), 110-113. doi: 10.1097/NNE.0b013e31828dc292

Krau, S. D. (2015). The influence of technology in nursing education. Nurs Clin North Am, 50(2), 379-387. doi: 10.1016/j.cnur.2015.02.002

Madsen, I. , Cummings, E. , & M., Borycki. (2015). Current Status for Teaching Nursing Informatics in Denmark, Canada, and Australia. Stud Health Technol Inform, 216, 1016-.

Murray, T. A. (2018). Nursing Education: Our Iceberg Is Melting. J Nurs Educ, 57(10), 575-576. doi: 10.3928/01484834-20180921-01

Nwozichi, C. U., Marcial, D. E., Farotimi, A. A., Escabarte, A. B. S., & Madu, A. M. (2019). Integration of information and communication technology in nursing education in Southeast Asia: A systematic literature review. J Educ Health Promot, 8, 141. doi: 10.4103/jehp.jehp_240_18

Risling, T. (2017). Educating the nurses of 2025: Technology trends of the next decade. Nurse Educ Pract, 22, 89-92. doi: 10.1016/j.nepr.2016.12.007

Tellez, M. (2012). Nursing informatics education past, present, and future. Comput Inform Nurs, 30(5), 229-233. doi: 10.1097/NXN.0b013e3182569f42

TOPAZ, M., RONQUILLO, Ch., PELTONEN, L., PRUINELLI, L., SARMIENTO, R. F., BADGER, M. K., . . . ALHUWAIL, D. (2016). Advancing Nursing Informatics in the Next Decade: Recommendations from an International Survey. Nursing Informatics 123-128. doi: 10.3233/978-1-61499-658-3-123

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.

Tuesday, 7 April 2020

Seeing through the gaze of a storytelling lens

Catherine Best

Today is World Health Day 2020. So, let’s celebrate and support the great work that our courageous and dedicated nurses across the globe are doing right now. Nurses who are ‘pulling out all the stops’ to ensure the provision of the best care possible, at a time of greatest need.

Seeing through the gaze of a storytelling lens shines a light on the importance of narrative in nursing through which nurses can gain valuable insight into the lives of patients, colleagues and situations faced.

Throughout history, books, film, drama, art and even cave drawings have been used to tell personal stories that help to support social and emotional processing, which in turn encourages empathy (Robson, 2018).

‘The Death of Ivan Ilyich” by Leo Tolstoy first published in 1886, for example tells explicitly and with compassion, the story of a man, who instead of cultivating love and kindness, chose to cultivate a life of obsessive behaviour and social gain. Compelled to confront his own death, he realises that his life should have been different. Ivan Ilyich is fortunate, he is supported by his servant Gerasim, who without question provides for his personal needs and throughout his illness demonstrates only compassion; traits Ivan Ilyich should have cultivated. Ultimately, he realises as his life fades away he can still, fortunately, make amends.

Tolstoy’s novella along with many others, including the work of Arthur W. Frank (2013); ‘The Wounded Storyteller’ through which he tells his personal story of life with illness, and ’Somebody I Used to Know’ by Wendy Mitchell (2019), as she shares insight into her life following a dementia diagnosis, enables people to tell their stories of suffering, disease, illness and dying in all its forms.

Nursing Narrative
In recent years the importance of narrative within nursing has become increasingly popular, both as a catalyst for research opportunities and as a process whereby patients are able to generate meaning from personal experience (Joyce, 2015).

Comprehending personal narratives contends Gaydos, (2005) is a matter of intuition and art; reasoning and science. This concept developed by Carper (1978) defines the ‘Fundamental Patterns of Knowing’; seminal work that acknowledges the inimitable contribution that nurses make to patient care.

Narrative nursing argues Fitzpatrick (2018) provides an important framework to enable effective communication to take place and supports the development of professional nursing practice. Furthermore, nursing narrative can be a powerful educational opportunity (McAllister, 2015) empowering healthcare professionals to reflect critically on their experience (Walton et al., 2018). If care is to be truly patient centred however, health professionals must acknowledge that patient stories; the illness narrative, becomes the dominant voice (Buckley, 2016).

Narratives can be used to open up a plethora of opportunities to enhance professional development, including reflective practice, allowing nurses to express and extend their current knowledge, whilst making visible clinical expertise and providing occasions for collective learning (Erickson et al., 2015). Narratives can support professional socialisation argues Traynor, (2020). Defined by (Price et al., 2018), professional socialisation is the dynamic process of coming to know a professional role, ensuring a smooth transition to professional practice (Newton et al., 2015).

Furthermore, narratives can facilitate nurse recruitment by illuminating the great work of historical nurses, (Traynor, 2020), Florence Nightingale, Mary Seacole and, Edith Cavell being the most well-known and by contrast be utilised to develop professional leadership skills, build strong cultures and connect with others (Sherman, 2012). Likewise, through the act of telling or listening to narratives can encourage resilience (Traynor, 2020). Developing this ideological approach, it could be argued has the capacity to become nursing’s most revered strength.

Our Greatest Teachers
Patients and their families, through the telling of personal stories, can be our greatest teachers, (Fitzgerald, 2015), the use of narrative allowing for a full portrayal of these experiences and an examination of the meanings derived (Wang and Geale, 2015).

Patient-centred approaches to care delivery stress the importance of understanding patients’ knowledge, emotions, well-being and life experience (Johnston et al., 2016); providing a lens through which patients can experience a release of emotion and a sense of catharsis (Roebotham et al. 2018); strengthening the otherwise silent voice (Trahar, 2013).

Whilst the understanding of patients' stories requires a focused and empathically-attuned level of attention (Corbally and Grant, 2016) when a personal story is shared we catch sight of a world that is different from our own (The Health Foundation, 2016). By learning to understand another’s perceived world, the experience can inspire empathy within others (The Health Foundation, 2016).

Furthermore, because narratives are inherently designed to persuade; they describe a particular experience rather than assert a generalised truth, narratives have no need to validate the accuracy of such experience; the narrative itself is sufficient (Dahlstrom, 2014).

Through the medium of narrative, nurses have an opportunity to engage with and learn from the patients’ experience and in so doing facilitate the development of patient-centred care. Patient narratives however are futile if told to nurses who have failed not only to grasp the concept of what it means to tell one’s story but also what it means to be human, to suffer and in what context.

Giving patients the time and opportunity to share their experiences therefore is central if nurses are to promote a sense of patient wellbeing and through their actions create a future that promote a sense of integrity, trust and professionalism. One in which they seek to listen, to understand and where necessary to act.

Buckley, A. (2016) Using Patient Stories to Reflect on Care. Nursing Times, 112 (10)  pp. 22-25.

Carper, B. (1978) Fundamental Patterns of Knowing. Advances in Nursing Science, 1 (1)

Corbally, M. and Grant A. (2016) Narrative competence: A neglected area in undergraduate curricula. Nurse Education Today, 36 January, pp. 7-9

Dahlstrom, M.F. (2014) Using narratives and storytelling to communicate science with nonexpert audiences. Proceedings of the National Academy of Science, 111 supp 4 , pp. 13614–13620

Erickson, J.I. Ditomassi, M. Sabia, S. and Smith M. E. (2015). Fostering clinical success: Using narratives for interprofessional team partnerships from Massachusetts General Hospital. Indianapolis: Sigma Theta Tau International.

Fitzgerald, F. (2015) Medicine: The greatest of Humanities. Journal of Pain and Symptom Management, 49 (5) May, pp. 964-966.

Fitzpatrick, J. (2018) Teaching Through Storytelling: Narrative Nursing. Nursing Education Perspectives, 39 (2) March/April, pp. 60.

Frank, A.W. (2013) The Wounded Storyteller: Body, Illness, and Ethics. 2nd ed. The University of Chicago Press Ltd: London.

Gaydos, H.L. (2005) Understanding personal narratives: an approach to practice. Journal of Advanced Nursing, 49 (3) , pp. 254-259.

Johnston, C. Banner, N. and Fenwick, A. (2016) Patient narrative: an ‘on-switch’ for evaluating best interests. Journal of Social Welfare and Family Law, 38 (3)  pp. 249–262 doi.org/10.1080/09649069.2016.1228146

Joyce, M. (2015) Using narrative in nursing research. Nursing Standard, 29 (38) May, pp. 36-41.

McAllister, M. (2015). Connecting narrative with mental health learning through discussion and analysis of selected contemporary films. International Journal of Mental Health Nursing, 24 (4) pp. 304–313.

Mitchell, W. (2019) Somebody I Used to Know. eBook. London: Bloomsbury Publishing.

Newton, J.M. Henderson, A. Jolly, B. and Greaves, J. (2015). A contemporary examination of workplace learning culture: an ethnomethodology study. Nurse Education Today, 35 (1) pp. 91-96.

Price, S.L. McGillis Hall, L. Tomblin Murphy, G and Pierce, B. (2018) Evolving career choice narratives of new graduate nurses. Nurse Education in Practice,  pp. 86-91.

Robson, D. (2018) Our Fiction Addiction Why Humans Need Stories [Online]. BBC. Available from: http://www.bbc.com/culture/story/20180503-our-fiction-addiction-why-humans-need-stories [Accessed 2nd April 2020.]

Roebotham, T. Hawthornthwaite, L. Lee, L. and Lingard L.A. (2018) Beyond catharsis: the nuanced emotion of patient storytellers in an educational role. Medical Education, 52 (5)  pp. 526-535.

Sherman, R. (2012) The power of nursing leadership stories. Available from: https://www.emergingrnleader.com/nurseleaderstories/ [Accessed 5 April 2020]

The Health Foundation (2016) The Power of Storytelling. [Online] Available from: https://www.health.org.uk/newsletter-feature/power-of-storytelling [Accessed 3 April 2020]

Tolstoy, L (2016) The Death of Ivan Ilyich. London: Penguin Classics.

Trahar, S. (2013) Contextualising narrative Inquiry: developing methodological approaches for local contexts. Abingdon: Routledge

Traynor, M. (2020) Stories of Resilience in Nursing. Tales from the Frontline of Nursing. London: Routledge.

Walton, J.A. Lindsay, N. Hales, C. and Rook, H. (2018) Glimpses into the transition world: new graduate nurses' written reflections. Nurse Education Today, 60 January, pp. 62-66.

Wang, C.C. and Geale, S.K. (2015) The power of story: Narrative inquiry as a methodology in nursing research. International Journal of Nursing Sciences, 2 (2) June, pp. 195-198 

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, 6 April 2020

Coronavirus: were science and statistics overruled by fear?

Niall McCrae
King's College London

Roger Watson
University of Hull

email: n.mccrae@kcl.ac.uk

A crucial lesson for students in science and statistics is that correlation does not necessarily equate to causation (Thapa, Visentin, Hunt, Watson & Cleary, 2020). To consider a relationship between two variables as causative could lead to absurd conclusions. For example, the extent of damage caused by a fire correlates with the number of attending fire engines and firefighters. Obviously, it would be ridiculous to interpret this as evidence that less intervention by the fire brigade would lead to less destruction, and to act on such flawed logic accordingly. Clearly a large building in flames needs more hands to the pump.
The coronavirus crisis has exposed basic errors of numeracy and reasoning not only in the scientifically and statistically naive general public but also among experts. The impact of drastic decisions, made on dubious rationale, may endure for years if not decades. Global and national economies and health services may be harmed not so much by the virus itself, but from reaction to the virus. Here, we present some widely perpetuated and persuasive myths about the coronavirus outbreak.
1. Covid-19 is an unprecedented pandemic
Covid-19 has frequently been compared to the Spanish influenza outbreak of 1918-1919. But the death toll from Covid-19, just over 252 thousand at the time of writing, is 198 times smaller than the 50 million toll of Spanish flu. Mortality appears to be similar to that of seasonal flu epidemics, at around 0.1 to 0.3% (unlike the 3.4% rate suggested by the WHO in March). Although the daily and cumulative death totals are alarming, in 2014 almost 29000 died in England from a winter flu outbreak (Office for National Statistics, 2015), like the number dying from Covid-19 but with minimal public or media attention.
Misleadingly high death rates were reported in the media, based on a dubious denominator of cases, which depended on the amount of testing. The numerator of deaths may also be inconsistently measured; dying with the coronavirus is not necessarily the same as dying of the coronavirus. While in some countries cause of death was recorded as Covid-19 only if the person had been tested and died primarily from this disease, in other countries deaths were attributed to the virus without firm evidence. In the USA, hospitals receive higher payments from the government for Covid-19 deaths (Creitz, 2020).
2. The whole population needs protection
The Spanish flu targeted fit and healthy younger people; American troop ships arriving in France in 1918 were like floating coffins (Hasley, 2018). Covid-19, by contrast, mostly spares children, who are hardly affected by the disease and do not appear to transmit it. Most fit adults do not get seriously ill from Covid-19. Data from Iceland showed that 50% of cases were asymptomatic (Tara, 2020).
The profile of fatalities from Covid-19 is consistent: most are frail, old or have a major chronic condition such as diabetes mellitus (type I) or cardiovascular disease. Such people are more likely to contract an infectious disease that has become endemic in society, because their immune system is compromised. The death rate of those aged over 80 and 70 are estimated to be ten times higher and five times higher than the mean, respectively (Cuffe, 2020).  To put the numbers into perspective, consider a town with a population of 10000. On a national rate of deaths per million of 500, this town would have had five deaths (perhaps three in hospital, two in care homes). Most inhabitants would not know anyone personally who had perished. 
Clearly it was sensible to protect vulnerable people from the virus, by minimising contact with others while the virus was spreading. However, most European governments went far beyond protecting the weakest members of society.
3. Lockdown saves lives
The evidence for the lockdowns imposed in European countries and states of the USA is contentious. The rationale was to reduce the rate of transmission per person (R). But, as well as unavoidable transmission within households, lockdown probably increased multiple occupancy, as young people returned to the family home after being unable to study and work. In Italy, hundreds of thousands of people fled from northern cities to other parts of the country prior to the declared lockdown, unwittingly taking the disease with them. The only way to operate a lockdown effectively would be to isolate each person, which would be practically impossible.
In the UK, mortality reached a peak five weeks after lockdown was imposed. According to pathologist John Lee (2 May 2020), mass immobilisation of the people reverses the natural progress of a virus towards milder symptoms. The evolutionary purpose of a virus is to survive. A virus spreads wider if it infects active people with mild symptoms.
Lockdown has disrupted the normal operation of healthcare systems, with planned surgery postponed and screening for serious diseases such as cancer reduced or stopped. This will cause major collateral damage. In the UK, the slogan ‘Protect the NHS’ (National Health Service) deterred people from going to hospital when sick, and this combined with fear of infection resulted in emptying of wards. A rise in suicide has been predicted, particularly in socially isolated people with severe mental health problems (Hammond, 2020). Lockdown has increased domestic violence (Home Office, 2020). Furthermore, shutting down most businesses will have devastating effects on the wealth-generating parts of the economy, on which health service funding depends. 
Was this a necessary evil? The country receiving most attention for keeping its schools and businesses open is Sweden (Moore 2020), but Japan also maintained life as normal. To justify taking this risk, these countries would need to show mortality rates not substantially higher than in lockdown countries. In fact, they have had lower mortality, as shown in Table 1.

Table 1: Covid-19 mortality in selected countries (Worldometer, accessed 3 May 2020)

Deaths per million
Lockdown (most states)
No lockdown
No lockdown

Sophisticated analysis by Thomas Meunier (2020) indicates that the draconian European lockdowns may not have saved any lives. Comparing the UK, Spain, Italy and France with other countries with less restrictive interventions, there was no indication of any difference in the temporal pattern of the epidemic.  Some smaller countries have been able to contain the outbreak, particularly islands such as Iceland and New Zealand. But countries with high population density and cross-border transit have fared badly, as the virus quickly became endemic. Lockdown was like shutting the stable door after the horse had bolted. 
4. Testing is the priority
The World Health Organisation urged as much testing as possible. However, a major obstacle was the global shortage of testing kits (Smith, Wright, & Moody, 2020). The high frequency of tests in Germany was useful in showing the spread of Covid-19, but not necessarily in slowing it. In the UK, special testing centres were created for National Health Service (NHS) staff, following political and public pressure. However, there was confusion between diagnostic testing and antibody testing (ITV News, 2020). The former simply shows whether the person has the disease at the time of testing. An antibody test can show whether someone has had the disease, but antibodies take approximately four weeks to be detectable. Sending busy NHS practitioners to a testing centre would be almost futile. A negative test result would be no guarantee that the doctor or nurse does not get infected soon after. An antibody test would be more valuable to the health services and to society as this would show that people have had the virus and are consequently immune and not contagious and can work safely. The same principle applies to hepatitis B testing, which has been administered to all clinicians since the 1980s.
5. The more advanced the healthcare system, the more lives will be saved
This is not supported by evidence. Western European countries, with well-equipped intensive care facilities, have the highest mortality. As a ‘free at the point of delivery’ service, the British NHS may have been expected to save more lives than in countries with mixed public/private systems. However, despite its nationally cherished status, evidence indicates that the NHS was unable to prevent coronavirus deaths any more effectively than in countries with predominantly private insurance schemes. Ventilators and other modern intensive care apparatus are vital, but there is no cure for Covid-19.
While the NHS has been applauded for their efforts with a weekly public tribute, it may have contributed to the death toll. Most care in Britain is provided outside the NHS, particularly in residential homes for older people, where as many as half of Covid-19 deaths have occurred.
Discharge guideline was issued by the Department of Health on 17 March 2020 'to free up NHS capacity via rapid discharge into the community and reducing planned care'. An anonymous whistleblower involved in the care home sector claimed that many older patients were discharged from hospital before receiving vital treatment, and without being tested for Covid-19 (Richardson, 2020). Another whistleblower reported that in a care home in Edinburgh residents known to be infected with Covid-19 were allowed to wander freely (Richardson, 2020). The care home had nine deaths in two weeks and a further ten residents tested positively for Covid-19.
Myths are misleading and they can be dangerous. Lockdown does not appear to have rescued people from the virus, and its economic impact will be devastating to public finances and individual livelihood. The clamour for something to be done, and the use of information which is not necessarily evidence-based, may have misguided governments. We appreciate that measures taken to ‘flatten the curve’ of the pandemic were taken to avoid overwhelming hospitals with finite resources (although the hurriedly built Nightingale Hospitals around the country have mostly remained empty). By whatever means this is done we know that we cannot live safely with this virus in our midst until approximately 80% of the population have been exposed and developed the necessary antibodies (Sadarangani, 2016) and all we can do is control the rate at which this is achieved. Sceptics of government policies have been demonised in the mainstream media, but clearly there are major flaws in the rationale and practice of disease containment. Truth and accuracy should not be victims of the Covid-19 pandemic; we will need these precious commodities more than ever as we strive to return to normal life. A key question is: if we have Covid-21, would we do the same again?
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Disclaimer: Editorials are opinion pieces. This piece has not been subject to peer review and the opinions expressed are those of the authors. RW is Editor-in-Chief of JAN. Neither NM or RW have relevant political or other affiliations to declare.