Friday, 21 July 2017

How do we evaluate nursing care?

Roger Watson, Editor-in-Chief

As long as I can remember we have been looking for ways to measure nursing care. These parallel discussions for definitions of  nursing and they come and go. Now they have definitely come back. Resources for medical and nursing care are limited worldwide, professional boundaries are becoming blurred and roles are beginning to change. Nurses nearly always work as parts of a multidisciplinary team and it is not always easy to decide what happens as a results of nursing. 

The issue of indicators is the subject of an article from Canada by Dubois et al. (2017) titled: 'Which priority indicators to use to evaluate nursing care performance? A discussion paper' and published in JAN. The aim of the article was: '(a) discussion of an optimal set of indicators that can be used on a priority basis to assess the performance of nursing care'.

By reviewing previous work the authors arrived at a list of 12 indicators which I will not list here; refer to Table 3 of the article. Some of the 'usual suspects' such as pressure ulcers and falls are there but also team composition and length of continuous work. The key references are provided and the evidence is summarised.

You can listen to this as a podcast


Dubois, C.-A., D'Amour, D., Brault, I., Dallaire, C., Déry, J., Duhoux, A., Lavoie-Tremblay, M., Mathieu, L., Karemere, H. and Zufferey, A. (2017), Which priority indicators to use to evaluate nursing care performance? A discussion paper. J Adv Nurs. doi:10.1111/jan.13373

Pressure sores are painful

Roger Watson, Editor-in-Chief

I am well aware the we no longer refer to 'pressure sores' and even the term 'pressure ulcer' has been replaced by 'pressure injury' - and a good thing too because that is exactly what skin breakdown due to pressure is: a pressure injury. However, the original term 'sore' reminds us also that pressure injury is painful as explained in this article from UK and Australia by Jackson et al (2017) titled: 'Pain associated with pressure injury: a qualitative study of community based, home-dwelling individuals' and published in JAN.

The aim of the study was 'to provide deep insights into the pain associated with pressure injuries' and towards that end 12 people experiencing or who had experienced pressure injury were interviewed. One person said: 'You tend to think that pain is a question of mind over matter, but it isn’t. There’s nothing, apart from taking the pain killers. You are at its mercy. And pressure sores are relentless. . . . the pressure ulcer is there 24 hours. And it doesn’t matter where you sit, where you lie, where you turn, it’s there, there’s no getting away from it.' Another person was more specific: 'Like there’s glass in it, that’s what that feels like. All the time, like I’ve got glass in my foot. It just rubs all the time. It’s horrible. Stings as well as rubs and they just cover it up.' The unbearable nature of the pain was expressed by someone who said: 'The one thing that’s consuming me at the moment is the pressure sore. Everything else fades into insignificance, the fact that your heart might stop at any moment doesn’t worry me as much as the pressure sore. It’s consumed me in the last two to three weeks. . .'

The authors concluded: 'Our findings suggest that both the assessment of pain and the subsequent
management of the pain were not well managed in this patient group' and '(t)here is clearly a need for revised nursing policy and practices with better assessment and recognition of risk to reduce (pressuse injury) developing, strong patient advocacy and involvement to ensure optimal pain management strategies are in place and adhered to.

You can listen to this as a podcast


Jackson, D., Durrant, L., Bishop, E., Walthall, H., Betteridge, R., Gardner, S., Coulton, W., Hutchinson, M., Neville, S., Davidson, P. M. and Usher, K. (2017), Pain associated with pressure injury: a qualitative study of community based, home-dwelling individuals. J Adv Nurs. doi:10.1111/jan.13370

Friday, 30 June 2017

How Much More Evidence Do We Need about Nurses’ Work Environments?

Ann-Marie Urban

Over three decades of research, monies, attention and recommendations highlight how the working conditions influence nurse turnover, retention, cost and more recently as highlighted in the recent virtual issue on nurses’ health. Gallagher and Pickler note the importance of healthy diets and stress management as part of improving nurses’ health, however, it is important to recognize the problematic work environment that continues to influence nurses’ health and their work. The realities of many work environments do not allow nurses to practise in a safe and caring way much of the time. Unfortunately, it requires nurses to be productive, expedite discharge, manage increasing complex patients and practise within a traditional hierarchical structure. Sadly, this disconnect has created nurses who are increasingly sick, stressed, bullied, burned out and morally fatigued.

What will the conditions be like in another decade? While nurses know that they work in the adverse conditions of acute care, they may not understand how they contribute to and are organized to meet institutional demands. Increasing patient acuity, budget constraints, a chronic shortage of staff, and overcrowding are routine in hospitals, yet no one discusses how this influences nurses’ work except when discussing nurses as stressed, fatigued or comprising patient care. Nurses are placed in situations where they lack the time, the resources and, in some cases, even the knowledge to care for patients. Because of these problems every year nurses suffer mental and physical injuries which are largely preventable. And sadly but not widely acknowledged, because the majority of nurses are women, this work is expected. Patriarchal underpinning and gendered assumptions situate nurses and their work in a quagmire of persistent problems with strategies focusing on nurses rather than on the system. While the nurse and nurses’ work have been widely studied, a focus on gender related to nurses’ physical and mental health is lacking. Understanding the realities and acknowledging the actualities of nurses’ work in hospitals are key to change. However, before a new reality will be realized, embedded assumptions about nurses and their work must be acknowledged by government, hospital managers and nurses. Similarly, nurses’ work must be understood within the context of the moving political and economic agendas. Further attention must be directed to the nurse’s work environment and how this influences patient care and the health of nurses.

Although efforts to improve the conditions in hospitals have been attempted, few strategies effectively support nurses’ health in their efforts towards patient care in the context of today’s hospitals. What has to change for hospital administrators, governments, professional associations, unions and researchers to notice and make changes? Is it not enough that nurses’ illness and injuries continue to be a problem, and that patient care is compromised? The existing traditional structure must be challenged to embark on another way. Supporting nurses’ health is vitally important for their overall well being for the care of patients.

A new structure would recognize nurses’ work by shifting their participation to a collaborative decision-making team. Different models of care delivery would move nurses to autonomous roles such as patient education, admission and discharge coordinators and patient advocates or to a model that incorporates an expanded role for nurses. Nurses and their work must also be understood within a broader sociopolitical context. Creating a collective awareness about the influencing powers could provide the space for discussion and possibilities for change. The gendered aspect of nursing must also be acknowledged as well as how nurses actively participate in maintaining their place in the hospital. Nurses, too, must realize other possibilities; they must realize that they do not have to become injured, stressed or leave the profession because of the patriarchal and political ruling. Untangling power will take time; however, if we begin to recognize and name it, nurses’ work has the potential to change.

Ann-Marie Urban, RN, RPN
Associate Professor
Faculty of Nursing, University of Regina,

Wednesday, 28 June 2017

Should residents in care homes have sex?

Roger Watson, Editor-in-Chief

My answer to the question that heads this entry is 'why not?' However, this entry covers an article from New Zealand by Cook et al. (2017) titled: 'Ethics, intimacy and sexuality in aged care' and published in JAN. The study on which the article is based aimed to: 'analyse the accounts of staff, family and residents to advance ethical insights into intimacy and sexuality in residential care.' Four  people, including a resident, were involved and interviewed.

With regard to the possibility of intimacy, the resident said: 'No. Couldn’t do anything here because if the door opened and somebody like [manager] walked in I’d be mortified. There are no locks on the door, as you notice. . .So there really is no privacy here at all . . .. I don’t feel like I’m home.' A care assistant expressed uncertainty about what to do with regard to sexuality: 'It [sexuality-related issues] does happen, I’ve seen it happen and nobody talks about it and, we’ve got to make a judgement call, which I have done on a few occasions. . ..and you just don’t know which is the right way . . ..'  The Registered Nurse was aware that some older people may be exploited but said: 'As long as they’re not being taken advantage of and I think for some it can open up new relationships, new caring. Again, when we talk about this everybody thinks of [penetrative] sex. . .but sometimes just to sit, cuddle, kiss, stroke, whatever, that’s more than enough for a lot of them.'

In conclusion, the authors said: 'The topic is complex: too often ageism shapes assumptions about older people’s entitlement to be intimate; where there is cognitive impairment, the debate about upholding the preferences of the “then” self or the well-being of the “now” self may result in conflict among decision-makers; proxy decision-makers may have limited knowledge of the resident’s lifetime of sexual preferences. Education and policies upholding rights may increase staff awareness beyond their own moral code. However, rigid policies may work against residents’ wellbeing. Instead, flexible responses that focus on person-centred wellbeing rather than a risk management approach are desirable.'

You can listen to this as a podcast


Cook, C., Schouten, V., Henrickson, M. and Mcdonald, S. (2017), Ethics, intimacy and sexuality in aged care. J Adv Nurs. doi:10.1111/jan.13361

Fatigue leads to nursing absence

Roger Watson, Editor-in-Chief

Fatigue and the work involved in nursing are closely related, but does fatigue lead to adverse outcomes for nurses? An article from the USA by Sagherian et al. (2017) titled: 'Acute fatigue predicts sickness absence in the workplace: A 1-year retrospective cohort study in pediatric nurses' and published in JAN came from a study that aimed to: 'examine the relationship between fatigue and sickness absence in nurses from a paediatric hospital over 12 months of follow-up. A secondary aim was to identify other work and personal factors that predict sickness absence.'

Forty children's nurses were involved and adminstered a measure of fatigue. Then they were followed up to check on their work patterns. The study showed that the extent of fatigue at the start of the study could predict sickness absence from work; nurses who were more fatigued were more likely to experience sickness absence. In conclusion, the authors say: 'Nursing management can monitor nurse fatigue and unit workloads to decrease this unfavourable outcome and consequently maintain safe practice environments.'

You can listen to this as a podcast


Sagherian, K., Unick, G. J., Zhu, S., Derickson, D., Hinds, P. S. and Geiger-Brown, J. (2017), Acute fatigue predicts sickness absence in the workplace: A 1-year retrospective cohort study in pediatric nurses. J Adv Nurs. doi:10.1111/jan.13357

Tuesday, 27 June 2017

Are nursing students angry people?

Roger Watson, Editor-in-Chief

The answer to the question is that they are more angry than other university students according to this article from Korea by Jun et al. (2017) titled: 'Comparing Anger, Anger Expression, Life Stress, and Social Support Between Korean Female Nursing and General University Students' and published in JAN which aimed to: 'compare anger, anger expression, life stress and social support among female students at a nursing university and a general university and to examine factors affecting anger in each group.'

Nearly 300 female university students, approximately divided into two equal groups of nursing students and other university students participated in the study which required them to complete a questionnaire on anger and sources of anger. The results showed that: '(n)ursing students’ anger scores were slightly higher than the scale’s median value but significantly higher than general students’ scores. Additionally, nursing students’ anger scores in this study were higher than those recorded by homeless people (who commonly reported alcohol problems and difficulty maintaining peer and familial relationships) using the same scale...' The reasons for the higher levels of anger in the nursing students was not clear but it may be the nature of their programme, as the authors explain: 'South Korean nursing students must complete large amounts of homework in each major course to satisfy nursing program certification standards set by the Korean Accreditation Board of Nursing Education.'

In conclusion the authors say: 'High levels of anger in health care providers may lead to poor mental health and reduced care quality. It is therefore particularly important to manage anger among nursing students' and '(a)nger expression and same-sex peer relationships affected nursing students’ anger...(t)herefore, nursing training programs should aim to reduce their students’ same-sex peer relationship stress and provide beneficial anger expression techniques.'

You can listen to this as a podcast


Jun, W. H. and Lee, G. (2017), Comparing Anger, Anger Expression, Life Stress, and Social Support Between Korean Female Nursing and General University Students. J Adv Nurs. doi:10.1111/jan.13354