Tuesday, 1 September 2015

Cost effective strategies for pressure ulcer prevention

Roger Watson, Editor-in-Chief

Pressure ulcers are the problem that never goes away.  From a mentality that used to say that they should always be prevented and always could be prevented, it is now clear that they are very hard to prevent but that some strategies are better than others.  However, where differences in effectiveness are marginal the issue of cost-effectiveness is an essential factor to study.

A recent UK study by Marsden et al. (2015) titled 'A cost-effectiveness analysis of two different repositioning strategies for the prevention of pressure ulcers' and published in JAN uses a health economics approach to 'assess the cost effectiveness of two repositioning strategies and inform the 2014 National Institute for Health and Care Excellence clinical guideline recommendations on pressure ulcer prevention'.  The data for the inputs to the model were obtained from a systematic review and the health economic methods are fully described.

The outcome of the study is best described in the authors own words: 'this analysis found that alternating 2 and 4 hourly repositioning is not cost-effective compared with 4 hourly repositioning, as a PU prevention strategy in older people in a nursing home with non-blanchable erythema. This conclusion was robust to a range of sensitivity analyses, demonstrating that despite uncertainty around the model inputs, variation within reasonable ranges does not alter the conclusion.'

You can listen to this as a podcast.


Marsden G, Jones K, Neilson J, Avital L, Collier M, Standby G (2015) A cost-effectiveness analysis of two different repositioning strategies for the prevention of pressure ulcers Journal of Advanced Nursing doi: 10.1111/jan.12753

Inductive or deductive: fallacious labels in qualitative content analysis

Mohammad Reza Armat
Mostafa Rad
Abbas Heydar
Hasan Sharifipoor Bahreman
Abdoghader Assarroudi

The dualism propounded in Content Analysis (CA) in quantitative and qualitative approaches has been widely supported and justified in then nursing literature (Cavanagh 1997, Hsieh & Shannon 2005, Schreier 2014). Nevertheless, another sort of dualism has been proposed for Qualitative Content Analysis (QCA), suggesting the adoption of inductive and/or deductive approaches in the process of qualitative dada analysis (Mayring & Fenzl 2014, Yan Zhang &. Wildemuth 2009). These approaches have been labeled and referred as ‘inductive’ or ‘conventional; and ‘deductive’ or ‘directed’ content analysis in the literature (Hsieh & Shannon 2005, Mayring 2000, Mayring & Fenzl 2014). We believe that these labels for QCA are probably false, and may lead ambiguity. Labeling the CA as inductive (conventional) and/or deductive (directed) alludes that the researcher can or must choose exclusively one of these approaches in his or her data analysis, while this distinction in the qualitative data analysis seems to be neither necessary nor possible.

Deductive CA (directed) may be used when there are existing views, research findings, theories or conceptual frameworks regarding the phenomenon of interest. The analysis relies on pre-existing categories developed based on theories or previous research findings. This approach may lead to confirmation, refinement, extension, or rejection of the theory or existing knowledge (Hsieh & Shannon 2005, Mayring 2000, Zhang 2006). This type of QCA, in turn, may be accomplished using two rather different strategies: a) generating primary codes based on pre-existing categories; b) generating primary codes as well as sub-categories regardless of pre-existing categories (inductive approach), then nesting these emerged sub-categories within the pre-existing categories. If this nesting is not logically or conceptually meaningful, then generating of new categories would be considered (Hsieh & Shannon 2005). The first strategy may lead to confirmation, refinement, and extension of theory; while the second, in addition to these, may be capable of rejecting the theory. As seen, it is quite possible to use ‘induction’, where needed, along with the ‘deduction’ during directed QCA.

On the other hand, inductive QCA (conventional) is used when there is lack of, or limited previous research findings or theories. Thus the researcher does not consider any pre-existing categories during data analysis (Elo & Kyngäs 2008, Hsieh & Shannon 2005, Mayring 2000, Mayring & Fenzl 2014). There is a subtle, yet important point here. The researchers' mind is not totally blank; instead, he or she analyzes the content based on the research question(s) or study aim(s), and/or some relevant assumptions in their mind (Harding 2013, Schreier 2014). Hence, in such cases, the researchers in addition to inductive approach inevitably employ deductive approach during the extraction and/or inference of findings.

Therefore, as it can be seen, both the inductive and deductive approaches in reasoning are inseparably used in both methods of QCA. In other words, analysis of qualitative data without concurrent use of both the inductive and deductive reasoning would not be complete nor is it possible. Because the researchers’ mind constantly moves back and forth on a continuum that holds induction on one side, and deduction on the other side, when they face a phenomenon (Gale et al. 2013, Harding 2013). In fact, depending on the research question, study aim, and the extent of existing knowledge, the researcher uses induction or deduction with unequal weight. The more the existing knowledge regarding the phenomenon of interest, the greater the weight would be given to deductive reasoning during data analysis, and vice versa.

Having said this, use of labels such as ‘inductive’ and ‘deductive’, equivalents of ‘conventional’ and ‘directed’, respectively (Hsieh & Shannon 2005), that implicitly denote the use of merely one of these reasoning approaches during QCA, may cause a disturbing fallacy in an audiences' mind, particularly novice researchers. To avoid this, the authors suggest using the more general and simple label of ‘qualitative content analysis’ without quoting any of the two approaches. As, in practice, both the inductive and deductive approaches are employed during the process of QCA. The researchers may denote in their reports, the weight they have given to the induction or deduction components of data analysis process.

Mohammad Reza ARMAT, MSc in Nursing, PhD Candidate in Nursing
Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad

Mostafa RAD, MSc in Nursing, PhD Candidate in Nursing, School of Nursing and Midwifery,
Sabzevar University of Medical Sciences, Sabzevar, Iran

Abbas HEYDARI, PhD, Associate Professor
Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Hasan SHARIFIPOOR BAHREMAN, MSc in Nursing, PhD Student in Nursing
Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Abdoghader ASSARROUDI, MSc in Nursing, PhD Candidate in Nursing
School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran. 


Cavanagh, S. 1997. Content analysis: concepts, methods and applications. Nurse Researcher, 4, 5-13

Elo, S. & Kyngäs, H. 2008. The qualitative content analysis process. Journal of Advanced Nursing, 62, 107-115

Gale, N. K., Heath, G., Cameron, E., Rashid, S. & Redwood, S. 2013. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13, 117

Harding, J. 2013. Qualitative Data Analysis from Start to Finish, Sage

Hsieh, H.-. & Shannon, S. E. 2005. Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288

Mayring, P. 2000. Qualitative Content Analysis. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 1(2), Art. 20, http://nbn-resolving.de/urn:nbn:de:0114-fqs0002204

Mayring, P. & Fenzl, T. 2014. Qualitative inhaltsanalyse, Springer

Schreier, M. 2014. 'Qualitative content analysis'. The SAGE Handbook of Qualitative Data Analysis, 170-183

Zhang, Y. & Wildemuth, B.M 2009. 'Qualitative analysis of content'. Applications of Social Research Methods to Questions in Information and Library Science. Westport, CT: Libraries Unlimited.

Zhang, Y. 2006. Content analysis (qualitative, thematic). (http://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=B199768CACB95DB352E742EAF4DD5BC8?doi=; Retrieved October, 6, 2008)

Friday, 14 August 2015

More on music in the operating theatre

Roger Watson, Editor-in-Chief

Our recently published article by Weldon et al. (2015) titled: 'Music and communication in the
operating theatre' which features in the previous JAN interactive entry has certainly 'got legs'. Today the altmetrics exceeded 200 and that is in less than one week since publication.

The article featured on the flagship BBC Radio 4 programme Today and this is presented in a podcast. In addition, the first author, Sharon-Marie Weldon, was interviewed on BBC World News.

The issue continues to attract interest and the JAN paper was juxtaposed against a Lancet article this week which reported how soothing music was for patients. Of course, this is all good material for the press as they like the debate and outside of the scientific arena a London based surgeon, Alex Chung, wrote a column in The Daily Telegraph of 14 August 2015 where he took a sarcastic angle on the JAN article and made it clear - revealing his arrogance in the process - that in the operating theatre his 'choices ruled'. He must be a real pleasure to work with!

What are your views on music in the operating theatre? Post them here, write an entry or Tweet us and remember to include the link to the article by Weldon et al. (2015).


Weldon. S-M., Korkiakangas. T., Bezemer, J. and Kneebone. R. (2015) Music and communication in the operating theatre. Journal of Advanced Nursing, doi: 10.1111/jan.12744

Tuesday, 4 August 2015

Is music in the operating theatre dangerous?

Roger Watson, Editor-in-Chief

Music is played during the majority of operations performed in operating theatres (OTs) and has been playing in OTs almost since it was possible to have portable music devices. Admittedly, some may nor seem that portable these days and with increasing portability has come increasing frequency of music being played and an increasing variety of the music being played.

Originally music in OTs was meant to benefit patients by creating a relaxing ambience as they were anaesthetised and, according to patients in at least one study, they like it (Stevens 1990).  According to another study, it does reduce pre-operative anxiety (Cooke et al. 2005).  However, there is an assumption that such music is soothing, suitable to a broad taste in music and not having any unexpected adverse consequences.

Apart from the fact that one person's music can be another person's torture, what if music is not soothing, but loud and intrusive?  Can this have adverse consequences?  According to a recent study conducted at Imperial College London by Weldon et al. (2015) titled: Music and communication in the operating theatre and published in JAN, it can. Music can be so loud and intrusive that it hampers staff communication and good communication in  the OT is essential for patient safety both in terms of speed and accuracy of information exchange, requests and instructions.

In the study by Weldon et al. video recordings were made of operations with and without music and the speed - in terms of how often things had to be repeated - of communication was observed and recorded.  In the presence of music the speed of communication was decreased as people had to ask for information to be repeated.

OTs are already noisy environments and the noise levels exceed recommended safety limits.  The addition of music which, by virtue of the already high background noise has to be played loud, adds to the problem.  According to the authors: 'This study has identified serious patient safety issues that cannot be ignored.  Regardless of whether music can increase surgeons' concentration and mask extraneous noise, anything that might impair team communication might place patients' safety in jeopardy.'  As a recommendation they say: 'We recommend that nurses join the discussion and debate around this topic that is currently heavily represented by the views of surgeons.'

You can listen to this as a podcast.


Weldon. S-M., Korkiakangas. T., Bezemer, J. and Kneebone. R. (2015) Music and communication in the operating theatreJournal of Advanced Nursing, doi: 10.1111/jan.12744

Cooke, M., Chaboyer, W., Schluter, P. and Hiratos, M. (2005), The effect of music on preoperative anxiety in day surgery. Journal of Advanced Nursing, 52: 47–55.

Stevens, K. (1990), Patients' perceptions of music during surgery. Journal of Advanced Nursing, 15: 1045–1051. 

World Breastfeeding Week

To mark World Breastfeeding Week, we invited Professor Julie Jomeen, Dean of the Faculty of Health and Social Care at the University of Hull, to select a few of the most important papers on breastfeeding published recently in JAN.

Julie Jomeen

Promotion of breastfeeding (BF) is a public health priority at an international level, yet many countries fail to enhance sustained BF rates and reach the WHO target of exclusive breastfeeding for six months. Many factors are acknowledged to influence intention, initiation and continued BF. In recognition of World Breastfeeding Week and, in the US, National Breastfeeding Month, I have selected five papers to discuss in this blog, published in JAN since 2013 that explore factors that might be influential to BF outcomes.

Artieta-Pinedo et al (2013) explore the association between attendance at antenatal education sessions and BF across the first postnatal year. The study was undertaken in Spain, where antenatal education is free to all women. Using a prospective observational design, 614 women were classified into 3 groups according to the level of education sessions received (0; 1-4; >5); telephone interviews assessed risk of cessation up to 12 months. Despite a 90% initiation rate across groups, by one month there was a dose response relationship between BF and level of attendance. However, there were no statistically significant differences between groups at 6 or 12 months. The authors suggest BF continuation for the first postnatal month was linked to greater awareness of physical changes and BF problems, gained through the antenatal education sessions. Sustained rates were less influenced, but the authors suggest may still be related to modifiable antecedents.

Wu et al (2014) explore BF self-efficacy as one such potential variable and sought to examine the effect of a self-efficacy intervention in Chinese mothers. In a pre-post test two group design, participants in the intervention group showed significantly greater increases in both BF exclusivity and duration than those in the control group. This study is limited by a small sample and that findings relate to short rather than long term outcomes, although results are promising enough to warrant further investigation. This paper successfully highlights that understanding the role of psychological aspects on BF initiation and duration as important to improving rates and supporting new mothers.

Brown (2014) sought to explore associations between BF duration and maternal personality; attitudes and experiences. Personality has been shown to be associated with characteristics such as self-efficacy as well as confidence and locus of control. Using a cross sectional survey design, 602 mothers with infants of 6-12  months competed self-report measures  for all variables. Women with high levels of conscientiousness were more likely to initiate BF, with extroversion and emotional stability both significantly associated with both initiation and longer duration of BF. These women were generally more confident in BF. Women who were more introverted were more likely to stop BF due to embarrassment and feeling pressured to stop. Mothers who were more anxious reported greater difficulty and lack of support. Lower conscientiousness was associated with greater body image concerns and pain. The author suggest that self-efficacy interventions may play a role in supporting women with introverted and anxious personality types, as well as interventions to increase maternal support.

Understanding potential modifiable factors that may be of importance in supporting BF initiation and continuation is useful, yet other influential factors have also been identified. Brown and Jordan (2013) explored the role of birth complications in BF cessation. In an exploratory cross-sectional design using an online survey the researchers found that women who experienced birth complications had shorter BF duration. Specifically, caesarean birth, foetal distress, failure to progress and postpartum haemorrhage were significant, due to associated pain and physical difficulties. Whilst these exploratory findings are limited by data collection methods and sample size, they raise interesting questions about targeted BF support for ‘at risk’ women. Whilst the causality here appears to be related to physical consequences, the authors suggest a potential link between physical complications and the psychological effects of birth complications on BF consequences, which may exacerbate low BF rates.

The recent paper by Spencer et al (2015) presents fascinating qualitative findings, which may illuminate the mismatch between BF initiation and continuation rates that international statistics and academic literature continue to demonstrate. The overarching theme that emerged from the data was ‘illusion of compliance’. Women described pressure to initiate BF to comply with ‘good mother’ discourse and conform to the moral obligation to BF, hiding the difficulties they encountered to avoid being labelled ‘a failure’. Successful BF to women did not mean exclusive BF; differing constructions of meaning led to women turning away from healthcare professionals. This paper raises important questions for healthcare professionals about their content and approach to providing interventions for women in support of BF.

Together these papers and many others published in JAN and elsewhere remind us that what would seem a simple and natural health behaviour may not be in our increasingly complex world. However, and despite challenges to achievement, international goals for BF or, at the least, breast milk provision to the world's children are important and worth the support of all who advocate for a healthier world.

Julie Jomeen is a qualified nurse and midwife, who has worked at all clinical levels and also in a practice development role within a women and children’s health department of a large acute trust, currently working as Dean: Faculty of Health and Social Care, University of Hull. Julie remains involved in both pre and post-registration teaching and post-graduate research supervision. Research interests focus on issues around women’s health and maternity care with particular interest in psychological/mental health across the maternity spectrum and choice in healthcare, evidenced by numerous national and international publications and conference presentations.

Isabel Artieta-Pinedo, Carmen Paz-Pascual, Gonzalo Grandes, Amaia Bacigalupe and Janire Payo

Amy Brown

Amy Brown and Sue Jordan

Rachael L. Spencer, Sheila Greatrex-White and Diane M. Fraser

Di Shi Wu, Jie Hu, Thomas P. McCoy and Jimmy T. Efird

Friday, 24 July 2015

Response to Commentary: How influential is carer burden in institutionalisation?

Hilde Verbeek, PhD
Jan PH Hamers, RN, PhD

Response to Commentary on Verbeek, H., Meyer, G., Challis, D., Zabalegui, A., Soto, M. E., Saks, K., Leino-Kilpi, H., Karlsson, S., Hamers, J. P. & RightTimePlaceCare Consortium (2015). Inter-country exploration of factors associated with admission to long-term institutional dementia care: evidence from the RightTimePlaceCare study. Journal of Advanced Nursing. 71(6), 1338 - 1350

In our recent paper, we have analysed factors associated with admission to long-term institutional care for people with dementia across eight European countries (Verbeek et al. 2015). We present results from the RightTimePlaceCare study, the first European study that has assessed factors influencing institutionalisation using standardised primary data collection across countries. We found that there was a wide variation in factors associated with institutionalisation and only few factors could be characterized as universal predictors.

Caregiver burden appeared in our study as one of the most consistent factors across countries to be associated with institutional care admission. In their response, Donnelly and Doyle (2015) write that our conclusion did not match the data presented in the article and they state that caregiver burden is not an important predictor. We disagree with Donnelly and Doyle and argue that our data do show that caregiver burden is an important factor shaping whether or not people with dementia are admitted to institutional long-term care, although its predictive value needs further exploration. 

In the RightTimePlaceCare study, we have included 2,014 dyads of people with dementia and their informal caregivers in eight countries for baseline assessment; 791 were recently admitted to a nursing home (< 3 months) and 1,223 lived at home but were at risk of institutionalisation. Sociodemographic and clinical data were collected. 

First, we investigated known factors from the literature associated with being recently institutionalised (such as cognition, neuropsychiatric symptoms and caregiver burden) as opposed to living at home with dementia and being at risk. Data from the baseline assessments were used (n=2,014). These descriptive analyses showed that caregiver burden was the only factor, next to independence in daily activities, which was significantly associated with institutionalisation in all countries, except for Spain. In Spain, the level of caregiver burden was reported to be very high in both groups at home and in nursing homes. 

As these analyses were conducted using cross-sectional data, no substantive inferences on causality can be drawn, as Donnelly and Doyle point out correctly in their response. However, these results do highlight the importance of caregiver burden in institutionalisation for people with dementia. We identified a specific target group in our study, that is people with dementia who are on the margins of care, meaning that their care needs can be met in more than one setting (i.e. either at home or in institutional long-term care). Caregiver burden significantly discriminated between people with dementia living at home and being at risk for institutionalisation from those people with dementia who recently were institutionalised. 

We agree with Donnelly and Doyle that it is most important to investigate the predictive value of caregiver burden for institutionalisation. In our study, 10% of the baseline sample (n=126) made an actual transition from home care towards institutional long-term care at the follow-up assessment three months later. Although this sub-sample was small, it allowed a first exploration of the predictive value of caregiver burden in institutionalisation of people with dementia.  

Univariate analyses showed that caregiver burden was a significant factor predicting institutionalisation. Caregivers of people with dementia who remained at home during the entire study period reported significantly lower caregiver burden at baseline compared with caregivers of people with dementia who lived at home during the baseline measurement and moved towards institutional care three months later (p<0.009). On average, the burden score as assessed with the Zarit Burden Interview was 3 points higher for caregivers of people who were admitted during our study compared with caregivers of people with dementia who remained at home. This pattern of a higher caregiver burden at baseline being related to institutionalisation three months later was similar across all countries. The difference was highest for Spain and England (14.4 and 11.6 respectively). In other countries this was at least 4.5 points. Only in France and Finland, the difference in caregiver burden between the groups was very small (only 0.5 to 1.5 points). 

Unfortunately, our transition sample was not balanced across countries. Over a third of our sample was from France (n=44) and also many people from Finland (n=20) made a transition. Furthermore, only very few people from Spain (n=4) were admitted to institutional care after three months. This may have introduced bias in our multivariate analyses, which especially may have affected the factor caregiver burden. In countries where the difference between caregiver burden at baseline and follow-up was largest (i.e. Spain), only very few people made the transition towards institutional care, whereas countries in which the difference in caregiver burden was smallest (France and Finland) were overrepresented in our transition sample. In our multivariate analyses, taking into account other factors such as cognition and neuropsychiatric symptoms, caregiver burden was no longer significant. Viewed as a causal pathway, inevitably carer burden is determined by behavioural and psychological symptoms of dementia, thereby shaping the propensity to institutionalisation. In addition, we also think that problems arising from a small and unbalanced sample size have affected the power of testing, which may have biased our results. Results should therefore be interpreted carefully.

Taking into account results from all analyses (i.e. descriptive and predictive), our results suggest that caregiver burden is an important factor in the process of institutionalisation for people with dementia and their informal caregivers. As caregivers have a crucial role in the decision about transition towards institutional care (e.g. Davies and Nolan, 2003), their psychological wellbeing and quality of life have been shown to be important determinants of admission (e.g. Argimon et al, 2005; Bleijlevens et al. 2015).  Of course only a longitudinal cohort study could address this conclusively and we would of course be very to undertake this, albeit a very costly study.

Hilde Verbeek, PhD
Assistant Professor

Jan PH Hamers, RN, PhD
Professor of Care of Older People
Department of Health Services Research
Maastricht University
The Netherlands

Email: h.verbeek@maastrichtuniversity.nl

On behalf of all co-authors and other members of the RightTimePlaceCare Consortium


Argimon J.M., Limon E., Vila J. & Cabezas C. (2005) Health-related quality-of-life of care-givers as a predictor of nursing-home placement of patients with dementia. Alzheimer Disease and Associated Disorders. 19(1), 41–44

Bleijlevens, M. H.C., Stolt, M., Stephan, A., Zabalegui, A., Saks,K., Sutcliffe, C., Lethin, C., Soto, M.E. & Zwakhalen, S. M. G. (2015). Changes in caregiver burden and health-related quality of life ofinformal caregivers of older people with Dementia: evidence from the European RightTimePlaceCare prospective cohort study. Journal of Advanced Nursing. 71(6), 1378–1391

Davies C.H. & Nolan M.F. (2003) Making the best of things: relatives' experiences of decisions about care-home entry. Ageing and Society. 23, 429–450.

Verbeek, H., Meyer, G., Challis, D., Zabalegui, A., Soto, M. E., Saks, K., Leino-Kilpi, H., Karlsson, S., Hamers, J. P. & RightTimePlaceCare Consortium (2015). Inter-country exploration of factors associated with admission to long-term institutional dementia care: evidence from the RightTimePlaceCare study. Journal of Advanced Nursing. 71(6), 1338 - 1350