Tuesday, 16 December 2014

Obesity – the epidemic that can be stopped if we address it as a societal as well as individual issue

Lin Perry, PhD RN RNT
Faculty of Health, University of Technology, Sydney and South Eastern Sydney Local Health District

Response to Lee, G. (2014), Obesity, the epidemic that CAN be stopped? Journal of Advanced Nursing. doi: 10.1111/jan.12584

Health services around the world are all now very familiar with the impending ‘pandemic’ of obesity. Until recently I resisted use of the term ‘pandemic’, in recognition of the primarily psycho-social origins of the problem. However, with the American Medical Association's determination of obesity’s disease status, it would seem that ‘pandemic’ it is.

Lee (2014) provides a very neat synopsis of this obesity ‘pandemic’: its precursors and consequences, its place in history and its dominance of the future. Simple advice – ‘eat less and exercise more’ – is cited as the 1816 solution, and for Lee, the ‘humble healthcare practitioner’ and ‘healthcare changes led by a nurse or similar practitioner’ remain the mainstay, albeit with ‘a need to acknowledge the local environments and the issue of socio-economic deprivation’.

I don’t disagree with these statements but I do think the emphasis is not quite right.

I do believe that nurses have a pivotal role to play in health promotion and the World Health Organisation has emphasised the need to strengthen the capacity of this workforce to meet the demands it is facing (World Health Organisation 2006). Nurses deliver the bulk of health education and health promotion initiatives world-wide. Nurses are visible and accessible as health behavioural role models. Nurses have the socio-economic benefits of above-average education, high health literacy and, generally, the social advantages of being employed. Yet our and others’ work shows that nurses are not just equally but even more affected by this ‘pandemic’ than the populations they serve (Bogossian et al 2012; Perry et al 2014). Our 2014 findings from 5,000 New South Wales nurses are beginning to tease out the implications of this for nursing as a profession and a workforce.

What is very clear, both from what Lee et al (2014) discuss and what we are finding, is that we must address this ‘pandemic’ from within as well as without, taking policy and practice steps to address obesity within the nursing workforce in order to enable nurses to play their pivotal role in addressing this within the world’s populations. Many common characteristics of the nursing workplace can be labelled as ‘obesogenic’. These include, for example, lack of facilities for healthy eating (Wong et al 2010), working practices that exhaust without opportunity for exercise, lack of change facilities to support cycling or running to work, etc. Many could be relatively easily addressed.

It is not a case of ‘physician (or nurse) – heal thyself’; it is not just a case of individual responsibility to ‘eat less and exercise more’. The power-brokers and policy-makers in nursing and healthcare as well as the wider world need to play their parts in making the environmental and socio-economic changes required to halt this pandemic. Halting it in nursing would be a good start.

Lin Perry
Faculty of Health, University of Technology, Sydney and South Eastern Sydney Local Health District
Editor, Journal of Advanced Nursing


Bogossian FE, Hepworth J, Leong GM, Flaws DF, Gibbons KS, Benefer CA, Turner CT. A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United KingdomInternational Journal of Nursing Studies 49 (2012) 727–738

Lee G. Obesity, the epidemic that CAN be stopped? Journal of Advanced Nursing 2014 DOI: 10.1111/jan.12584
Perry L, Gallagher R, Hoban K, Shea A. The health of nurses: health risk factor profiles of Australian metropolitan nurses. Wellbeing at Work Third International Conference, Copenhagen 2014 

WHO (2006). Resolution WHA59.27. Strengthening nursing and midwifery. Geneva, World Health Organization.
Wong, H., Wong, M., Wong, S., Lee, A., 2010. The association between shift duty and abnormal eating behaviour among nurses working in a major hospital: a cross sectional study. International Journal of Nursing Studies 47, 1021–1027

Monday, 15 December 2014

Military nurses returning from war

Roger Watson, Editor-in-Chief

Then involvement of western countries in war has been a constant feature of life since 1990 and the First Gulf War which, in addition to the mobilisation of fighting troops and their support, saw one of the largest mobilisations of military medical services since the Second World War.  Nurses play a significant role in military medicine and these are constituted of both regular military and reservists.  Either way, large numbers continue to be mobilised, most recently to Afghanistan, and when they return to their countries they return to 'normal' life working in military and civilian hospitals.  But coming back is never normal and military service changes nurses' perspectives, provides stress and feelings that they no longer fit in on return.

Some of the conflicts, dilemmas and stresses are explored in a recent article from the USA published in JAN by Elliott (2014) titled Military nurses' experiences returning from war.  Elliott interviewed 10 military nurses returning from conflict and developed nine themes including 'Facing the reality of multiple loss', 'Serving a greater purpose', and 'Looking at life through a new lens'.  Clearly there were positive and negative experiences and, in the words of the author: 'Through this research, nurses and healthcare providers will be better prepared to interact and support returning veteran nurses'.


Elliott B (2014) Military nurses' experiences returning from war Journal of Advanced Nursing DOI: 10.1111/jan.12588

Saturday, 13 December 2014

Education, certification and employment of assistants in nursing

Roger Watson, Editor-in-Chief

'Assistants in nursing' encompasses a wide range of titles ascribed to an occupational group that works alongside registered nurses to perform a range of duties normally associated with the 'basic' aspects of care. Examples of these aspects of care include washing and feeding patients and performing routine tasks such as bed-making. That is the traditional picture; in fact, assistants in nursing  variously called 'nursing assistants', 'nursing auxiliaries', 'auxiliary nurses', 'nurse aides' and, in the UK, 'healthcare assistants' (HCAs)  often do much more. Assistants in nursing in the UK take vital signs and elsewhere have been reported to take electrocardiograms and to initiate intravenous infusions (Duffield 2014).

It is easy for registered nurses to take exception to various aspects of their traditional domain being encroached on while, at the same time, encroaching on various aspects of medicine and surgery. I doubt those for whom we purport to care  our patients and the general public  care about who does what in clinical practice; often they are not clear who is who in any case. The registered nursing scope of practice is, according to the International Council of Nurses, 'dynamic' but, whatever their scope of practice, registered nurses are registered; their names appear on a register which testifies to their preparation and good standing. Frequently, and in most of the UK, assistants in nursing do not appear on any kind of register. The question arises: does it matter?

It clearly does matter. Following the scandals at the Mid-Staffordshire NHS Foundation Trust in England, the Francis Inquiry specified several points which were relevant to assistants in nursing. Specifically, Francis called for standardised preparation, a code of practice and some form of registration. Specifically, the British government have refused to implement these steps, notwithstanding that a form of education and training for HCAs exists in Scotland and, 'in the wake of the Francis Inquiry' the first recommendations of the The Cavendish Review in England referred to the need for education and certification of healthcare assistants.

The risks and advantages around regulation of assistants in nursing can be weighed as follows:
  • Risks: without regulation an assistant in nursing can be dismissed from one hospital for providing poor care or worse and, provided they have not committed a criminal offence, they can take up employment elsewhere with impunity.
  •  Advantages: the above risk is obviated; preparation can be specified and standardised; and an expected standard of practice can be expected. As some may say: 'what's not to like?'
Naturally, regulation costs money and the issue of who regulates assistants in nursing could occupy our politicians and civil servants for months. Nevertheless, the end in this case must justify whatever means evolve. The issue of payment is surely straightforward; those who are regulated and seek to be recognised as such must pay. Currently the Nursing and Midwifery Council is struggling to regulate the nursing register but, surely, they are the obvious choice and if 'pump-priming' funding is required from central government resources, then surely this would be money well spent. After all, we are dealing with people's lives, safety and physical and psychological comfort. If we really think this is too expensive then we may, consequently, get the kind of healthcare we do not deserve.

Duffield C (2014) How long in forever? 2014 Australian Capital Region Nursing and Midwifery Research Conference Canberra, Australia

Thursday, 27 November 2014

Is there an economic case for nursing?

Roger Watson, Editor-in-Chief

Interest in nurse staffing levels and whether or not nursing is money well spent is intense. Perhaps international economic recession has focused attention on this against a background of changing demographics leading to deteriorating dependency ratios, increasing illness and the ‘bottomless pit’ that healthcare has become—especially in the developed world—as ever more illness becomes treatable, people survive longer and some seek healthcare for reasons that, to many, seem trivial. A systematic review from Australia by Twigg et al. (2014) titled ‘Is there an economic case for investing in nursing care –what does the literature tell us?’ and published in JAN investigates the economic case by looking at the existing evidence.

As with so many systematic reviews and studies on the cost of nursing care, the outcome is ambiguous. This will be sad news for those who simply advocate spending more money on nurses to increase nursing care with the aim of improving patient outcomes. Again, in common with many reviews, the problems are methodological with disparate methods being applied and multiple outcomes being used. In the words of the authors: ‘This review was unable to determine conclusively whether or not changes in nurse staffing levels and/or skill mix is a cost-effective intervention for improving patient outcomes due to the small number of studies, the mixed results and the inability to compare results across studies.’ Nevertheless, this rigorous review provides a valuable insight into the ‘state of the science’ of economic evaluation of nursing and should be a stimulus for further work with agreed outcomes and methods whereby the issue can be investigated consistently.


Twigg DE, Myers H, Duffield C, Gies M, Evans G (2014) Is there an economic case for investing in nursing care – what does the literature tell us? Journal of Advanced Nursing doi: 10.1111/jan.12577