Wednesday, 24 May 2017

Orthopaedic Nurse Practitioners shorten hospital stays and save money

Roger Watson, Editor-in-Chief

The case for advanced nursing roles has been well supported by evidence, much of it published in JAN, and a new study from Australia demonstrates the value of Nurse Practitioners in orthopaedics. The study by Coventry et al. (2017) aimed to: 'compare acute hospital length of stay and cost-savings for patients with hip fracture before and after commencement of the Orthopaedic Nurse Practitioner and identify variables that increase length of stay in hospital' and the article published in JAN is titled: 'Impact of the Orthopaedic Nurse Practitioner role on acute hospital length of stay and cost-savings for patients with hip fracture: A retrospective cohort study'.

The length of patient stay was related to co-morbidities such as dementia and cardiovascular disease but lengths of stay (LOS) were reduced using Orthopaedic Nurse Practitioners (ONP) and '(the) cost-savings to the hospital over one year was $354,483 and the net annual cost-savings per patient was $1,178.' The authors concluded: 'This study has shown that implementation of the role of the ONP significantly decreased acute hospital LOS without increasing mortality or complication rates. Further research is required into interventions that optimize time to surgery, manage anaemia and co-morbid conditions, reduce complications and lead to improved patient outcomes.'

You can listen to this as a podcast


Coventry, L. L., Pickles, S., Sin, M., Towell, A., Giles, M., Murray, K. and Twigg, D. (2017), Impact of the Orthopaedic Nurse Practitioner Role on Acute Hospital Length of Stay and Cost-savings for Patients with Hip Fracture: A Retrospective Cohort Study. J Adv Nurs. DOI: 10.1111/jan.13330

Tuesday, 16 May 2017

Women living with polycystic ovary syndrome

Roger Watson, Editor-in-Chief

According to the UK website NHS Choices polycystic ovary syndrome (PCOS) three main features are:

  • irregular periods – which means your ovaries don't regularly release eggs (ovulation)
  • excess androgen – high levels of "male hormones" in your body, which may cause physical signs such as excess facial or body hair
  • polycystic ovaries – your ovaries become enlarged and contain many fluid-filled sacs (follicles) which surround the eggs (it's important to note that, despite the name, if you have PCOS you don't actually have cysts).
The aim of this study from the UK by Tomlinson et al (2017) titled: 'The diagnosis and lived experience of polycystic ovary syndrome: A qualitative studyand publised in JAN was to: 'explore the impact of the diagnosis of polycystic ovary syndrome on health/ill health identity, how women experience this diagnosis and their health beliefs'. Thirty-two women were interviewed and a range of concerns were identified including: 'general lack of empathy by the medical profession'; 'difficulty in accessing specialist referral'; 'lack of information from professionals' amongst other things. 

The authors concluded: 'Women face a great deal of uncertainty as the diagnosis of PCOS is not straightforward and this leads to a view that the medical profession has little regard for the emotional and social consequences of their condition. However, from a medical perspective, the doctors also face uncertainty as there are many conditions that can mimic PCOS. These findings suggest that the experience of women with PCOS would be improved if their principal concerns were better addressed.'

You can listen to this as a podcast


Tomlinson JPinkney JAdams L, et al. The diagnosis and lived experience of polycystic ovary syndrome: A qualitative studyJ Adv Nurs. 2017;00:19

Wednesday, 10 May 2017

Putting the ‘Physical’ Back into Nursing: Recognising Nursing as a Physically Demanding Occupation

Commentary on: Blake, H., Stanulewicz, N. & McGill, F. (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929

Stephanie E. Chappel
Julie Considine
Brad Aisbett
Nicola D. Ridgers

In the April issue of JAN, Blake et al. (2017) investigated predictors of physical activity and barriers to exercise in nursing and medical students. Of specific interest are the findings related to nursing that showed close to 50% of nursing students were not meeting the national physical activity guidelines of 150 minutes of moderate-intensity physical activity a week (Department of Health 2014). Further, the most common barriers to nursing students’ engaging in physical activity were that physical activity was tiring, hard work, time-consuming, caused fatigue, and did not suit inconvenient work schedules (Blake et al. 2017). Blake and colleagues (2017) suggested that physical activity should be promoted to nursing students, and interventions should be tailored more broadly to accommodate the barriers of shift work.

However, these recommendations raise several questions. First, it is possible that physical activity, which is any movement requiring energy (Caspersen et al. 1985), was misinterpreted by the participants as exercise, which is planned physical activity (Caspersen et al. 1985), leading to an underestimation of actual activity levels. Second, physical activity occurs in a range of domains, including household duties, active transport, leisure-time and occupational activity (Hagströmer et al. 2006). The short version of the International Physical Activity Questionnaire (IPAQ) used in this work only captures a summary of all physical activity across a week and, does not separate physical activity into different domains (Hagströmer et al. 2006). The IPAQ also asks individuals to report the amount of walking completed in the last week, which can be misinterpreted as purposeful walking for exercise. Incidental walking that may occur at work (e.g., to and from a patients room; Hagströmer et al. 2006) may be under-reported. Finally, as with any subjective measure, there is potential for recall bias that can lead to an under- or over-estimation of actual physical activity levels; a limitation acknowledged by Blake et al. (2017). To avoid issues related to subjective reporting of physical activity, Blake et al. (2017) suggests future work should use objective monitoring, such as accelerometers, to more accurately capture physical activity. A particular advantage of using accelerometers would be the ability to quantify physical activity levels at work, given collected data are date- and time-stamped.

We recognise that this study was focused on students, although Blake et al. (2017) recommend that the healthcare workforce needs strategies to increase physical activity for shift workers. This conclusion raises several questions about whether nursing students are representative of a nursing workforce, and, whether data from nursing students were collected during clinical placement. Interestingly, in addition to nursing students, Registered Nurses (RNs) have also been identified as not meeting the national physical activity guidelines through their leisure-time physical activity (Naidoo and Coopoo 2007, Ahmad et al. 2015, Jung and Lee 2015), leading to a national focus on promoting nurses’ engagement in physical activity (National Insititue for Health and Care Excellence 2015). However, many of the claims that nurses do not meet physical activity guidelines and calls for increased physical activity among nurses are based on leisure-time activity alone. Given that a considerable proportion of waking hours are spent at work (Kikuchi et al. 2015), it is potentially misleading to conclude that strategies are required when occupational activity is not captured.

Although a lack of time and tiredness are consistently reported as the barriers to physical activity by both nursing students and RNs (Blake et al. 2017, Chin et al. 2016, Jung and Lee 2015), there is variability in the drivers of these barriers for physical activity. Nursing students are required to balance study, work and clinical placements that may or may not involve shift work (Blake et al. 2017). For RNs, lack of time is most likely the result of shift work as they spend majority of their waking hours at work (Kikuchi et al. 2015). Shift work also causes tiredness as sleep patterns are disrupted, yet this is further compounded by the physical demands of nursing work (Chin et al. 2016). Nursing involves several physically demanding tasks such as cardiopulmonary resuscitation, transferring patients, and pushing beds and wheelchairs. Studies have shown that in one shift nurses can lift up to 1800 kilograms (Babiolakis et al. 2015), maintain a high heart rate (51-64% maximal heart rate; Chen et al. 2011), and walk over 15,000 steps (Wakui 2000) or up to 8 kilometres (Chen et al. 2011). These physiological measures suggest that nurses are engaging in high amounts of physical activity through their daily duties and, are potentially meeting physical activity guidelines through their occupational physical activity. It is therefore too early to conclude that workplace physical activity interventions are required to increase nurses’ leisure time activity when little is known about nurses’ physical activity during a shift and the interaction between different domains of physical activity is poorly understood.

Nursing has been described as a physically demanding occupation. Yet despite the predominance of nurses in healthcare delivery, the ‘physical’ aspect of their work is poorly understood. A detailed understanding of nurses’ occupational physical activity using robust, valid measures is lacking. In order to ensure that nurses can provide the best care to their patients, there is an urgent need to understand the physical demands of nursing work.

Ms. Stephanie E. Chappel, BExSc (Hons)
PhD Candidate
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @Steph_Chappel

Professor Julie Considine, PhD
Professor of Nursing
School of Nursing and Midwifery and Centre for Quality and Patient Safety Research
Deakin University, Geelong, Victoria
and Centre for Quality and Patient Safety Research – Eastern Health Partnership
Box Hill, Victoria
Twitter: @julie_considine

Associate Professor Brad Aisbett, PhD
Associate Head of School (Teaching & Learning, Exercise and Sports Science)
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @BradAisbett

Dr Nicola D. Ridgers, PhD
Senior Research Fellow
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @NickyRidgers


Ahmad, W., Taggart, F., Shafique, M.S., Muzafar, Y., Abidi, S., Ghani, N., Malik, Z., Zahid, T., Waqas, A. & Ghaffar, N. (2015) Diet, exercise and mental-wellbeing of healthcare professionals (doctors, dentists and nurses) in Pakistan. PeerJ, 3, e1250.

Babiolakis, C.S., Kuk, J.L. & Drake, J.D.M. (2015) Differences in lumbopelvic control and occupational behaviours in female nurses with and without a recent history of low back pain due to back injury. Ergonomics, 58(2), 235-245.

Blake, H., Stanulewicz, N. & McGill, F. (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929.

Caspersen, C.J., Powell, K.E. & Christenson, G.M. (1985) Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 100(2), 126.

Chen, J., Davis, L.S., Davis, K.G., Pan, W. & Daraiseh, N.M. (2011) Physiological and behavioural response patterns at work among hospital nurses. Journal of Nursing Management, 19(1), 57-68.

Chin, D.L., Nam, S. & Lee, S.J. (2016) Occupational factors associated with obesity and leisure-time physical activity among nurses: A cross sectional study. International Journal of Nursing Studies, 57, 60-69.

Department of Health (2014) Australia's Physical Activity and Sedentary Behaviour Guidelines. Vol. 2016. Commonwealth of Australia, Canberra.

Hagströmer, M., Oja, P. & Sjöström, M. (2006) The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity. Public Health Nutrition 9(06), 755-762.

Jung, H.-S. & Lee, B. (2015) Contributors to shift work tolerance in South Korean nurses working rotating shift. Appl Nurs Res, 28(2), 150-155.

Kikuchi, H., Inoue, S., Odagiri, Y., Inoue, M., Sawada, N. & Tsugane, S. (2015) Occupational sitting time and risk of all-cause mortality among Japanese workers. Scand J Work Env Hea, 41(6), 519-528.

Naidoo, R. & Coopoo, Y. (2007) The health and fitness profiles of nurses in KwaZulu-Natal. Curationis, 30(2), 66-73.

National Insititue for Health and Care Excellence (2015) Physical activity: for NHS staff, patients and carers.

Tuesday, 9 May 2017

Balancing Quality, Cost and the Nursing Workforce

Balancing Quality, Cost and the Nursing Workforce

Claire Su-Yeon Park, MSN, RN
CEO, Center for Econometric Optimization in the Nursing Workforce, Seoul

How can we achieve value-based nursing care resulting from improved quality yet reduced cost? We long for the best point of leverage balancing quality and cost; however, most studies seem to still present fragmented “snap shots” of the phenomenon of interest. We should be mindful of this because an unclear picture may lead to muddled policy-making. In this regard, I proposed a theory entitled “Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory” which explains “the inter-relationship in the continuum of changes between quality of care and cost, in particular, as they relate to nurse staffing.” The study “Optimizing staffing, quality and cost in home healthcare nursing: Theory synthesis” (Park 2017) is published in JAN.

I took note of inconsistent and non-conclusive evidence on both quality and cost in home healthcare, gaining insight into the limited theoretical basis on the dynamics between quality and cost that such evidence must be built upon.

To address this discrepancy, we created “Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory” through the theory synthesis process, which helps determine a practical and applicable optimum level of nursing staffing where nurses, patients and healthcare organizations (or stakeholders) can all be satisfied. The specific approach pinpoints “the theory-driven Optimum Nurse Staffing Zone as well as the Optimized Nurse Staffing (Sweet Spot), which can be navigated by Mathematical Programming (Optimization) based on the Duality Theorem in Mathematical Economics (Diewert 1982, p. 556)” (Park 2017). The “Optimized Nurse Staffing (Sweet Spot)” signifies a single best point of leverage “to achieve the maximum quality of care for patients while simultaneously delivering nurse staffing in the most cost-effective way” (Park 2017).

Non-linear optimization illustration produced by MATLAB

My theory could significantly impact nursing workforce policy-making to ensure optimal patient care relative to cost. “Not only does it address a timely issue – i.e., the balance between quality and cost – in the healthcare delivery system, but it is also applicable, durable and valuable due to the fact that Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory can be used to determine the sweet spot among quality, nurse staffing and cost in any healthcare/research setting” (Park 2017). Innovation in the healthcare delivery system as well as advancing nursing practice in real-world situations would be ultimately achievable.

Claire Su-Yeon Park, MSN, RN
CEO, Center for Econometric Optimization in the Nursing Workforce
Seoul, Republic of Korea


DIEWERT W.E. (1982) Duality approaches to microeconomic theory. In Handbook of Mathematical Economics: Volume II (Arrow K.J. & Intiriligator M.D., eds.), North-Holland Publishing Company, Amsterdam, Netherlands, pp. 535-599.

PARK C.S. (2017) Optimizing staffing, quality and cost in home healthcare nursing: Theory synthesis. Journal of Advanced Nursing. doi: 10.1111/jan.13284.

Note: This article is published under an exclusive license agreement with John Wiley & Sons, Limited; Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory: Copyright ⓒ 2016 Park, Claire Su-Yeon. All Rights Reserved. The copyright has been registered in Korea [C-2016-031091] and is pending in the U.S.A. [1-4218094011] with an effective copyright date of 02 Dec 2016; patent-pending in Korea (Park’s User-friendly Cloud-based Intersectional Optimized Nurse Staffing (Sweet Spot) Decision-making Support System [10-2017-0052130] with an effective patent-pending date of 24 Apr 2017); the Patent Cooperation Treaty (PCT) patent claiming priority of the Korean patent application pending [in progress]. Use of the contents, illustrations, and even ideas in Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory, even in part, requires written permission from the copyright/patent holder.

Tuesday, 2 May 2017

Disaster leads to disaster

Roger Watson, Editor-in-Chief

Disaster leads to disaster - at least, that's the case for adolescent girls after a natural disaster, according to a study from the USA by Sloan et al (2017 and published in JAN. The article is titled: 'Experiences of violence and abuse among internally displaced adolescent girls following a natural disaster' and was based on a study following the 2010 earthquake in Haiti.

Can you imagine losing your home and possibly your whole family as an adolesecent girl in the wake of a devastating earthquake and ending up homeless, hungry and alone? Could anything be worse? Well, in the case of adolescent girls in Haiti, it could and it did. The study set out to: 'describe the physical, psychological and sexual violence among internally displaced adolescent girls following the 2010 Haiti earthquake.' Computer assisted self-interviews were used to collect information between 2011-2013. The majority of the 78 girls who responded reported some kind of abuse - including sexual - at the hands, often, of boyfriends or other family members. It should be noted that such abuse was reported prior to the earthquake and, due to the low response rate to questions about abuse prior to the earthqaake, it was not entirely clear if there had been an increase.

In conclusion, the authors say: 'The findings from this study are important because they increase our understanding of violence against adolescent girls who were displaced from their homes and separated from their immediate families following a catastrophic natural disaster' and '(T)he results from this study suggest that there are many areas that organizations, foundations and governments can address in the future. Interventions and policy initiatives for adolescent girls should include education that increases their awareness of their vulnerability for gender-based violence as well as strategies for self-protection.'

Listen to this as a podcast


Sloand, E., Killion, C., Yarandi, H., Sharps, P., Lewis-O'connor, A., Hassan, M., Gary, F., Muller, C. N. and Campbell, D. (2017), Experiences of violence and abuse among internally displaced adolescent girls following a natural disaster. J Adv Nurs. doi:10.1111/jan.13316

Sunday, 23 April 2017

Caring for a dying child at home

Roger Watson, Editor-in-Chief

There can be few things that have more impact on a family than the death of a child. But the period leading up to death is also hard. Where parents may receive post-bereavement counselling, support is also needed when death is approaching as this study from Switzerland by Eskola et al (2017) titled: 'Maintaining family life balance while facing a child’s imminent death—A mixed methods study' and published in JAN explores.

The aim of the study was to: 'understand parents’ experiences and needs during a child’s end-of-life care at home and to identify systemic factors that influence its provision.' From a nationwide study in Switzrland between 2012-2015, 47 families were studied between 2011-2102 who had a dying child at home. Information from questionnaires and interviews was used.

The physical and emotional toll on some parents is captured in this quote from one father: 'I drove home in the evening, parked in front of the garage. . . Do you think I was able to get out of the car?! I remained seated three quarters of an hour, just sat there and slept. In fact, I was at home, but couldn’t manage to get out of the car. No energy, empty batteries.' Practical help was really appreciated as explained by one mother: 'This daily household crap—getting groceries, cooking, cleaning, paying the bills (. . .) It would have been so nice, if there had been somebody to take over all these tasks and we could have spent the time with our child.' The authors concluded: 'Paediatric end-of-life care at home is only feasible if parents make extraordinary efforts. If family-centred end-of-life home care is provided by a hospital-based paediatric palliative home care team, which includes paid housekeeping help and psychological support, parents needs could be better met.'

You can listen to this as a podcast


Eskola K, Bergstraesser E, Zimmerman K, Cignacco E (2017) Maintaining family life balance while facing a child’s imminent death—A mixed methods study Journal of Advanced Nursing DOI: 10.1111/jan.13304