Sunday, 15 April 2018

Duty rosters - how far ahead should they be made up?

Roger Watson, Editor-in-Chief

When I was a Charge Nurse, the job I hated most was making up the staff roster. You could never please everyone and, of course, if you were making it up then you certainly could not be seen to be pleasing yourself. Planning ahead was vital, but plan too far ahead and then staff had no flexibility; plan to close to the time when the roster was needed and you had less flexibility as staff requests were too numerous. How far ahead is enough and when is the optimum time to plan rosters, especially as staff may then simply take the time off as sick-time anyway and then you are short of staff or have to employ short-term staff to cover?

This article by from the UK by Drake (2018) titled: 'Does longer roster lead‐time reduce temporary staff usage? A regression analysis of e‐rostering data from 77 hospital units' was based on a study the aim of which was to investigate: 'whether longer roster lead-times reduce temporary staff usage.' Over 9 months nearly 700 rosters were examined from 77 hospitals in England. The effect of late roster approvals may contribute to nearly 40% of the use of temporary staff and longer approval time of 4-6 weeks reduced this to 15%. The complexities of the relationship are explained in the article.

The authors conclude: 'Between 2–4 weeks, roster lead-time is inversely proportional to temporary staff usage and reflects the assumed relationship between these two variables. However, beyond 4 weeks’ lead-time, the relationship enters a “plateau” phase where longer lead-time has negligible effect on staffing. At this stage, other factors, such as sickness, absenteeism, type of unit and patient demand pattern, define the lower limit of temporary staff usage. Consequently, this research implies that the optimum approval lead-time lies between 4–6 weeks.

You can listen to this as a podcast


Drake, R. G. (2018), Does longer roster lead‐time reduce temporary staff usage? A regression analysis of e‐rostering data from 77 hospital units. J Adv Nurs. doi:10.1111/jan.13578

Saturday, 7 April 2018

Menopause and sexual health

Roger Watson, Editor-in-Chief

Menopause is an inevitable feature of ageing in women who live long enough to experience it. Is is accompanied by age induced hormonal changes in the female reproductive tract which indicate the imminent end of fertility and is accompanied in many women with a period - sometime lasting years - of unpleasant side-effects. The most notable and visible of of these being 'hot flushes'. In any population of women the menopause has an impact on sexuality, this is known from research mainly involving western women. But what do we know about this in a relatively sexually conservative society such as the Cantonese Chinese population?

The study described here by Wong et al. (2108) was conducted in Hong Kong and and article titled: 'The Impact of Menopause on the Sexual Health of Chinese Cantonese Women: A Mixed Methods Study' was published recently in JAN. The study explored 'the impact of menopause on sexual health and marital relationships, the associated factors and the support needed among middle-aged and older women' and involved a sample of over 500 women who completed a questionnaire and 30 of whom were interviewed.

There was a high prevalence of sexual dysfunction and this was associated with depression. The effect on the women's sexual lives was negative and the most commonly reported effects of menopause were low sexual drive and vaginal dryness. As one woman said, more specific information about sex, in addition to the other aspects of menopause, needs to be provided: “I think it (information) should be more focused on sexual life. Because there is a lot of other information already. . . like there are videos about hot flashes, etc.. . . But not much about sex for both partners.”

In conclusion the authors say: 'This study gave a context for healthcare workers to better understand the challenges and needs of middle-aged and menopausal women and to ensure the provision of appropriate management of menopause in both clinical and community settings, targeting the family unit instead of women only. Better knowledge of the menopausal transition will enable healthcare service providers to implement appropriate programmes, education and services for different target populations.

You can listen to this as a podcast


Wong, E. L., Huang, F. , Cheung, A. W. and Wong, C. K. (2018), The Impact of Menopause on the Sexual Health of Chinese Cantonese Women: A Mixed Methods Study. J Adv Nurs. doi:10.1111/jan.13568

Wednesday, 28 March 2018

Establishing priorities on the range of conditions managed by UK community practitioner nurse prescribers

In the United Kingdom (UK), around 35,000 community and public health nurses (including district nurses, community staff nurses, school nurses and health visitors) can independently prescribe from a limited list of medicines described in the Nurse Prescribers Formulary (NPF) for community practitioners. Although prescribing is viewed as a key role for these nurses, by both nurses themselves and healthcare policy, decreasing numbers of these nurses actively prescribe, and there have been reports that items included in the NPF no longer meet the needs of the patients these nurses manage.

Changing population profiles have led to international interest in the work of community and public health nurses. Although there is a huge diversity in community and public health nursing roles globally, the available international evidence suggests a shift in focus, over the last 20 years, in the typical activities of these nurses. Activities have moved away from longer term support and care, to the provision of a more ‘acutely’ focussed episodic care with increasing involvement in health promotion activities. 

As the items listed in the NPF have remained unchanged for two decades, it is highly likely, given the changing population profiles and changing patterns of client and service delivery, that these items no longer reflect the prescribing needs of these nurses. This study, a modified Delphi technique, was designed to provide national consensus on the range of conditions CPNPs manage, and for which it is considered important that they can prescribe. 

Panelists reached a consensus, with consistent high levels of agreement reached, on nineteen conditions (both chronic and more acutely focused) for which each group of CPNPs believed it to be important for them to be able to prescribe.

Strategies are required to address health service demands in low-, middle- and high-income countries. Strengthening nurses’ capacity by extending their scope of practice to include prescribing is one such strategy which improves nurse’s ability to reach more people with quality health services. Although it is recognised that the findings of this work originate from a UK perspective, and so leaves open the need for adaptation to other healthcare systems and consideration of other national and regional concerns, our findings provide some guidance for those countries in which prescribing by community and public health nurses is established, and for those countries wishing to establish prescribing by these nurses, with regards to the conditions they manage and so the medicines they will need to prescribe. Our findings can also be used to direct national education and training for the preparation of community and public health nurses.

by Molly Courtenay


Courtenay, M, Franklin, P, Griffiths, M, Hall, T, MacAngus, J, Myers, J, Penistone-Bird, F, Radley, K (2018). 'Establishing priorities on the range of conditions managed by UK community practitioner nurse prescribers': A modified Delphi consensus study. Journal of Advanced Nursing

What leads to missed care?

Roger Watson, Editor-in-Chief

The concept of 'missed care' has been very prominent in nursing in recent years and has been extensively reported over the years in JAN. A recent UK study titled: 'The association between nurse staffing and omissions in nursing care: a systematic review' and published in JAN presents some interesting findings.

The study is by Griffiths et al. (2018) on behalf of the Missed Care Study Group and aimed to: 'identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.' Eighteen studies reporting missed care and meeting the criteria for the review were identified. 

The results are presented in detail in the article but, to summarise: 'Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care. Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy.'

The authors conclude: 'While reported missed care is associated with nurse staffing levels and such reports may indeed be indicators of inadequate nurse staffing, there is no research demonstrating associations with objective measures of care. The extent to which the relationships observed in these studies represent actual omissions of care and the consequences of such failures, remains largely uninvestigated. Future research should focus on objective measures of missed care to investigate the impact of missed care on patient outcomes.'

You can listen to this as a podcast.


Griffiths, P. , Recio‐Saucedo, A. , Dall'Ora, C. , Briggs, J. , Maruotti, A. , Meredith, P. , Smith, G. B., Ball, J. On behalf of the Missed Care Study Group (2018), The association between nurse staffing and omissions in nursing care: a systematic review. J Adv Nurs. doi:10.1111/jan.13564

Wednesday, 28 February 2018

Commentary on Drevin et. al. (2017) Measuring pregnancy planning: A psychometric evaluation comparison of two scales.

Geraldine Barrett, Jennifer A. Hall, Ana Luiza Vilela Borges, Corinne Rocca, Eman Almaghaslah, Judith Stephenson

Dear Editor-in-Chief,

As those who have developed and evaluated a variety of language versions of the London Measure of Unplanned Pregnancy (LMUP), we welcome Drevin et al.’s (2017) new evaluation of the LMUP. Drevin et al. compare a translated Swedish version of the LMUP with a single question named the “Swedish Pregnancy Planning Scale” (SPPS). This asks (in Swedish) “How planned was your current pregnancy?” with the response options “highly planned”, “quite planned”, “neither planned nor unplanned”, “quite unplanned”, and “highly unplanned”. They make the surprising admission that, without cognitive interviews, they do not know how women interpreted the question so a key aspect of validity is unknown. Given previous work about the variability of understanding of terms such as “planned” (Barrett and Wellings, 2002) this seems a high risk measurement strategy.

Drevin et al. state that “pregnancy planning is a concept that is difficult to measure due to the complexity of the concept” (2017, p.2). They continue this argument throughout their background section, thus seeming to suggest the need for a latent-trait model of measurement, i.e. that the concept is not easily observable and is hard to measure with a single question. Yet this is exactly what they propose. A single question of a latent construct is inherently prone to greater measurement error than a multi-item validated measure. Many of the tests of reliability and validity which the authors applied to the LMUP simply cannot be applied to the SPPS.

We have some concerns with how the evaluation of Swedish LMUP was conducted. The steps in the translation/cultural adaptation and evaluation of psychometric measures are well established. The authors report the translation and back translation of the LMUP, but no cognitive testing was carried out. Furthermore, the sample was based on women recruited via antenatal clinics, which (by omitting those with pregnancies ending in abortion) means that a portion of the construct (the less planned end of the pregnancy planning continuum) was poorly represented. This may be significant given that analyses based on Classical Test Theory (as these are) may be affected by the range of the construct contained within the sample. Certainly, the authors report a strong left skew to their LMUP scores (towards the more planned end of the spectrum). Unusually, the authors reported the split-half reliability of the LMUP items (items 1-3 vs items 4-6); Cronbach’s alpha is normally reported as it is the average of all possible split-half coefficients. It would also have been useful if the authors had reported the item-rest correlations and the range of the inter-item correlations, as this would have given more detail on the internal consistency of the Swedish LMUP. The authors reported Spearman’s correlation coefficient for test-retest reliability; weighted Kappa should have been used given it is a measure of agreement rather than correlation (i.e. if all scores had risen by one point in the re-test the correlation using Spearman’s coefficient would have been excellent, though the agreement would not have been).

Drevin et al. are disingenuous when they say that the LMUP “has previously not been psychometrically evaluated using a method that tests the fit of the pre-specified London Measure of Unplanned Pregnancy model” (2017, p2). In fact, the LMUP has been psychometrically validated, including using methods that test the fit of the pre-specified LMUP model, in ten language versions across eight countries (LMUP publications, 2018) with further studies underway. While confirmatory factor analysis may not have been done previously, the unidimensionality of the LMUP items has been assessed in all psychometric evaluations except one by means of Principal Components Analysis or Principal Axis Factoring. These are methods in the exploratory factor analysis family, often used in a hypothesis testing role and used appropriately with new translations. Running a confirmatory factor analysis on the second field test of the original UK development and evaluation study produces the following standardized factor loadings: item 1, 0.62; item 2, 0.88; item3 – 0.93; item 4 – 0.90, item 5 – 0.86; and item 6, 0.68; with good model fit (CFI, 0.99; SRMR, 0.01; RMSEA, 0.07, 90% CI 0.04 to 0.09). Unsurprisingly, the factor loadings are extremely similar to those produced by the principal component analyses in the development study and subsequent evaluations, confirming what we already know about the fit of the LMUP. The authors also make much of their finding of “item reliability”, including it in their key findings. Again, this is unusual. The “item reliability” is the square of the standardized factor loading in the confirmatory factor analysis, rarely reported because it is implied by the factor loading (which the authors present in table 2). The authors did find that all six LMUP items were measuring one construct (i.e. fitting the pre-specified unidimensional LMUP model) but they did not include this in their key findings.

On the basis of their confirmatory factor analysis, Drevin et al. recommend removing one, and possibly two, LMUP items, both of which measure behaviour. Whilst revision of established measures does happen, one has to consider how these changes relate to the underpinning qualitative work/conceptual model and, in this case, the contribution of the behaviour items to content validity, despite their lower statistical coherence. Indeed, the authors could have carried out sensitivity analyses relating to these items, as has been done in previous studies. These analyses have supported retaining these items given that they do not affect the performance of the scale overall and because there are good reasons for the performance of these items, such as reflecting unmet need for contraception or low awareness of preconception care, which may change over time and can be detected using the LMUP.

Drevin et al. conclude that researchers should use the SPPS rather than the LMUP. We believe that researchers, however, should be aware of the limitations of this single question, some of which we have detailed here, and, in contrast, the body of work that underpins the LMUP, particularly that the LMUP meets internationally accepted standards of psychometric validation (U.S. Department of Health and Human Services Food and Drug Administration, 2009; Mokkink et al, 2010a, 2010b; Reeve et al, 2013) whereas the SPPS does not.

Dr Geraldine Barrett, PhD
Principal Research Associate, Institute for Women’s Health, University College London, London WC1E 6AU

Dr Jennifer A. Hall, PhD
Principal Clinical Researcher, Institute for Women’s Health, University College London, London WC1E 6AU

Dr Ana Luiza Vilela Borges, PhD
Associate Professor, Department of Public Health Nursing, University of São Paulo School of Nursing, São Paulo, Brazil

Dr Corinne Rocca, PhD
Associate Professor, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, U.S.A

Dr Eman Almaghaslah, MPH
Health Promotion Officer and Medical Resident, Primary Health Care Administration and Preventive Health Department in Qatif, Saudi Arabian Ministry of Health, Qatif, Eastern Province, Saudi Arabia

Professor Judith Stephenson, FFPH
Professor of Sexual and Reproductive Health, Institute for Women’s Health, University College London, London WC1E



Drevin, J., Kristiansson, P., Stern, J., Rosenblad, A. (2017) Measuring pregnancy planning: A psychometric evaluation comparison of two scales. Journal of Advanced Nursing, 00:1–11.


Barrett, G., Wellings, K. (2002) What is a “planned” pregnancy? Empirical data from a British study. Social Science and Medicine 55:545-557.

LMUP publications. (2018)

Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter LM, de Vet HCW. (2010a) The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes, Journal of Clinical Epidemiology, 2010, 63:737-745. doi:10.1016/j.jclinepi.2010.02.006

Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter LM, de Vet HCW. (2010b) The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study, Quality of Life Research, 2010, 19:539-549 doi:10.1007/s11136-010-9606-8

Reeve BB, Wyrwich KW, Wu AW, Velikova G, Terwee CB, Snyder CF, Schwartz C, Revicki DA, Moinpour CM, McLeod LD, Lyons JC, Lenderking WR, Hinds PS, Hays RD, Greenhalgh J, Gershon R, Feeny D, Fayers PM, Cella D, Brundage M, Ahmed S, Aaronson NK, Butt Z. (2013) ISOQOL recommends minimum standards for patient-reported outcome measures used in patient-centered outcomes and comparative effectiveness research. Quality of Life Research 22:1189-1905 doi:10.1007/s11136-012-0344-y

U.S. Department of Health and Human Services Food and Drug Administration.(2009) Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims.

Friday, 23 February 2018

Baby boomers and generations X & Y in nursing

Roger Watson, Editor-in-Chief

Are there differences between the generations amongst nurses when it comes to coping with the job? It appears that there may be according to a recent study from Finland and Italy. An article entitled: 'Workplace-related generational characteristics of nurses: a mixed-methods systematic review' by Stevanin et al and published in JAN reports the study, the aim of which was to: 'describe and summarize workplace characteristics of three nursing generations: Baby Boomers, Generations X and Y'.

The study reviewed 33 published studies a looked at: job attitudes, emotion-related job aspects, and practice and leadership-related aspects. Baby boomers reported less stress than generations X and Y but greater intention to leave than generation X. In conclusion the authors state: '(a)ccording to the findings, some intergenerational differences and similarities have emerged on the part of nurses in current workplaces' and '(n)urse leaders’ education also should develop the ability to understand and support clinical nurses with different generational traits, as well as to manage multigenerational workforces effectively.'

You can listen to this as a podcast


Stevanin, S., Palese, A., Bressan, V., Vehviläinen-Julkunen, K. and Kvist, T. (2018), Workplace-related generational characteristics of nurses: a mixed-methods systematic review. J Adv Nurs doi:10.1111/jan.13538