Monday, 21 April 2014

Non-pharmacological pain interventions

Roger Watson, Editor-in-Chief

A systematic review by Hökka et al. (2014) published in JAN considers non-pharmacological treatment of pain in advanced cancer. The search for such treatments is doubtless spurred by the desire for treatments that will not lead to dependence and will have few, or no, adverse side-effects. However, it is hard to imagine any treatment that has an effect not having a side-effect. That is how treatments work; they disrupt some function of the body to produce a desired effect and this, inevitably, has an unwanted effect. The search continues for treatments with good therapeutic indices: the appropriate balance between desired effect and unwanted side-effect. From this perspective, the search for – so-called – non-pharmacological treatments may be fruitless as, if they work, they are either having an effect, with the risk of side-effects, or the person receiving them thinks they work; i.e. they have a placebo effect. 

Non-pharmacological treatments fall under the umbrella of complementary and alternative medicine (CAM) and this covers a very broad range of purported treatments that are united by a single concept: they have not been shown to work. Numerous reviews over the years have, largely, demonstrated this. Some would say that the ‘jury remains out’ on the issue; others would say that judgement has been delivered. 

Nevertheless, the use of CAM continues and the reasons they are used range from mild to severe symptoms and – while it could be argued that resources should not be invested in their development and testing – the fact that they are widely used, despite the lack of evidence, merits their study. Certainly, the evidence for efficacy needs to be evaluated and reported.

Hökka et al. (2014) report very little evidence that the treatments they reviewed work for people with advanced cancer. Moreover, in the words of the authors: ‘There are several research gaps: we found no studies about music, spiritual care, hypnosis, active coping training, cold or ultrasonic stimulation.’ This means that, for a remarkably wide range of non-pharmacological treatments being used to treat pain in advanced cancer, there seems to be no effort to study them. If people are asking to use these treatments or if nurses are proposing them, then they need to be honest about the state of evidence in this field.


Reference

Hökka M, Kaakinen P, Pölkki T (2014) A systematicreview: non-pharmacological interventions in treating pain in patients withadvanced cancer Journal of Advanced Nursing doi:10.1111/jan.12424








Tuesday, 15 April 2014

Older nurses in the workforce

Roger Watson, Editor-in-Chief

A study of nurses over 50 years of age in New Zealand, published in JAN, provides a very interesting and clear pattern of the decisions and career shifts that nurses make in the final 10-15 years of their career.

The ageing of the nursing workforce has been a major consideration worldwide for at least a decade with reports highlighting the issue and proposing solutions (Buchan 1999, Watson et al. 2003). The ageing of the nursing workforce cannot be ignored for the sake of political correctness; older nurses are closer to retirement and older nurses cannot possibly undertake some of the roles of their younger counterparts if they have had a full career in nursing. Nursing is a physically and psychologically demanding profession and the accumulated physical and mental stresses are bound to have an effect. However, health services need to function in hospitals and communities, and there is also a recognised shortage of nurses entering the profession (Buchan & Calman 2004) and a propensity for attrition from the profession (Buchan 2013), often for the reasons stated above. Increasingly, therefore, we rely on older nurses as a proportion of the nursing workforce (Watson et al. 2003). We do not have the option of allowing older nurses to retire too early and if we do we lose an incredible repository of knowledge and experience and also investment in education and career and professional development, often over up to four decades.

The study by North et al. (2014), using a retrospective cohort analysis over 5 years of nurses aged over 50 shows that there is a move out of hospital care and into community care. However, a quarter of the cohort were no longer practicing, therefore, there was a net loss of practising nurses. Over the 5 years of the analysis there was a clear trend towards reduced working hours. It is clear - generally - what older nurses like to do: work fewer hours and work out of hospital and in the community. If this is the case then, to staff vital areas where older nurses like to work and to maintain their valuable contribution to healthcare, some accommodation of these facts must be made.


References

Buchan J (1999) The ‘greying’of the United Kingdom nursing workforce: implications for employment policy andpractice. Journal of Advanced Nursing 30, 818–826

Buchan J (2013) Nurses’ turnover: reviewing the evidence, heeding the results. Journal of Advanced Nursing 69, 1917-1918

Buchan J, Calman L (2004). The global shortage of registered nurses: An overview of issues and actions. International Council of Nurses, Geneva

North N, Leung W, Lee R (2014) Aged over 50 years and practising: separation and changes in nursing practice among New Zealand’s older Registered Nurses. Journal of Advanced Nursing DOI: 10.1111/jan.12426

Watson R, Manthorpe J & Andrews J (2003) Nurses over 50: Option, Decisions and Outcomes. The Policy Press, Bristol

Monday, 31 March 2014

Reporting instrument development and testing

Roger Watson, Editor-in-Chief

David L Streiner
We commissioned two leading psychometricians, David L Streiner and Jan Kottner, to write a special paper for us; one that would be helpful to authors in submitting manuscripts to JAN on instrument development and testing. I am pleased to present their superb paper: 'Recommendations for reporting the results of studies of instrument and scale development and testing'.

Jan Kottner
The paper is a readable, authoritative and contemporary 'take' on the subject. The sources cited are the key ones and the ideas expressed should resonate beyond the pages of JAN.

Old notions of reliability and validity are challenged and, of supreme importance, the need to develop a new scale where an suitable alternative exists, is challenged. The recommendations cover every aspect of an instrument development paper - as currently required by JAN - from the title to the conclusions.

In particular, authors should be cautious in the claims they make about their instruments: no longer should we refer to an instrument as being 'reliable'; instead we should refer to the ways reliability was tested. Similarly, we should no longer refer to instruments as being valid or that some particular aspect of validity has been established; rather, we should realise that all tests of validity are providing insight into the construct validity which is, in fact, unobtainable. We can only claim any level of validity for an instrument for the samples or populations with which it has been tested and  only then if we have really been able to establish that the instrument really does measure what is was designed to measure.

I urge all authors to read these recommendation, especially if you intend to submit a manuscript on instrument development.





Reference

Streiner DL, Kottner J (2014) Recommendations for reporting the results of studies of instrument and scale development and testing Journal of Advanced Nursing



Monday, 24 March 2014

Trial by author

Roger Watson, Editor-in-Chief

Periodically, authors scrutinise what is published in journals and then publish it. I welcome this and, with respect to h-indices (Thompson & Watson 2010), open access (Watson et al. 2012), peer review (Watson 2012), authorship (Hayter et al. 2013) and citations (Hunt et al. 2013, Watson et al. 2013) I have done some of this myself. Publishing about publishing is increasingly common and, while some may see this as futile self-absorption, it is important in exposing and improving standards.

A recent JAN paper by Chiavetta et al. (2014) considers whether there is a difference in methodological quality between positive and negative published clinical trials. They conclude that there is and that negative trials tend to do better when scored using the Jadad scale which looks at randomisation, blinding and how all patients are accounted for. The years studied were 2010-2012 and, since the journals they analysed include JAN, my attention was drawn to this paper by our Managing Editor.

Ideally, there should be no difference in the methodological quality of positive or negative clinical trials and none of us - without appropriate qualification or description (e.g. pragmatic, single-blind, quasi-experimental) - should be publishing items labelled clinical trials that are not described fully. For the details of the disparate points between trials I urge you to read the paper; of more interest to me as Editor-in-Chief of JAN is ‘why?’. Why was there a difference and, of course, what can we do about it?

The authors speculate that it is still hard to publish the results of negative clinical trials; this should not be true but it may be. At JAN we do not have a policy of not publishing negative trials and I hope we convey that message. Nevertheless, as I travel the world and give writing workshops I am frequently asked about our policies on negative trials. Clearly, people do find it hard to publish these and whatever efforts we are making to dispel this, we are not making them strongly enough.

The argument by the authors, therefore, runs as follows: it is harder to publish negative trials and they come under greater scrutiny than positive trials; thus the standard of their publication is driven up. However, editors and reviewers like positive trials and they receive less scrutiny and ‘slip the net’ of the reviewing and editing process. If this is true then we need to work harder to obviate this as it is surely a contributory factor to publication bias and this is bad because poor positive results are published and exaggerated. This leads to misuse of resources and could even endanger patients.

The solution proposed by Chiavetta et al. (2104) includes the use of the CONSORT guidelines which we do recommend in JAN there may be a case for emphasising this in our guidelines and strengthening its implementation by authors, reviewers and editors.



References

Chiavetta N, Martins ARS, Henriques ICR, Frengi F (2014) Differences in methodological quality between positive and negative published clinical trials Journal of Advanced Nursing doi: 10.1111/jan.12380

Hayter M, Noyes J, Perry L, Pickler R, Roe B, Watson R (2013) Who writes, whose rights, and who’s right? Journal of Advanced Nursing 62, 2599-2601

Hunt GE, Jackson D, Watson R, Cleary M (2013) A citation analysis of nurse education using various bibliometric indicators Journal of Advanced Nursing 62, 1411-1445

Thompson DR, Watson R (2010) h-indices andthe performance of nursing professors in the UK Journal of Clinical Nursing 19, 2975-2958

Watson R (2012) Peer review under the spotlight in the UK Journal of Advanced Nursing 68, 718-720

Watson R Cleary M, Jackson D, Hunt GE (2012) Open access and online publishing: a new frontier in nursing? Journal of Advanced Nursing 68, 1905-1908

Watson R, Cleary M, Hunt GE (2013) What gets highly cited in JAN? Can editors pick articles which will contribute to a journal’simpact factor? Journal of Advanced Nursing doi:10.1111/jan.12261