Wednesday, 22 November 2017

Sleep, burnout and performance

Roger Watson, Editor-in-Chief

Nursing is notoriously hard work and it is also, for many nurses, shift-work with late evening and night working being common. In addition, it is emotional work and it leads to burnout. But does this affect job performance? This was the subject of an article from Italy titled: 'Can sleep quality and burnout affect the job performance of shift-work nurses? A cross sectional study' by Giorgi et al (2017) and published in JAN.

The study on which the article was based aimed to: 'investigate any possible relationship between sleep disorders, burnout and job performance in a shift-work population of nurses.' Involving over 300 nurses in seven Italian hospitals, the participants were given three questionnaires to complete: one on sleep, one on burnout and one on job performance. The results showed that poor sleep and burnout were related and that females were more affected in this regard. Particular settings - for example psychiatry - and working long shifts led to burnout and there was an effect of burnout on work performance.

The authors conclude: 'Specific characteristics of shift-work nurses can directly affect sleep quality and burnout and indirectly job performance' and '(s)leep quality appears to be worse in women than in men', therefore, '(t)his evidence offers healthcare administrators opportunities to intervene with measures to promote nurse’s health, well-being and safety.'

You can listen to this as a podcast


Giorgi F, Mattei A, Notamicola I, Petrucci C, Lancia L (2017) Can sleep quality and burnout affect the job performance of shift-work nurses? A cross sectional study Journal of Advancd Nursing DOI: 10.1111/jan.13484

Commentary: Collaboration in Canadian Health Care

Ken Cabrera

This is in response to the article entitled: Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system by Clausen et al. (2017). As a graduate student pursuing my nurse practitioner degree, I found this study to be fascinating, meaningful and significant.

For years now, Quebec has been undergoing sweeping health care reforms aimed at integrating health care and social services at various structural levels to improve the overall quality and delivery of care (Vedel et al., 2011). The reorganization of primary care, the integration of primary and secondary care at the clinical level, and developing effective governance and change management have been identified as three of most important challenges facing Quebec health care. Moreover, the implementation of nurse practitioners at the primary care level has been identified by the Quebec government as a key initiative to strengthening the delivery and quality of primary care (Vedel et al., 2011). The ability of the nurse practitioner to provide cost-effective, high quality care as indicated by positive patient-outcomes is well-documented (Martin-Misener et al, 2015).

The article refers to today’s rapidly changing climate, the complexity of challenges and the daunting task of meeting these challenges while striving to maintain safety and quality of care. In response to these challenges, key factors have been identified to facilitate change and transform care delivery: collaborative healthcare management structures and leadership. As a result, several health care systems in Canada are instituting co-leadership and co-management models- the benefits of which have been documented (e.g. greater unity, co-responsibility, interdependence, mutual obligation, preservation of the individuality of the partner).

Clausen’s substantive theory of ‘intentional partnering’ could not be more relevant considering the current state of affairs. The recognition of the nurse practitioner as an indispensable resource and their ever-expanding presence at various levels of the health care system coincides with this shift towards collaborative management in health care delivery systems. To meet this end, the successful transformation of health care can only be achieved within a context that is firmly grounded in collaborative leadership. Understanding and embracing ‘Intentional partnering’ which involves moving through a three-cog system of ‘accepting mutual necessity’, ‘daring to risk (together)’ and constructing a shared responsibility is the key to unlocking the power of the nurse practitioner and physician co-leadership dyad.

The findings of this study clearly illuminate for us as physicians and nurses alike that we share a common goal, and despite our allegiance to our own professional agendas - we are better together. Not only can we meet our own professional objectives through respectful co-leading and collaboration, but as a united team, we can achieve immeasurably more resulting in benefits for everyone. I believe only by working collaboratively can we meet the challenges of the future. 

The knowledge generated from this study by Clausen et al. has extended our understanding of nurse-physician dyadic relationships to new depths. Furthermore, it has provided us with a theoretical framework out of which we have a systematic approach to foster inter-professional collaboration. I believe, this seminal study represents a monumental contribution to the nursing profession and nursing leadership with enormous implications for the future of all Canadians.

Ken Cabrera
Graduate student, Primary Care Nurse Practitioner Program
McGill University
Quebec, Canada


Clausen C., Lavoie-Tremblay M., Purden M., Lamothe L., Ezer H. Mcvey L. (2017) Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system. Journal of Advanced Nursing 73(9), 2156–2166

Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., Bryant-Lukosius, D., Kaasalainen, S., Marshall, D. A. & Charbonneau-Smith, R. 2015. Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review. BMJ open, 5, e007167.

Vedel, I., Monette, M., Beland, F., Monette, J. & Bergman, H. 2011. Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada. International journal of integrated care, 11.


Monday, 20 November 2017

On Nursing Burnout, Staff Shortages and Travel Nurses

Kaitlyn Williams, RN

I am writing with regards to the journal article titled “Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time lagged study” (2016) by Sheila Boamah PhD(c) RN MN, Emily Read PhD RN, and Heather Laschinger PhD RN FAAN FCAHS. Burnout in the nursing field is a national issue. Healthcare is such a demanding field to be in. Boamah draws specific attention to the fact that short staffing and the lack of structural empowerment in the work environment are some of the most common reasons nurses experience dissatisfaction among their job. I was once one of the ones on the verge of nursing burnout within a year of my nursing career, and this author describes all of the emotions and frustrations that I experienced during a time when I thought I was the only one experiencing it.

It is so very unfortunate that some nurses feel unappreciated for the extra work that they offer. I cannot honestly say that our clinical supervisors and manager have ever made it feel like doing extra was an expectation. They are always so grateful for the help and understand that we are giving up our time off. The clinical supervisors are always checking in with the nurses to see if they need anything, assess the status of new admission, and are willing to help in any way that they can.

While most facilities are experiencing staffing shortages, the nurses are experiencing a higher workload and an increased patient to nurse ratio. We welcomed a new nurse to our night shift family and after talking to her for a while about why she left her old facility she explained that it was because of staffing. While they were losing staff members, the people higher in administration felt it was appropriate to increase their patient to nurse ratios from 6:1 on night shift to 8:1. She felt that it was not safe for her or the patients and was not willing to take the chance.

Facilities are experiencing high turnover rates within their departments. On my unit especially there are many nurses that plan to continue to get their nurse practitioner license. I think that is a wonderful thing for them to continue and applaud their decisions. However, after speaking to some about why they chose that pathway it was alarming to hear how many were “just tired” of bedside nursing. Our night shift staff experienced the effects of short staffing almost every night. We were offered monetary incentives as well as gift certificates if we were willing to pick up an extra shift to help. The majority of the night shift staff picked up extra shifts for weeks until we were approved to bring in travel nurses. One of our more experienced clinical supervisors made the comment that she has only seen travelers brought in to the unit one other time in her 19 years there.

Travel nurses are a wonderful resource to have and provide a sense of relief to the ones that have been working extra to help staffing needs. Jan Cottingham, in the Arkansas Business article “Health Care Demands Push Growth of NLR’s Travel Nurse”, explains that the concept of travel nursing came about as a “short-term solution” for staffing shortages in the 1980s. The effects of staffing shortages are being felt nationwide still today. If the hospital’s budget permits it, travel nursing contracts should be initiated more often instead of allowing the staff to work beyond mental and physical fatigue each week.

This article made me reflect on the past year in my nursing career. As I was reading each section I found myself relating to the situations and circumstances described. It is so common for nursing staff to experience these frustrations. I never thought it would happen to me so soon in my career. Through this article I realized that I am lucky to be a part of the team that I have. We are being reminded that we have to take care of ourselves, too. We cannot allow our patients to be the ones to deal with the repercussions of our fatigue.

Boamah S.A., Read E.A. & Spence Laschinger H.K. (2017) Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time-lagged study. Journal of Advanced Nursing 73(5), 11821195.

Cottingham, J. (2017) Health Care Demands Push Growth of NLR's Travel Nurse. Arkansas Business. [Online]. Available from:

Commentary: Coping with Parkinson’s

Commentary on: Navarta-Sánchez MVCaparrós NRiverol Fernández MDíaz De Cerio Ayesa SUrsúa Sesma MEPortillo MC. (2017) Core elements to understand and improve coping with Parkinson's disease in patients and family carers: A focus group study. Journal of Advanced Nursing. 73, 2609-2621.

Demetra Horotan
On reading the study conducted by Navarta-Sanchez et al. (2017) two issues warrant mention. First, the methodology used for proposed intervention was based on the Chronic Care Model (Coleman et al., 2009), which is a framework for improving chronic illness care at both the individual and population level. However, in this study, the researchers focused on the idea that nurses should take charge of redirecting the coping process related to Parkinson’s Disease when it is inadequate. Furthermore, they stress the importance of reinforcing the “acceptance” of this disease in both the patients and their family carers (Navarta-Sanchez, 2017). This approach appears to focus on a medical view of the patients and their families. Considering using the Resilience Theory (Zauszniewski, Bekhet & Suresky, 2009) as a guiding framework would have been more appropriate in addressing the idea of “acceptance of disease as one of the most important steps” (Navarro-Sanchez, 2017). Creating opportunities to change perspectives, creating positive, constructive strategies and strengthening family bonds can be accomplished through fostering resilience (Zauszniewski, Bekhet & Suresky, 2009). Considering this approach in their study would have reinforced the individual and family strengths as opposed to focusing on a healthcare providers’ perception of what is deficient and what needs “acceptance” (Gottlieb, 2014).

Second, the intervention suggested in this study was a combination of ten topics where “all components interact and are necessary and relevant to improve coping with Parkinson’s Disease” (Navarro-Sanchez, 2017). Even though the intervention addresses the process of coping with Parkinson’s Disease, it’s generalization to both the patient and the caregivers is questionable. From the “relatives focus group”, Peter (one of the carers in the study) expresses the desperate need for caregiver support. However, in the discussion section, the researchers refer to redirecting coping skills for improving patient and carers’ well-being and quality of life. Little attention is given to caregivers' own health and handling of the chronic illness. Previous research has demonstrated that caregivers’ decrease in well-being and perceived burden is directly related to patients’ functional status, thus strategies should be aimed at reducing psychological burden associated with caregiving and not just at “redirecting” the process of coping (Grunfeld et al, 2004).

Overall this study has expressed the importance of the meaning of coping with Parkinson’s Disease and its relevance for clinical nursing practice, related both to patients and their caregivers. While it acknowledges the need for resources in helping nurses integrate the intervention proposed, its feasibility and relevance to nursing practice could be challenged.

Demetra Horotan,

McGill University, Ingram School of Nursing
Montreal, Canada


Navarta-Sánchez MVCaparrós NRiverol Fernández MDíaz De Cerio Ayesa SUrsúa Sesma MEPortillo MC. (2017) Core elements to understand and improve coping with Parkinson's disease in patients and family carers: A focus group study. Journal of Advanced Nursing. 73, 2609-2621.
Coleman, K., Austin, B., Brach, C., & Wagner, E. (2009). Evidence on the Chronic Care Model
in the new millennium. Health Affairs, 28, 75-85.

Gottlieb, L. N. (2014). Strengths-Based NursingAJN American Journal of Nursing114(8), 24-33.

Grunfeld, E., Coyle, D., Whelan, T., Clinch, J., Reyno, L., Earle, C., & … Glossop, R. (2004). Family caregiver burden:results of a longitudinal study of breast cancer patients and their principlecaregivers. CMAJ: Canadian Medical Associaltion Journal, 170, 1795-1801.

Zauszniewski, J., Bekhet, A., & Suresky, M. (2009). Effects on resilience of women family caregivers of adults withserious mental illness: the role of positive cognitions. Archives of Psychiatric Nursing, 23, 412-422.

Response to Commentary on Douglas T, Redley B, Ottmann G. The need to know: The information needs of parents of infants with an intellectual disability—a qualitative study.

Response to Commentary on Douglas T, Redley B, Ottmann G. The need to know: The information needs of parents of infants with an intellectual disability—a qualitative study. Journal of Advanced Nursing 2017; 73:2600–2608

Tracy Douglas

Bernice Redley
Goetz Ottmann

The commentary by Ms Kudzman on on Douglas, Redley & Ottmann  (2017) highlights some important points for how the findings of our research can be translated into practice.  The parent participants in our research identified information-seeking was a significant part of them establishing their role as the parent of an infant with an intellectual disability; but this was not well supported by the health professionals they encountered.  As reported in our earlier paper outlining the broader study findings (Douglas, Redley & Ottman 2016), information needs were one of three themes describing the support needs of parents caring for a child with an intellectual disability in the first year of life.  In this subsequent paper, we reported sub-analyses that conceptualised parents’ identified information needs into three knowledge types based on patterns that emerged in analyses of parents’ narratives.  Such findings can provide a framework to assist health professionals to begin to support parents to access the information they require at the ideal time.

Ms Kudzman quite rightly points out the need for information to be tailored to the individual needs of each family and their child.  Our research findings provide guidance for clinicians to do this.  The theme “Information about the infant’s specific needs” (Douglas, Redley & Ottmann 2017) captures this requirement for individualisation.  However, in addition, our research found parents also needed “Information about their infant’s condition”, often as a prerequisite to being able to engage in meaningful information-seeking specific to their individual needs and circumstances.  When placed into the context of the broader study findings (Douglas, Redley & Ottmann 2016), the need for information about the child’s condition was closely linked to parents’ emotional needs, particularly early in the parent journey.  Our findings suggest that providing general information about their child’s condition, whatever it may be, is needed in the first instance for reassurance, so parents can begin to assimilate what has happened, before they can identify the specific knowledge they may need to better understand what this means for their child and family.  Understanding common patterns in the types of information parents may need, and when this may occur, can provide health professionals with a starting point to engage with parents about the care of their child, and lay the foundations to appropriately tailor and individualise subsequent care and information.

It is not the claim of this qualitative descriptive study to explain every circumstance, but to use the data to identify common patterns that may be transferable to other situations.  Qualitative descriptive research aims to understand and describe in everyday language the experiences of the research participants (Sullivan-Bolyai, Bova & Harper 2005).  The strength of this methodology lies in its facilitation of new and rich insights into the experiences of the participants, and its tenet to present this data in a way that remains true to participants’ perspectives (Sandelowski 2000).  It has further been argued that qualitative description lends itself to the identification of factors that can improve the utilisation of health services because the findings are based on the perspectives of the people who use those services (Sullivan-Bolyai, Bova & Harper 2005).  Consistent with the qualitative descriptive methodology, our research findings stay close to the data, telling parents’ stories as told by them.  The identification of common patterns and themes across the range of parents suggests there are some needs that are shared regardless of the specific conditions or circumstances (Douglas, Redley & Ottmann 2016), and these are potentially transferable to other parents of children with a wide range of disabilities, as captured in the participant group.

Further, every parent involved in our research self-selected based on the invitation for parents of children with intellectual disabilities to participate.  The requirement for participation was that the parents knew there were signs that the infant had an intellectual disability and that parents could share their stories about seeking support for this during the first year of the child’s life (Douglas, Redley & Ottmann 2016).  The voluntary participation of parents whose infant had been diagnosed with cerebral palsy in no way implies that all people with cerebral palsy have an intellectual disability.  Rather, the inclusion of these parents, as well as the parent whose child did not have a diagnosis at all, supports our research finding that there are some common support and information needs across a range of parent circumstances (Douglas, Redley & Ottmann 2016).  In fact, a maximum variation sample that aims to capture a wide range of experiences is important to identify common patterns across the diversity of conditions experienced by the families health professionals care for in the course of their work, and these patterns are even more significant given they have emerged from a heterogeneous cohort (Palinkas et al. 2015).  Identification of these common needs across this varied sample can assist health professionals to understand the general patterns in the types of supports they need to provide when caring for a wide range of parents and their infants who may have a range of conditions leading to intellectual disability.  This is particularly important because, as demonstrated in our research, failure to meet these needs can have a direct impact on how well parents are able to coordinate the care their infants require, which in turn can impact on the infant’s health and developmental outcomes (Douglas, Redley & Ottmann 2017; Intellectual Disability Rights Service 2009).

Every parent in our research described the challenges they experienced trying to access accurate and reliable information about their child’s condition, their child’s unique needs and the supports and services available to them.  In response to this, the important role of health professionals both directly providing information and recommending quality information sources (Douglas, Redley & Ottmann 2017) enables parents to access the information they require when they require it.  The articulation of the three types of knowledge provide a starting point to assist health professionals who are often unknowledgeable about disability, to understand how they can better support the nuanced, information-seeking of parents so they are empowered to take charge of their own child’s care as they desire.

Tracy Douglas & Bernice Redley, School of Nursing and Midwifery
Dr Goetz Ottmann, School of Health and Social Development
Deakin University
221 Burwood Highway
Burwood, Victoria 3125 Australia



Douglas T, Redley B & Ottmann G (2016) The first year: the support needs of parents caring for a child with an intellectual disabilityJournal of Advanced Nursing 72(11), 2738-2749.  doi: 10.1111/jan.1305

Douglas, T, Redley, B & Ottmann, G (2017) The need to know: The information needs of parents of infants with an intellectual disability: a qualitative studyJournal of Advanced Nursing 73(11), 2600-2608. https://doi .org/10.1111/jan.13321

Intellectual Disability Rights Service (2009) Introduction to intellectual disability.  Retrieved from on 7 November 2017.

Palinkas L, Horwitz S, Green C, Widsom J, Duan N & Hoagwood K (2015) Purposeful sampling for qualitative data collection and analysis in mixed method implementation researchAdministration and Policy in Mental Health and Mental Health Services Research 42(5), 533-544. doi: 10.1007/s10488-013-0528-y

Sandelowski M (2000) Whatever happened to qualitative description? Research in Nursing & Health 23(4), 334-340.

Sullivan-Bolyai S, Bova C & Harper D (2005) Developing and refining interventions in persons with health disparities: the use of qualitative descriptionNursing Outlook 53(3), 127-133.

Sunday, 19 November 2017

Burnout in midwives

Roger Watson, Editor-in-Chief

Midwifery is a caring profession and caring professionals are prone to burnout. Burnout leads to indifference to those in your care and a feeling that your job is not worth it and that nobody cares for you. The ultimate problem is that it leads to psychological morbidity and to absence from work.

This article from Australia titled: 'Personal, professional and workplace factors that contribute to burnout in Australian midwives' by Fenwick et al (2017) and published in JAN is based on a study that aimed to: 'identify personal, professional and workplace factors that contribute to burnout in midwives'. A survey of over 1000 midwives using a burnout questionnaire showed that nearly half of the midwives were suffering from severe burnout. Midwives were more burned out in some states of Australia than others; for example, burnout was highest in Victoria and lowest in South Australia. A caseload model of care was associated with lowest burnout and also those less happy at work were more burned out.

The authors conclude: 'Understanding the factors contributing to burnout will enable healthcare organizations to reduce costs associated with staff attrition, reduce human costs in regard to the health and well-being of midwives and most importantly, improve the health and safety of women and their newborns. Flexible, activity-based work patterns afforded in midwifery caseload models should be the norm.

You can listen to this as a podcast


Fenwick, J., Lubomski, A., Creedy, D. K. and Sidebotham, M. (2017), Personal, professional and workplace factors that contribute to burnout in Australian midwives. J Adv Nurs.  doi:10.1111/jan.13491