Thursday, 1 October 2015

International Day of Older Persons

Robyn Gallagher
Editor, JAN

Older people are a rapidly increasing proportion of populations worldwide, yet health services have not responded to this challenge well, continuing to focus on acute care when multiple care avenues are needed. Several papers in JAN help nurses consider the care of the older person and offer hope that future research will address their needs.

The emergency department (ED) represents the front-line in care for many older people. This is because older people have more repeat ED visits and more frequent hospital admissions and re-admissions than their younger counterparts and these admissions occur primarily through the ED (Lowthian et al., 2013). Increasingly, ED presentations for older people are coming from nursing homes, not just because of the rise in residential aged care placements, but also because nursing home staff are facing increasing challenges in care provision. Laging and co-authors (Laging et al., 2015) report on a meta-synthesis of 17 qualitative studies that the factors that influence nursing home staff decisions are often resource-driven. Nursing home staff have limited capacity within their team or in the form of medical advice to provide interventions that could prevent the need for ED transfer. As a result nurses are likely to opt for automatic transfer for diverse and often non urgent health problems. On the other hand, many ED presentations for older people occur in a pattern of readmissions (Gallagher et al., 2014) indicating that hospital discharge processes may not have been adequate. Readiness for hospital discharge measures may not appropriately address older people, and modifications for older people to measures is recommended in Mabire et al., 2015. The results of their research indicate that incorporating scaling for living alone, older age and the patient not feeling ready for discharge is important when using the Readiness for Hospital Discharge Scale in older people.

Two areas that result in ED presentations and the need for urgent care for older people are falls and elder abuse and neglect. Two papers included in JAN this month flag promising interventions. Loh and co-authors (Loh et al., 2015) published a protocol to help nurses detect and manage elder abuse, a common and well-hidden problem. In another promising intervention, Francis-Coad and her team (Francis-Coad et al., 2015) are testing a community of practice to help reduce falls in residential aged-care. In this proposed community of practice the partners are academics and aged-care staff across a very wide geographic area in Western Australia.

These four papers bring together past, present and future for supporting older people.


Francis-Coad, J., Etherton-Beer C., Bulsara C., Nobre D. & Hill A.M. (2015) Investigating the impact of a falls prevention community of practice in a residential aged-care setting: a mixed methods study protocol. Journal of Advanced Nursing.

Gallagher, R., Fry, M., Chenoweth, L., Gallagher, P. and Stein-Parbury, J. (2014) Emergency department nurses' perceptions and experiences of providing care for older people. Nurs Health Sci. Vol 16(4):449-53.

Lowthian, J., Curtis, A., Stoelwinder, J., Mcneil, J. and Cameron, P. (2013) Emergency demand and repeat attendances by older patients. Intern Med J. Vol 43(5):554-60.

Laging B., Ford R., Bauer M. & Nay R., (2015) A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital. Journal of Advanced Nursing.

Loh D.A., Choo W.Y., Hairi N.N., Othman S., Hairi F.M., Mydin F., Jaafar S.N.I., Tan M.P., Ali Z.M., Aziz Z.A., Ramli R., Mohamad R., Mohammad Z.L., Hassan N., Brownell P. & Bulgiba, A. (2015) A cluster randomized trial on improving nurses’ detection and management of elder abuse and neglect (I-NEED): study protocol. Journal of Advanced Nursing

Mabire C., Coffey A. & Weiss M. (2015) Readiness for Hospital Discharge Scale for older people: psychometric testing and short form development with a three country sample. Journal of Advanced Nursing

Tuesday, 29 September 2015

FGM - a practice that must be banned

Roger Watson, Editor-in-Chief

The repulsive practice of female genital mutilation (FGM) is the subject of a recent review from Spanish authors Reig-Alcarez et al. (2015) and published in JAN titled: 'Health professionals and Female Genital Mutilation'.  The aim of the study was: 'To synthesize knowledge, attitudes and experiences of health professionals about Female Genital Mutilation.'

Publications between 2006–2014 were reviewed and it appears, worldwide, that while nurses and midwives are at the forefront of preventing FGM, they are also responsible in some countries for condoning it.  As the authors explain: 'WHO estimates that between 100 and 140 million girls and women have been subjected to genital removal, and that every year 3 million girls are at risk of FGM. Currently, 29 African countries continue this practice, and countries in Southeast Asia. Migration of women who come from cultures where FGM is practiced have contributed to the increase in women affected by FGM in countries where it was not previously practiced.'

Seventeen full text articles were reviewed and they are analysed in detail in the article by Reig-Alcarez et al. (2015) who state: 'This is the first synthesis of evidence on the perspectives and experiences of Health Professionals concerning FGM that raises important implications for nursing and midwifery practice.'  The authors conclude: 'Health and legal systems, professional regulation and governance, and professional training require strengthening to eradicate FGM, prevent the medicalization of FGM as an acceptable procedure, and to better manage the lifelong consequences for affected girls and women.'


Reig-Alcaraz M, Siles-Gonz alez J, Solano-Ruiz C (2015) Health professionals and Female Genital Mutilation Journal of Advanced Nursing doi: 10.1111/jan.12823

Smoking in China

While smoking is declining globally, it is not declining in China and, in the words of these authors 'China is the epicentre of the tobacco epidemic'. The aim of this study from China by Sarna et al. (2105b) titled 'Helping smokers quit: behaviours and attitudes of Chinese Registered Nurses' and published in JAN was to use the 5 As (i.e. Ask, Advise, Assess, Assist, Arrange) framework to assess Chinese nurses' involvement in smoking cessation.  The 5 As framework was also evaluated by Sarna et al. (2015a)

A large sample of nurses (N=2240) participated from two major cities in China.  The authors found that 'the majority of nurses asked about smoking status, but few assisted patients with quitting. Further efforts are needed to help nurses actively promote smoking cessation interventions.'  Nurses did think that they should be non-smoking role models.

The authors conclude: 'Given the enormous proportion of the health threat of tobacco use in China, nursing involvement in tobacco control is essential, especially in supporting quit efforts of patients.' and 'This survey provides important information about frequencies of intervention prior to the launch of an educational intervention, especially the need to support follow-up after hospitalization to
prevent relapse after quitting.'

Listen to this as a podcast.


Sarna L, Bialous SA, Zou XN, Wang W, Hong J, Wells M, Brook J (2015a) Evaluation of a web-based educational programme on changes in frequency of nurses’ interventions to help smokers quit and reduce second-hand smoke exposure in China Journal of Advanced Nursing doi: 10.1111/jan.12816

Sarna L, Bialous SA, Zou XN, Wang W, Hong J, Chan S, Wells MJ, Brook J (2015b) Helping smokers quit: behaviours and attitudes of Chinese Registered Nurses Journal of Advanced Nursing doi: 10.1111/jan.12811

World Heart Day 2015 Tuesday 29 September 2015

David R Thompson PhD FRCN FAAN
Professor and Director, Centre for the Heart and Mind, Australian Catholic University, Melbourne, Australia

To mark World Heart Day, we asked Professor David Thompson to select some recent relevant papers from JAN.
David Thompson
Heart disease not only remains the world’s leading cause of death but also results in significant disability and distress, which impose a major human and economic burden. Two key areas where nurses have made major research contributions to the care of people with heart disease are in cardiac rehabilitation and heart failure self-care. I have therefore selected two very recent papers, both from Canada, that address these topics.

The first paper by Angus et al. (2015) addresses the issue of gender and access to cardiac rehabilitation. It is well recognized that access to, and uptake and completion of, cardiac rehabilitation is poor, especially for women, older people, ethnic minority groups and rural and remote communities. Why women, for example, are less likely to attend cardiac rehabilitation is unclear and there is a need to understand the barriers to uptake that exist. This meta-synthesis of 69 qualitative studies found that only four of them had specified a definition or theoretical position on gender. The authors argue that conceptual clarity about the social origins of gender is needed in order to work towards understanding the social determinants of access disparities.

The other paper by Spaling et al. (2015) addresses the issue of heart failure patients’ self-care. It is well recognized that there is inconsistency in patients’ knowledge and practices around self-care and interventions to improve it. Thus, patient-focused recommendations are needed to improve this care. This systematic review and qualitative interpretive synthesis of 37 studies found, for instance, that while patients could often recall health professionals’ self-care advice, they were unable to integrate this knowledge into daily life. The authors argue that merely providing patients with more sophisticated knowledge of heart failure is unlikely to improve heart failure self-care. What are also needed are strategies with patients and family members to promote mastery and self-efficacy, learning and adaptation/application. 

Both of these papers make important contributions to the nursing literature and will, hopefully, influence the provision of better care to people with heart disease.


Angus JE., King-Schier KM., Spaling MA., Duncan AS., Jaglal SB., Stone JA. & Clark AM. (2015) A secondary meta-synthesis of qualitative studies of gender and accessto cardiac rehabilitation. Journal of Advanced Nursing doi: 10.1111/jan.12620

Spaling MA., Currie K., Strachan PH., Harkness K. & Clark AM. (2015) Improving supportfor heart failure patients: a systematic review to understand patients’ perspectiveson self-care. Journal of Advanced Nursing doi: 10.1111/jan.12712

The stethoscope, a patient and me

Mr Jamie Ranse
Faculty of Health, University of Canberra, Canberra, Australia
Flinders University, South Australia, Australia

During the 2015 Miss America pageant, a contestant and nurse, Kelley Johnson, stood on the stage dressed in her nursing uniform wearing her stethoscope. Kelley delivered a monologue about nurses, including her first-hand accounts of interacting with patients. Following the pageant, commentators on the American Broadcasting Company television program The View commented about the monologue stating: ‘what is she doing with a doctor’s stethoscope’? Internationally, nurses responded via social media.

The anecdote below provides insight into the phenomenological natural attitude of the stethoscope and what it may be like to experience a stethoscope as a nurse or as a patient. A stethoscope is a thing that has concrete properties, purpose and meaning. The stethoscope holds purpose and meaning for me as nurse:
I walk into the hospital and place my stethoscope around my neck. The stethoscope turns me from a lay person into a nurse, with tools ready-at-hand. My stethoscope is ready to be used for a particular purpose, auscultation. When I use my stethoscope I am interested in the patient as a whole, but I am concentrating on the sound that is reverberating through the tubing of the stethoscope. I am concentrating on the intricacies of the sound that is being listened to, such as the lub dub of a heartbeat. Whilst the stethoscope amplifies a sound of interest; I find it difficult to hear the conversations of those nearby or the sound of monitors alarming in the distance. External sounds are reduced to a muffle. I need to concentrate. The stethoscope allows for the unheard to be heard. The unheard provides insight into the patient’s condition. I hear what the patient themselves do not hear, I now know what the patient themselves do not know. My auditory insight provides knowledge about the patient’s condition for the sake of planning and evaluating care.
The patient’s experience of the stethoscope maybe different from that of the nurse. Perhaps patients have an expectation of a nurse with a stethoscope around their neck? That the nurse has a certain level of clinical knowledge? The stethoscope partners the nurse and patient in a collaboration of care:
As a patient I willingly lift my shirt for the nurse to use their stethoscope. I may not always be willing; on occasions I am hesitant to lift my shirt. The stethoscope may be cold. The stethoscope reminds me of my previous illness. The illness of a loved one. It may evoke a stressfully moment in life. I cannot hear my own heartbeat; it is only heard by the nurse that uses the stethoscope.
The young child or confused older person may not want the stethoscope near them. They may use their hand to brush away the stethoscope. Fighting against the stethoscope. Not realising that this tool is being used with the intent to assist, not hinder. For the unconscious patient or deceased, they have no choice. The nurse just uses the stethoscope without their willing or knowing.

Monday, 28 September 2015

Family group conferences outcomes are not always sustainable

Gideon De Jong
Researcher, Department of Medical Humanities
EMGO+, VU University Medical Centre Amsterdam, Netherlands

Gert Schout
Senior Researcher, department of Medical Humanities
EMGO+, VU University Medical Centre Amsterdam, Netherlands

Since 2009, we have been studying the process and outcomes of Family Group Conferencing (FGC) in mental health care as a social intervention to restore ties between psychiatric clients and their social network, and promote their social resilience. This resulted in two reports: a report focusing on FGC organised for ‘underserved groups’ in public mental health care (Schout & De Jong 2013) and, recently, a second report on the possibilities of FGC in preventing coercion in psychiatry (Schout et al. 2015). In total, more than 100 conferences were analysed and 600 semi-structured interviews conducted with the participants. To date, this is the world’s most in-depth research into FGC for adult clients in mental health care.

Eighteen months after the Eigen Kracht-conferenties

We reported earlier in JAN about the successful outcomes of a conference organised in a small neighbourhood where an imminent involuntary admission to a psychiatric ward and home eviction of a client was prevented and the living conditions restored (De Jong et al. 2014). During a period that lasted several months, in this neighbourhood liveability problems were reported where a man with psychotic problems was involved. The conference that got organised in the spring of 2012 took place without the client; participation in an upcoming conference caused too much stress and thereby worsening of psychotic problems. The conference was prepared in consultation with his sister, neighbours and professionals, and a plan was maintained that helped the neighbourhood becoming liveable again while the threat of an involuntary admission and home eviction was averted. The co-operation that was set in motion during and shortly after the conference, initially ensured rest: the neighbourhood had a short communication line to the mental health services and the sister for advice on psychotic and unacceptable behaviour.

In this commentary we want to share the insight that the positive outcomes in this case, but in other cases as well, may not always be sustainable. A year after the initial successes, the living conditions worsened gradually. The neighbourhood had increasingly difficulties to keep up with the client. Moreover, they and the client’s sister experienced less support from the mental health services. At the moment the situation seemed to escalate, no co-operation between the mental health services, the local police men, the housing association and the municipality got off the ground. This finally resulted in that the client being involuntarily admitted to a psychiatric ward and evicted from his home. He was hospitalised for several months, and during his admission, professionals were looking for another place for him to live.

Several lessons can be learned from this case. First, a family group conference does not mean that professionals afterwards can stay aloof. On the contrary, professionals are needed to provide information and support so that clients and their network can establish the potential most effective plan. In this case also by providing mediating techniques so that conflicts and disruptive behaviour can be addressed when they are still small. This requires professionals who are sensitive, approachable and accessible to not only clients but also their close relatives, friends and neighbours. The conference helps professionals getting a better picture of their clients so that subsequently they can adept more effectively to the given situation. Professionals who also have more than just the psychiatric problems of individual clients in mind; who address the necessity of their socio-cultural integration; who present themselves as the link between clients and their social environment. A professional who is also able to apply the pressure that is usually deployed by police men and housing associations to curb unacceptable behaviour. When not only clients but also their social environment experience support of professionals and other neighbours, they dare to show their commitment and are better able to endure the situation.

Interviews with the neighbourhood and the client’s sister that were held two years after the conference revealed that the company of other clients in the psychiatric ward did do the client visibly well. In other words, the admission was not any longer a nightmare for him. Simultaneously, the involuntary admission was a springboard to a form of supportive housing. Although the conference did not provide grounds for a sustainable positive outcome (prevention of coercive measures) in the long run, it helped the neighbourhood and mental health services to connect with each other. The mental health services thus became a partner who has something to offer, not only to the client but also to his social environment.

Balance between direct and indirect malleability

The FGC decision-making model is strongly embedded in the tradition of indirect malleability as it encourages learning processes and self-organisation. Convening stakeholders around an issue and empowering them to come up with solutions of their own meets the complexity of contemporary issues. The problems of the client population studied in this research project are complex. Apart from the unruliness of the psychiatric symptomatology itself, most clients have other problems as well, such as addictions, social isolation, a lack of sense of purpose and daily activities, debts and housing problems. Problems which altogether have a complex character. A core fundament of the FGC philosophy is that the fusion of the brain power from a large social network with professional expertise, responds to the complexity of clients’ problems. Here it is also crucial that a wider circle of concerned bystanders gets involved, generating new ideas and solutions the other actors may not have thought of, thus preventing blind spots and providing a wider range of solutions.

Also in other cases we observed that clients and/or their social network were unable to participate in a FGC process, let alone to take part in the private family time of the conference and establishing the final plan. In all these case, nevertheless, (the preparations of) the conferences were valuable in the eyes of the interviewees. What the case as described in this commentary illustrates is that the mental health services sometimes need to act in the tradition of direct malleability by first treating psychiatric symptoms so that in a later stage – following the tradition of indirect malleability—they can bring in their expertise when clients together with their social network establish their own plan. In other words, sometimes family driven should alternate with professional driven. (e.g. Merkel-Holguin 2004).


De Jong G., Schout G. & Abma T. (2014) Prevention of involuntary admission through Family Group Conferencing: A qualitative case study in community mental health nursing. Journal of Advanced Nursing 70(11), 2651-2662.

Merkel-Holguin L. (2004) Sharing power with the people: Family Group Conferencing as a democratic experiment. Journal of Sociology and Social Welfare 31(1), 155-173.

Schout G., Landeweer E., Van Dijk M., Meijer E. & De Jong G. (2015) Eigen Kracht-conferenties bij verplichte GGz. Een onderzoek naar proces en uitkomsten [Family Group Conferencing in coercive psychiatrie. A study into process and outcomes]. VU Medical Centre, Amsterdam.

Schout, G. & De Jong, G. (2013). Eigen Kracht-conferenties in de Openbare Geestelijke Gezondheidszorg. Een onderzoek naar proces en uitkomsten [Family Group Conferencing. A study into process and outcomes]. Lectoraat OGGz, Hanzehogeschool Groningen, Groningen.