Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


The Starfish Project: reflections on an interprofessional learning opportunity


In 1860 Florence Nightingale wrote:
The very alphabet of the nurse is to be able to interpret every change which comes over a patient’s countenance without causing him the exertion of saying what he feels.’
Supplementary chapter in Skretkowicz (ed) 1996: 169

More recent experiences suggest the empathy and skills required for such care are often lacking in healthcare staff, (HMSO, 2013).
An interprofessional learning project, inspired by The Patients Association, enabled healthcare students to closely examine communication skills and empathy in clinical practice. The nursing students participated whilst undertaking a ‘volunteering module’ as a course option.


Student Community Engagement (SCE) is an optional 10 credit module at level 5 in a Nursing honours degree programme, (Framework for Higher Education Qualifications (FHEQ), (QAA, 2008)).  Students commit to undertake 30 hours of volunteering in a health and social care project that is agreed with a workplace supervisor in a local not-for-profit organisation.  Concurrent classroom teaching facilitates an inductive process so that students learn about the purpose of their volunteer placement organisation and how this contributes to the health and wellbeing of a community.

The Starfish Project[1] was designed and led by the Patients Association (PA) in a local National Health Service (NHS) acute hospital in the South of England.  Seven nursing students studying the SCE module, seven pharmacy students and four occupational therapy students participated as volunteers working in pairs as PA Ambassadors.  The following is a reflection on this unique project from the four perspectives of the authors: NHS hospital Associate Chief Nurse (CD), PA view (LD), university volunteer manager (BTH) and university academic (DH).  Driscoll’s (1994) reflective model What? So What? Now What? frames the account of this interprofessional learning venture.

The Patients Association are committed to working on projects involving students– if you would like to know more please contact <>Heather Eardley, Director of Development or visit their website


Brighton and Sussex University Hospitals NHS Trust (BSUHT) in collaboration with the Patients Association explored different methods to improve patient experience in the Trust.  One concern was the care of patients with dementia. This had been identified in BSUHT complaints, patient surveys and incident reporting.  Approximately a quarter of patients in acute hospitals are living with dementia and have traditionally been a group more difficult to access for feedback, (Alzheimer’s Society, 2009).

In discussion with the PA it was decided to give students opportunity to develop the appropriate awareness, knowledge, skills and experience that will enable them to develop a patient-centred approach in future clinical work and ensure that compassion and dignity are the cornerstones of their clinical practice.

The project highlighted some areas of skilled patient-centred care but also raised some issues about how nurses and other health care professionals communicate compassionately with patients with dementia.  As a result of this the nationally recognised Butterfly Scheme ( for recognising and communicating with people has been rolled out across the Trust and observations of care are widely used throughout all care settings.

The Trust has since worked in collaboration with the Patients Association on a project with student nurses and pharmacists, interviewing patients at discharge about their knowledge of their medications.  The report will form the basis of further joint nursing and pharmacy development work.


The C.A.R.E. Campaign jointly run by the journal Nursing Standard and the Patients Association (2012) aims to tackle poor care and its causes, based on the four most frequent complaints about patient care received by the PA through their Helpline; these complaints include poor communication. See Box 1.

the C.A.R.E. campaign






Communication with patients and carers is a vital component of delivering patient centred health care and set out in the vision and strategy to deliver a ‘culture of compassionate care’, (Department of Health and NHS Commissioning Board, 2012).  Students used the C.A.R.E. campaign audit documents to achieve the aims and objectives of the project.  See Box 2

Aims and ojbectives of starfish project









Non participant observation and patient and carer interviews demonstrated that the use of such tools provide valuable information about how members of staff communicate, and increase awareness and compassion in student volunteers through the co-production of knowledge with service users, individual and group reflection.

The students described their overall experience of the project as invaluable, giving insight into the work of a busy hospital environment; and although they found the experience difficult at times, it allowed them to gain interviewing skills, confidence in approaching patients, and ‘personal growth’.

The PA was able to recommend the use of non-participant observation and patient and carer interviews on a regular basis with other cohorts of nursing and AHP students, as a learning ‘tool’ to assist understanding of the importance of compassionate communication in clinical practice.


The role of Active Student, the University’s Volunteering Service, was to work with the PA to create a rewarding, safe and supported volunteering opportunity that was mutually beneficial to students, the Trust, the nursing course module and the PA.  Volunteering on this unique project enabled students to develop skills in patient engagement, enhance knowledge of shared decision-making and engage in interprofessional learning.  Reflective learning opportunities were a key part of the volunteering journey and facilitated by BTH and LD.

It created opportunities for students from different disciplines to come together, share their thoughts and experiences and learn from each other.

pharmacy student quoteThe hospital Trust has gained confidence in the merits of involving student volunteers and more projects and new collaborations have since been generated.  Students add value to bespoke projects that otherwise might not have taken place.  Students have referred to their volunteering experiences at employment interviews and reported favourable responses.


The module is assessed by written report analysing the skills the student has used and developed, and reflecting on the transferability to nursing.  Students must consider the wider implications of volunteering and future design of integrated health and care services given the increasing number of people with long term needs (Naylor et al, 2013).

Patient and carer involvement is a regulatory requirement in the preparation and education of health care professionals, (NMC 2010, HCPC 2013 and GMC 2011).   ‘Starfish’ was an opportunity for nursing students to participate in a patient and carer-led project whilst working with and learning from other health care students as well as patients and their carers.  It enabled learners to improve their listening, close noticing and thoughtful communication skills:

nursing student quote






OT student quote






In addition, it honed data collections skills integrating learning from other course modules and improved understanding of the patient experience:

Now What?

The University’s Volunteering Service has initiated further opportunities for interprofessional learning whilst volunteering on local community engagement projects.  Pharmacy and nursing students took part in another programme with The Patients Association to look at patients’ experiences of knowing their medicines on discharge from hospital.

The university’s new curriculum design framework indicates 20 credits as the smallest denominator for module credit from 2017/18.  Together with new developments for interprofessional integrated care teams in the workplace, the next step for the SCE module team is to make the case for greater and more formal assessment within the curriculum in recognition of student community engagement, (Millican and Bourner, 2014).


The Starfish Project provided a novel opportunity for learning from patients and carers, (experts by experience – see ), and about the work of a not for profit user-led organisation in health and social care.  The nursing students benefitted from working with pharmacy and occupational therapy students.  They gained insight into the disciplinary perspectives and knowledge base whilst affirming their own skills.

Partnership working is central to new models for integrating health and care services.  The People and Communities Board led by National Voices, a coalition of health and care charities in England, has set out six principles for engaging people and communities, one of which is volunteering and social action as a key enabler.   The Board is one of seven governance boards for planned changes to health care and social care services set out in Five Year Forward View, (NHS England, 2014) that heralds a more engaged relationship with patients, carers and citizens.  Therefore, it has never been more timely for health care students to gain an enhanced understanding of the value of working in partnership with each other and not for profit user-led organisation such as The Patient Association.

[1] The name of the project is derived from the anecdote of a small child throwing beleaguered starfish washed up on the beach back into the sea, and when told by a passerby that his efforts would not make any difference was heard to say, “Made a difference to that one” with each starfish that he threw back into the sea.

Debbie Hatfield, Senior Lecturer;  Beth Thomas-Hancock, Volunteering Manager, University of Brighton; Lynn Dunne Macmillan Cancer Care Facilitator, South West Ambulance Services NHS Foundation Trust & Caroline Davies, Deputy Chief Nurse – Patient Experience, Brighton and Sussex University Hospitals NHS Trust


Alzheimer’s Society 2009.  Counting the cost. Caring for people with dementia on hospital wards. London: Alzheimer’s Society

Department of Health and NHS Commissioning Board.  2012.  Compassion in Practice Nursing Midwifery and Care Staff.  Our Vision and Strategy.  Leeds: Department of Health and NHS Commissioning Board.NHS England 2012

Driscoll, J (1994)  Reflective practice for practise – a framework of structured reflection for clinical areas.  Senior Nurse 14 (1): 47 – 50

General Medical Council 2011. Patient and public involvement in undergraduate medical education.  Advices supplementary to Tomorrow’s Doctors 2009.  Available on line at:  [Accessed 20 December 2016]

Health & Care Professions Council.  2013.  Service user and carer involvement in education and training programmes.  Executive summary and recommendations.  Available on line at:  [Accessed 20 December 2016]

HMSO  2013.  Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.  London: The Stationery Office

Millican, J and T Bourner.  2014.  Learning to make a difference.  Student-community engagement and the higher education curriculum.  Leicester: National Institute of Adult Continuing Education

Naylor, C et al. 2013.  Volunteering in health and social care.  Securing a sustainable future.  London:  the King’s Fund

NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England, Trust Development Authority.  2014.  Five Year Forward View.  Available online at: [Accessed 20 December 2016]

Nursing & Midwifery Council.  2010.  Standards for Pre-registration Nursing Education, Standards 5 and 8.  Available online at:   [Accessed 20 December 2016]

The Patients Association (2012)  The Practices in C.A.R.E. Review.  Available online at:   [Accessed 20 December 2016]

People and Communities Board and National Voices.  2016.  Six principles for engaging people and communities.  Available online at:  [Accessed 20 December 2016]

The Quality Assurance Agency for Higher Education 2008.  The Framework for Higher Education Qualifications in England, Wales and Northern Ireland.  London: QAA

Skretkowicz, V.  (ed) 1996Florence Nightingale’s Notes on Nursing.  London: Ballière Tindall.


Life as Narrativised in ‘24 Hours in A&E’: Early documentary film to modern-day docusoap.

WARNING – Contains graphic images of traumatic injury

A place where life, love, and loss unfold every single day.
All the patients you are about to see were treated in one 24 hour period’.
(Channel 4, 2015)

This paper will focus on the role of narratives in 24 Hours in A&E (Channel 4, 2015). In an attempt to understand these narratives, this paper will take a look at early surgical film, and its interest to the public as a form of attraction. This paper will then look at the role of docusoap, including structure and function, including the vehicle of narrative to tell stories. Exposure of a storyline in a recent episode (Channel 4, Series 8, Episode 8, ‘Free Fall’, 2015) will be described, including figures to illustrate points of narrative interest. This paper will then draw upon the issues raised from early medical cinema through to docusoap, and give a brief critique of the narratives explored in an episode of 24 Hours in A&E.

The role of film as an aid to medical research can be rooted in documentary cinema (Ostherr, 2012). In the early twentieth century, anatomy, physiology, and dissection of the body were written about extensively in books and journals of the time. The most effective form of surgical medical education was seeing the event live (Ostherr, 2012).

It is here that we turn to Eugène-Louis Doyen (1859-1916) (Figure 1), a famous Parisian surgeon.

Eugene-Louis Doyen

Figure 1: Eugène-Louis Doyen (1859-1916),, 2015

Doyen famously used photographs to publicise his surgical techniques to his fellow peers (Ostherr, 2012; Van Dijck, 2015). It was therefore no surprise to these same peers that after viewing the Lumière Brothers first public ‘moving pictures’ screening, Doyen was keen to use these same moving pictures to capture his surgical skills (Clark, 2015; McKernan, 2015).

It was noted that, at the ‘Clinical Congress of Surgeons, 1910’, Doyen provided ‘wet clinic’ surgical demonstrations. These demonstrations on cadavers and living participants, were highly anticipated and demand to attend was high (Ostherr, 2012). With demand to understand his work proving profitable, Doyen decided to film his surgical procedures for medical educational advancement (Clark, 2015; McKernan, 2015; Ostherr, 2012).

To do this he recruited two ‘opèrateurs cinematographes’, Clement Maurice and Ambroise-François Paraland (Van Dijck, 2015, p.543). Doyen converted his operation suite in a medical film studio, ‘the walls, for instance were covered with special paint to avoid unintended light reflection, and in addition to the room’s natural light source, four electric lamps assured sufficient light for both surgeons and cameras’ (Van Dijck, 2015, p.543).

The separation of the Neik Sisters, who were Siamese twins, was Doyen’s most famous educational surgical film (Figure 2).

Separation of the Neik sisters

(Figure 2: Separation of Neik Sisters,, 2015)

Unfortunately for Doyen, although successful in bringing moving pictures to his medical surgeries (and with the disapproval of many of his peers), his reputation was scarred when it was found that his surgical films were being secretly sold by his cinematographer Paraland to fairgrounds, as a form of freak show ‘attraction’ for the curious lay population (McKernan, 2015).

One hundred years on and the popularity of educational medical films has found a new form in the medical TV ‘docusoap’, itself a form of medical ‘attraction’ for general consumption (Kilborn, 2013; Kilborn, Hibberd and Boyle, 2001; Beck, Hellmueller and Aeschbacher, 2012).

Stemming from direct documentary, docusoap is a form of reality TV, which is commissioned for production under the overarching genre of Factual Television, and which rose to prominence between 1996 and 2000 (Kilborn, Hibberd and Boyle, 2001). Some popular examples of the genre include Vets in Practice (BBC 1, 1996-2002); the Educating Essex franchise (Channel 4, 2011-ongoing) and 24 Hours in A&E (Channel 4, 2011-ongoing). Docusoaps are often set in ‘a particular organisation, or pursuing some form of professional activity’ (Kilborn, 2000, p. 112) such as an airport, a hospital, an academic institution. There are also a plethora of international factual entertainment formats, which are a hybrid of docusoaps and ‘reality’ television (Kilborn, 2013) such as Big Brother, Jersey Shore (an example of the ‘structured reality’ format), and Bauer Sucht Frau.

Docusoap itself is considered to be a hybrid form of factual entertainment; Kilborn (2000, p. 112) states that ‘docusoaps combine features associated with ‘classic’ observational documentary with structuring techniques that are regularly deployed in soap-opera narratives’.

Docusoaps often carry an extended opening sequence, to locate an audience in the context of the program and to familiarise the cast of characters, a device not dissimilar to that used in soap opera (Donnelly, 2001).

Beck, Hellmueller and Aeschbacher (2012) cite Nabi (2007, pp. 372-373), when considering the key elements utilised to construct a docusoap, these include ‘(a) a portrayal of themselves, (b) filmed at least in a part of their living or working environment rather than a set, (c) without a script (or at least pretending to be without a script), (d) with events placed in a narrative context, (e) for the primary use of entertainment’. Queens University (2015, p.1) also note that some techniques employed in docusoap include, ‘interviewing, the ‘voice of God’, dramatic reconstructions, editing for heightened suspense and storylines which follow from one week to the next’.

The characters are at the centre of docusoaps, and these are (usually) ordinary people chosen to be observed, narrate (Beck, Hellmueller and Aeschbacher, 2012), and to ‘wash their dirty linen in public’ (Matthews, 2006). There is often an underlying desire for celebrity and fame (Donnelly, 2001), and docusoaps have been blamed for encouraging the ‘15 minutes of fame syndrome’ (Kilborn, 2013; Queens University, 2015). It is this ‘ordinary to famous’ journey which has proven demonstrably popular with audiences (Hill, 2000).

There are two key strategies deployed to create a docusoap that are imperative to explore in this paper; these include the development of narrative (Kilborn, 2000), and the role of editing (Kilborn, 2013).

In an attempt to ‘create’ good narratives, interesting characters appear to be sophisticatedly interwoven within a structured sense of temporality (i.e. their lives over a period of time) (Kilborn, 2013). Intrinsic to the docusoap format is an observation of ordinary people’s lives, unfolding in familiar environments and under a microscope, encouraging them to engage in a confessional mode (‘a tell all exposé of life’)(Thomas, 1996).

These lived experiences/narrated lives are used to create a new ‘formatted form of reality’ (Kilborn, 2013, p.294), by editing them for entertainment value (Thomas, 1996) e.g. the soap in docusoap.

This newly-constructed form of reality suggests an inherent ‘lack of truth’: constructing a new soap-narrative ‘truth’ for the purposes of entertainment. Thomas (1996) notes concern with the creation of docusoaps and their narratives in connection with documentary suggesting that the ‘truth we are representing becomes secondary to the primary role of televisual ‘entertainment’ (p.423).

With these theoretical perspectives in mind, this paper will now present a brief narrative description of an episode of 24 Hours in A&E (Channel 4, 2015) entitled ‘Free Fall’ (Season 8, episode 8, aired on 25th February 2015, at 9.00pm, Channel 4). One narrative storyline embedded within this episode will be explored.

The overall theme of the episode is about love between parents and their children; however the single narrative that this essay will focus upon, is about the love of a couple, after their children have gone, and living in their old age.

24 Hours in A&E is a medial docusoap on Channel 4, utilised in one of the channels midweek primetime television slots (Figure 3: Program Logo).

24 hours in A&E

Figure 3: Channel 4, 2015

Channel 4 advertises 24 Hours in A&E under the genre of factual entertainment (Channel 4, 2015). The series won a ‘Royal Society Television Award for a Documentary Series’ (Guardian, 2012). The program now in season 8, is filmed at St Georges Hospital, Tooting, London. Location shots situate the audience with a montage of London and St Georges Hospital (See Figures 4, 5 and 6). (25)



(Figure 4: Opening Views of London, Channel 4, 2015)

(Figure 4: Opening Views of London, Channel 4, 2015)

Figure 5: St Georges Hospital, Channel 4, 2015

(Figure 5: St Georges Hospital, Channel 4, 2015)

(Figure 6: A Helipad Arrival, St Georges Hospital, Channel 4, 2015) (28)

(Figure 6: A Helipad Arrival, St Georges Hospital, Channel 4, 2015) (28)

While the montage rolls, a ‘voice of God’ modality openings the program:

‘A place where life, love, and loss unfold every single day. All the patients you are about to see were treated in one 24 hour period’.
(Channel 4, 2015)

The opening sequence utilising characters (patients and medical staff) that are central to the season’s narratives. The opening sequence not only provides us with an insight into the lives of the patients, but also the medical professionals that treat those patients.

At the same time ‘talking head’ narratives engage us emotionally from the offset, providing a personalised and human window onto the working life of an A&E department.

A voiceover of a consultant doctor states:

‘A lot of really bad things happen to a lot of really good people, and you don’t think it’s going to be you’.

We are then introduced to our consultant Rhys (Figure 7), who engages by talking directly into the camera:

‘We see situations where someone’s life has just been turned upside down. People always try and remember what the last conversation was, or the last words that that person said to them… and I suppose it’s so much nicer if those last words were, I love you’.

As an audience, we are emotionally hooked. The docudrama can start.

(Figure 7: Consultant Rhys, Channel 4, 2015)

(Figure 7: Consultant Rhys, Channel 4, 2015)












Each episode revolves a 24 hours period in an A&E department (adhering to docusoap format, see previous references). A clock lets us know the time of the day within those 24 hours. Anticipation focuses on the arrival of new patients and ultimately the emergency ‘red phone’ ringing (Figure 8). If the red phone rings, it signals that a serious case is about to arrive, raising the stakes of the drama.

(Figure 8: The Red Phone, Channel 4, 2015)

(Figure 8: The Red Phone, Channel 4, 2015)

The narrative of a story develops thus; the red phone rings, medical staff answer the phone, they write down the symptoms. Voiceover proceeds, “a woman in her 70’s is being brought straight to resus (resuscitation) after a fall at home. Christine fell just five feet falling into a rockery, landing on her face”. Medical jargon is discussed between the paramedic and the consultant, and then we meet Christine (Figure 9) – we see her surrounded by doctors (Figure 10, note similarity to Figure 2) and her husband Mike (Figure 11).

(Figure 9: Christine’s Injuries, Channel 4, 2015)

(Figure 9: Christine’s Injuries, Channel 4, 2015)

(Figure 10: Christine Surrounded by Doctors, Channel 4, 2015)

(Figure 10: Christine Surrounded by Doctors, Channel 4, 2015)

(Figure 11: Mike, Christine’s Husband, Channel 4, 2015)

(Figure 11: Mike, Christine’s Husband, Channel 4, 2015)

We are told in narration that this is the second time Christine has fallen in six months. The episode cuts between the medical evaluation of Christine and the narrative of Mike’s life with his wife. Mike talks empathetically about her as both a wife and a mother, and his fears of life without her, “I couldn’t imagine life without her….No, No I can’t, we have spent our entire lives together, coping on my own would be horrendous”. He is close to tears.

Medically it is revealed that Christine has a lot of bruising, a broken wrist and a lacerated eyelid.

The narrative points us towards her age and growing older. Consciously or otherwise it invites us to reflect on the things we might not be able to do in old age. Mike looks directly into the camera (talking to an unseen interviewer but also addressing the audience) and says “I don’t want to get old- we need to start living our lives a little differently. We moved our sleeping arrangements down stairs, so they are less accidents”.

We then cut to Christine, out of hospital and recovered, who surmises that “You get old, but you still feel like you are eighteen years old”. And in an emotional sign-off, Mikes says “she has the utmost care for the human race. She will find good in everyone, even you?”

As an audience, we are emotionally invested in their happiness. The final cue card of the episode (Figure 12) shows them healthy and reunited back at home.

(Figure 12: Happy Back at Home, Channel 4, 2015)

(Figure 12: Happy Back at Home, Channel 4, 2015)

































As a brief critique of the ‘Free Fall’ episode of 24 Hours in A&E comparisons can be drawn between 1920’s ‘attraction’ cinema and this new form of medically-themed docusoap. They share characteristics which are consistently popular with a general audience; for instance, look at Figure 2, 6 and 7, examples embedded in the medicalisation of the body in traumatic states. Today however, we embed this medical attraction with personalised narratives, to soften any sense of exploitation or voyeurism.

These personalised narratives, are edited and structured around unfolding events from a triangulated perspective, a concept represented in Figure 13 (below). The audience sits centrally to all narratives and characters. The narratives intersect each other so that we (the audience) are central to every narrative that occurs from a different perspective. Even from a distance, the described triangulation and intersectionality allows the audience to fully-immerse in the program, at the centre of the action and the narrative, emotionally connected.

Figure 13: The Interrelatedness of Characters, Audience and Narrative

Figure 13: The Interrelatedness of Characters, Audience and Narrative

Hellmueller and Aeschbacher (2012, p.9) call this ‘narrative reality TV’. The ‘stars’ are medical professionals at work, and patients who are in a state of trauma. As an audience we believe in a sense of ‘truth’ existing here, because we trust these professionals, and people in pain. We are aware that it is both a constructed and an edited form of reality, for the purposes of creating heightened drama. Winston (2013) states, ‘Flaherty understood the need to make drama arise from the life being observed’ (p. 89). In essence we like these people, we know these people, and this docusoap posits relatable characters and scenarios in our front room.

In conclusion, this paper brings together new discourses surrounding the role of narrative in the medical-docusoap format. This paper has suggested that the early work of Doyen in medical education should be considered the ignition of medical ‘attraction’, in the form of medical docusoap. The current theoretical discourses surrounding the structure/form of docusoaps are evident in 24 Hours in A&E; the program conforms to many of these traditional strategies. The use of narrative is exposed to its full potential, whilst drawing upon the soap opera style drama, to keep us emotionally engaged.

To conclude, life is a narrativised reality throughout 24 Hours in A&E, triangulated with narratives and embedded structurally in the docusoap format, whilst presenting a form of ‘truth’ and ‘reality’. The characters are strong, the plot gripping, the medical staff inspiring. As a docusoap goes, it could be argued, that this is a sophisticated form of ‘narrative reality TV’.

Dr. Chris Morriss-Roberts – Senior Lecturer Podiatry


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An exploration of occupational therapists’ views and experiences of using evidence-based practice to develop professional knowledge in a local authority setting


Occupational therapists are expected to engage in evidence-based practice and to be aware of the importance of research as the foundation of the profession’s evidence base. This appears to be the first study that has explored local authority occupational therapists’ views and experiences of evidence-based practice and how they use it to develop professional knowledge.


A focus group data collection method was employed. Two focus groups, comprising seven occupational therapists each were conducted.  Occupational therapists who participated in the study had been working in the local authority setting from between six months to thirty years.


Occupational therapists did not draw on research evidence to build their knowledge.  Therapists valued the evidence of the lived experience of clients, their own and other’s knowledge and experience, including the perceived evidence-based knowledge of health colleagues. Therapists developed their knowledge using these sources of evidence, through reflection and participation in wide communities of practice.  Therapists looked to others to lead on developing evidence-based practice in the local setting.


Occupational therapists did not use an evidence-based practice approach to develop professional knowledge.  Peer learning and role modelling strategies may enable occupational therapists to become more evidence-based in order to enhance their practice and meet professional standards.


The purpose of evidence-based practice is to provide effective care and improve client outcomes, to promote an attitude of inquiry in health professionals and ensure resources are used wisely (Hoffman et al 2010).  Evidence-based practice has also been viewed as a matter of professional survival, set against a backdrop of rationing resources, consumerism and managerialism (Taylor 2007, Trinder, 2008). The high value placed on evidence-based practice by the occupational therapy profession, is reflected in the College of Occupational Therapists’ Code of Ethics and Professional Conduct (COT 2015), the College’s Standards of Practice (COT 2011) as well as the Health and Care Professions Council Standards of Proficiency for Occupational Therapists (HCPC 2015), all of which require occupational therapists to engage in evidence-based practice and to be aware of the importance of research as the basis of the profession’s evidence base.

A local authority consultation exercise, in the researcher’s practice setting, was undertaken with staff groups to ascertain the values that underpinned their day-to-day work.  Consultation with a group of occupational therapists revealed the importance they placed on evidence-based practice to justify the profession and their interventions. The occupational therapy literature has highlighted the value placed on evidence-based practice by occupational therapists although in practice, it has proved difficult to implement, with studies focussed on the barriers to research utilisation primarily in health-based settings (Robertson et al., 2013; Upton et al., 2014).  Few studies have investigated how occupational therapists use different evidence types, including research evidence to construct knowledge and it would appear, none have explored evidence-based practice from the perspective of occupational therapists working in a local authority.  The aim of this study was to gain insights into occupational therapists’ views and experiences of evidence-based practice and how they use it to develop their professional knowledge in one local authority setting.

Literature Review

An early, often quoted definition of evidence-based practice, derived from evidence based medicine, is: ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett et al 1996 p.71).  Brannigan (2007) described the evidence-based process as using the best evidence from research, balanced with clients’ values, clinical judgement and resource implications.  Nevo and Slonim-Nevo (2011) objected to the prominent role of research in the evidence-based practice process and in particular, the hierarchy of evidence where systematic reviews and quantitative randomised controlled trials were valued to the detriment of experience and professional judgement.  Nevo and Slonim-Nevo (2011 p.1193) used the term ‘evidence- informed practice’, to represent the use of a broader range of evidence to be used in a client-centred, flexible and intuitive way by practitioners to support the client’s changing needs and situation.  Reagon et al (2008) developed the idea of ‘multiple truths’ (p.433) from a grounded theory study, where evidence-based occupational therapy involved the systematic consideration of information from multiple sources and applied in conjunction with the client within a client-centred, occupational therapy paradigm.  However, Hoffman et al (2010) argued that the term ‘evidence’ in evidence-based practice served a specific purpose, which was to highlight the need to value and use information from research which was often underused.

A systematic review of published research on the subject of occupational therapists’ attitudes, knowledge and use of evidence-based practice was undertaken by Upton et al (2014).  Thirty-two research papers, published between 2000 and 2012 were reviewed: twenty-three were quantitative, eight were qualitative and one was a mixed methods design, carried out in health-based settings in a number of countries, including the United Kingdom.  The strengths and weaknesses of the studies were discussed with fourteen out of a total of thirty-two papers rated as good or strong quality.  This review found that whilst occupational therapists held positive views of evidence-based practice, a number of barriers to its implementation were identified: lack of time and caseload pressures; the culture of the organisation; limited research appraisal skills; poor access to research and tensions with client-centred practice. In an action research study, Robertson et al (2013) found that the barriers to implementing evidence-based practice reflected the findings of earlier research papers reviewed by Upton et al (2014), prompting questions about how occupational therapists constructed their knowledge, using evidence, through critical reflection and participation in communities of practice (Lave and Wenger 1991).

The seminal theory of Schon (1987) proposed that professionals developed their knowledge in complex and challenging practice settings through a framework of reflection-in-action (thinking and acting in the moment), and reflection-on-action (analysing and interpreting the event after it has happened).  Brookfield (2009) argued that a deeper level of critical reflection was required to examine and challenge the assumptions and power dynamics that framed everyday practiceA key element of critical reflection is being able to view situations and actions from multiple perspectives, including those from theory and research, to lead to informed actions and ‘an appreciation of the bigger picture of implications, surrounding the problem at hand’, (Jay and Johnson, 2002 p.79). In evidence-based practice, critical reflection can provide a framework for exploring and managing the power imbalances between the different evidence types (Petr and Walker 2009), and reconcile the tensions that exist between the technical rationality of research and occupational therapy practice (Blair and Robertson 2005).

Professional knowledge has been described as more than a store of cognitive knowledge, involving shared values, beliefs, ways of reasoning and tacit knowledge that are constructed through the interaction between professionals (Higgs et al 2004).  This interaction can occur through a process of engagement in a community of practice (Lave & Wenger 1991), defined as: groups of people who share a concern or a passion for something they do and learn how to do it better as they interact on a regular basis (Wenger 2007 p.1).  In relation to evidence-based practice, Gabbay and le May (2004 p.3) undertook an ethnographic study in primary care teams, and observed that general practitioners and nurses rarely consulted research evidence but relied on collectively constructed ‘mindlines’, informed by brief reading, their own and other’s professional experience, patients, organisational demands and developed through informal interactions in fluid communities of practice. The researchers acknowledged that their research had been conducted in well-functioning teams and that their ideas concerning ‘mindlines’ needed to be tested in different settings.

In summary, the debates in the literature concern what constitutes best evidence in health and social care practice, based primarily on the opinions of academics rather than empirical research and the views and experiences of practitioners and clients. The occupational therapy literature comprises of mostly quantitative studies focussed on the challenges to putting research into practice in health-based settings and it would appear that few studies have been conducted in local authority settings.  It also appears that little attention has been given to understanding how occupational therapists develop evidence-based knowledge, through strategies such as reflection or participation in communities of practice.  The apparent gaps in the literature helped to define the research question: An exploration of occupational therapists’ views and experiences of using evidence-based practice to develop professional knowledge in a local authority setting.                                             


A qualitative design, by means of focus group interviews, was applied to the research question. Qualitative research explores how human beings understand, experience, interpret and create the social world (Sandelowski 2004).  The nature of the research question, which concerned exploring occupational therapists’ views and experiences of evidence-based practice, was therefore deemed compatible with the qualitative research paradigm.  Focus groups collect qualitative data from a homogeneous set of people through a focussed group discussion and place a value on the interaction of group members to elicit information and collective viewpoints (Krueger and Casey 2009).  Group interviews can have an advantage over individual interviews as they offer insight into how social knowledge can be constructed through the group process (Green and Thorogood 2004).


The research project gained ethical approval from the University of Brighton and the Local Authority Research Unit.  Ethical issues included maintaining the anonymity of participants and mitigating power imbalances between participants and researcher and participants. An invitation to take part in the research and an information sheet were emailed to all occupational therapists employed by the local authority. Fourteen occupational therapists consented to take part from different teams across the local authority area, with a range of experience of working in social care of between six months to thirty years.  The sample size allowed for the formation of two focus groups, each with seven participants, to allow for observing patterns and themes emerging within and across both groups (Krueger and Casey 2009).

The researcher

The researcher is employed as a learning and development officer within a local authority organisation and has a key responsibility for supporting occupational therapists in their continuing professional development.  The researcher is not managed by the occupational therapy service and has no supervisory or managerial role with occupational therapy staff. The researcher acted as the moderator of the focus group discussions and due to being known to the participants, maintained a reflexive diary throughout the research process to raise awareness of researcher bias (Shaw 2010).

 Data collection and analysis

A questioning route was devised, based on a process by Krueger and Casey (2009).  Questions included:

  • What do you think counts as evidence?
  • What do you think is the best evidence?
  • How do you develop your knowledge using evidence?

Each focus group discussion lasted one and a half hours.  An assistant moderator from the learning and development team, took notes of key points made in the discussions to assist with the analysis of the audio-recordings.  A process of thematic content analysis, as proposed by Braun and Clarke (2006), was used to analyse the data: familiarisation of the data and transcription, initial coding, collating codes into themes, reviewing the themes before defining and naming them with ongoing analysis, relating the analysis back to the research question and literature in the final report.


The study was fully supervised by an academic from the University of Brighton and guided by the quality principles for qualitative research as set out by Yardley (2008).  These principles were applied as follows: 1. sensitivity to context by relating the research to theory and literature, being open to alternative interpretations in the data; 2. commitment and rigour through in-depth data collection and analysis; 3. transparency and coherence through the alignment of the research question, the methods used to collect and analyse data, the use of quotes to enable the reader to judge the adequacy of interpretations, and keeping a reflexive journal (Shaw 2010); 4. impact and importance of the study by examining the practical and theoretical implications of the research for occupational therapists working in a local authority setting and the wider professional context.


Three main themes were extracted from the data: I know I should but I don’t; evidence-based practice is different in social care; learning outside the classroom. The main themes and sub-themes represent the prevalence of views, the greatest amount of time spent on certain points and those that related directly to the research question.

main themes and sub-themes

I know I should but I don’t

Participants in both groups associated the term ‘evidence-based practice’ with the use of research and expressed their concern that research was rarely used to guide their practice. As one participant put it, ‘I know I should but I don’t.  This theme runs as the thread throughout the following sub-themes: justifying occupational therapy, the barriers to using research in practice and looking to leaders and role models to develop evidence-based practice within the local setting.

  • Justifying what we do

The views of the participants concerning justification of their actions appeared to operate at two levels, dependent on whether research was used to justify the profession or formed part of their day-to-day practice with clients.  In focus group one, research was perceived as having a critical role in justifying the occupational therapy profession with some anxiety expressed about the survival of the profession without it:

 ‘I suppose the scary thing is if there was some seismic change in our role, we would be thinking why wasn’t there more evidence to support it, with things changing as they are’.

Evidence-based practice was discussed as a broader concept in both focus groups, moving away from research as the dominant feature when working with clients.  This was described as an intuitive process, rather than a more conscious evidence-based approach:

 ‘It’s about what you have worked on this week, the client evidence, your own experience, the evidence from your co-workers by having a chat with them. For me, there is rarely a process where I stand there thinking about a particular client, thinking about the best evidence to go forward’

  • Barriers and Challenges

Participants in both groups shared their concerns about the lack of time they had for developing their evidence-based practice, with few reporting experiences of using research.  Participants in focus group two discussed their frustration at the value placed on quantitative research, which was viewed as being at odds with the ethos of occupational therapy practice and its limitations with the complexities of practice in social care:

‘In terms of day to day practice and the people we work with, it can get a bit messy and although random controlled trials can be useful for a particular subset of people, it’s very difficult to isolate that when you’ve got people with multiple conditions and lots of complications that go on’.

A further barrier was a lack of interest in using research evidence, due to a view that few studies were relevant to occupational therapy practice in a social care setting:

‘What’s the point in reading research on ten people in New Zealand that has no correlation to what we do….it can be hard to find up to date research about  community based working, like practice around adaptations in the UK’

  • Leaders and role models

In both focus groups, participants highlighted the importance of leaders and role models to engage others with evidence-based practice and demonstrate putting research into practice, with one participant suggesting ‘if other people are passionate, it filters down, doesn’t it?’  Another participant agreed, but reported difficulties motivating peers and getting them to regard evidence-based practice as a priority:

‘You need someone to actually drive that forwards as I don’t think everyone has a person or a few people in that team to actually move things on.  Because just setting up the journal club was a bit of pain, to try and get people to allocate time for it and want to do it and get involved with it’.

Participants in focus group one became excited about their idea of having a group of individuals, or a kind of leadership team, which they called a ‘super team’ who would have the necessary time and skills to search for and evaluate research evidence and make recommendations for practice change.  The responsibility for putting research into practice was viewed as someone else’s responsibility, as opposed to an individual or shared responsibility:

‘Wouldn’t it be nice if we had an evidence-based practice team who actually had a role of recognising a gap in practice, gathering evidence, formulating it and making a recommendation for a change of practice, just delivering it’.

Evidence-based practice in social care is different

Evidence-based practice in social care was perceived by participants as shaped primarily by clients being seen as the expert in their condition and working in people’s homes, with comparisons made with hospital-based settings.

  • The client is the expert

Participants in both groups felt their clients often held the best evidence in terms of their personal experience of their disability, its impact on their day to day lives and the choice and control they wished to exercise with regard to the outcomes they wanted to achieve.  This was a strong influence when making decisions, planning and evaluating interventions:

‘If they’ve had a lot of experience living with a health condition for a long time, sometimes they know what’s best.  Sometimes we can come in with a big idea about what might change things and make things better, but actually, they’re the expert in it’.

Participants, especially in focus group two, spent some time discussing their experience of clients questioning their interventions and proposing their own solutions, triggering a process of consulting with colleagues and evaluating the risks involved:

‘Looking back, I discussed it with other people, colleagues and involved the moving and handling team and I guess, at the end of the day, I risk assessed, considered her capacity to make that decision and understand the risk’

  • Health are better at evidence-based practice

The nature of the work environment was considered a key influence when applying evidence-based practice and in focus group one, this was explored in relation to health-based settings.  There was a view that health colleagues were better at being evidence-based in their practice, due to having a medical model approach aligned to the more highly regarded objective, measurable types of research which were perceived as more easily applied in clinical settings:

‘In a hospital, you have distinct evidence-based pathways you follow in a particular way.  Whereas in the community, everyone is individual so it makes it more difficult to pick out one bit of evidence’.

‘In a hospital, everyone is in the same environment, so the same practice might apply more. You come across different things in the community’.

Another reason suggested by the group, was that the NHS needed to be more robust in its evidence base, in order to respond to complaints and legal challenge. Their view possibly reflects the impact of media coverage of cases where failures in care and treatment have resulted in calls for disciplinary action and compensation. One participant posed the question ‘does it come down to, perhaps in health, a blame culture and a fear of being sued?’

Learning outside the classroom

Participants in both groups expressed similar views about the role of reflection, learning from doing and talking with their peers as critical to the development of their practice knowledge.  Other sources for building knowledge, such as reading books, research articles, participating in courses or conferences were not mentioned.

  • Reflection

Terms commonly used by participants in both focus groups included: ‘I think all the time’, ‘I think a lot of my reflective practice is here, in my head’ to describe a continuous mental process of reflecting in the moment or after the event, in order to achieve the best outcomes for clients:

‘I use reflection to look back on my practice to see if I got the best outcome, or if I could have done something differently for a better outcome.  Then depending on what your conclusion is, it would tailor my practice when I came to that situation again’.

‘…. even during involvement, you could use reflection to change the way you do something if you think, actually, I am on the wrong course here’.

Linked to this, was the term used in both groups of how knowledge and experience was shaped by a matter of ‘trial and error’ and that this was deemed as a crucial way of building an evidence base for interventions:

‘I think trial and error sometimes.  We might have done something with someone else at some point which worked and we can maybe use that and that’s good evidence because if it worked for that person, it may work for this other person.  But sometimes it doesn’t, but then you learn from that as well. It’s just as useful’.

  • Learning from and with others

There was consensus within and across both groups that learning from and with others was a vital resource for developing their practice knowledge.  This moved beyond the idea of the knowledge and experience of immediate team members, to encompass a wide community of practice:

‘I know in our team; we are quite reliant on learning from each other.  We throw things to the floor quite regularly and discuss stuff.  So learning form others is quite day to day.  Joint working with colleagues, carers, families and we can learn from all these different people’.

The knowledge held by health colleagues was also discussed and valued in both groups; particularly their knowledge and information regarding specific medical conditions and prognosis of individual clients:

‘I have worked with the neuro-team quite a bit and I tend to ask their opinion of that person or other people with that condition.  They don’t have a crystal ball, but they tend to say this person will probably progress at this rate.  So yeah, I will go to them because I value their opinion and evidence as well’.

These interactions possibly reflect those that occur in multi-disciplinary teams where opinions are sought on a case-to-case basis, compensating for occupational therapist only teams in this particular local authority setting.  This also links to the earlier notion, that health colleagues were perceived to hold evidence-based opinions.

Discussion and implications

Occupational therapists in the study associated evidence-based practice with research and discussed rarely using research evidence due to time pressures, lack of relevant research and the tensions it presented with client-centred practice, themes that are consistent with the literature (Robertson et al 2013, Upton et al 2014).  Research was valued more highly in relation to justifying the profession than in day-to-day practice with clients, when other types of evidence held greater importance, notably the lived experience of their clients and their own and other’s professional knowledge and experience.  These findings highlight occupational therapists are not drawing on current research to inform their practice, although it is worth bearing in mind the limited research base in occupational therapy and social care.  The reliance on their own and other’s professional knowledge and experience may pose a risk that practice can be outdated as well as subject to personal bias (Hoffman 2010). The provision of support, such as protected time alongside personal commitment, may enable occupational therapists to develop their evidence-based practice and adhere to professional ethics and standards (COT 2010, COT 2011, HCPC 2015).

A broader implication of the findings is that occupational therapists appeared more attuned to an evidence-informed approach, which can be understood as not excluding research, but valuing professional experience and the judgements of practitioners and clients who are in constant interaction with each other (Nevo and Slonim 2011).  This suggests the need for further discussion within the profession about whether an evidence-informed approach is more congruent with occupational therapy practice in a social care context, mindful that research utilisation is essential to both evidence-based and evidence-informed practice.

A theme that emerged from the findings, not apparent in previous studies, was the perception by a number of occupational therapists that health colleagues were better at evidence-based practice, due to the nature of their work environment and use of research-based treatment protocols.  However, the systematic review of Upton et al (2014) would suggest otherwise, since health-based occupational therapists in numerous studies, reported similar views and experiences to those held by social care occupational therapists participating in this study. Further research that explores the views and experiences of evidence-based practice of occupational therapists working in health and social care settings would be useful and timely, in light of the integration of health and social care (Care Act 2014).

Occupational therapists looked to others to lead on evidence-based practice and research utilisation, with little acknowledgement of individual responsibilities for implementing evidence-based practice, as required in professional ethics and standards (COT 2010, COT 2011, HCPC 2015).  The views about leaders link with thoughts from Upton et al (2014 p.36) about the role of ‘knowledge brokers’ who could disseminate up-to-date research, and the findings from an action research study by Morrison and Robertson (2016), which indicated the importance of senior occupational therapists for demonstrating and motivating evidence-based behaviours in new graduates.  An action-research project undertaken by Andrews et al (2015 p.4) identified facilitation as a crucial element for developing ‘evidence-enriched practice’ in health and social care with older people.  The researchers used the metaphor of making a cake, with the facilitator acting as a ‘good cook’ who supported a collaborative approach to selecting, preparing, mixing and baking different types of evidence to achieve the desired result.  The value occupational therapists placed on learning from each other, may lend itself to the development of peer learning approaches. Peer learning is defined as ‘the acquisition of knowledge and skill through active helping and supporting through status equals’ (Topping 2005 p.631), a strategy which may enable all occupational therapists to become ‘good cooks’ of evidence-based practice.

Occupational therapists discussed developing their knowledge through a process of reflecting-in-action and reflecting-on-action (Schon 1987), often describing this as a matter of trial and error, carried out in collaboration with the client. This may be understood as professional artistry, where individuals demonstrate a blend of creativity and expertise built up through reflection and experience (Beeston and Higgs 2001), or as the unique and innovative practice that requires audacity, courage and risk-taking (Higgs and Titchen 2001).  Blair and Robertson (2005) highlighted the challenges for bridging the gap between the professional artistry of occupational therapy practice and research, and suggested critical reflection as a way of reconciling the tensions between the two elements. An implication for the organisation is how it can create opportunities for occupational therapists to develop their ability to become critically reflective, such as using supervision for reflective dialogue and critical analysis (Fook and Gardner 2007) and peer-based, critically reflective action learning (Skills for Care 2014).

As noted previously, occupational therapists believed a crucial way of developing knowledge was by learning from and with each other, and this extended beyond their immediate team members to include clients, carers, and health colleagues.  This took the form of a community of practice (Lave and Wenger 1991), which was shaped around the particular needs and situations of individual clients.  This appears to resonate with the research by Gabbay and le May (2004 p.3) where GPs and nurses integrated evidence from various sources, including ‘opinion leaders’, in negotiation with individual patients through daily networking to form collectively reinforced, tacit guidelines, named as ‘mindlines’.  Opinion leaders were identified as trusted individuals, within or outside their teams, who were perceived to hold up-to-date, research-based knowledge in their particular field.  For occupational therapists in this study, health colleagues were viewed as external opinion leaders, due to a belief that their practice was underpinned by research evidence. One of the key recommendations made by Gabbay and le May (2004) was to invest in opinion leaders to ensure their knowledge was research-based, alongside a collective responsibility to help strengthen the evidence-base of the ‘mindlines’ created by communities of practice.  In connection with previous points, such leaders would need to facilitate collaborative approaches for strengthening the evidence-based knowledge of occupational therapists and the ‘mindlines’ of their communities of practice, in line with individual responsibilities for meeting professional ethics and standards and (COT 2010, COT 2011, HCPC 2015).  Key individuals may help to build an evidence-based culture, by modelling the skills, knowledge and behaviours associated with evidence-based practice and facilitating peer learning that can enable all occupational therapists to become evidence-based practitioners.


The study involved a small number of occupational therapists in one local authority setting, so it cannot be regarded as representative of local authority occupational therapists as a whole. The participants who volunteered to participate, may have been predisposed to the idea of evidence-based and were also likely to feel comfortable with a group discussion format.  One-to-one interviews may have captured more in-depth data about individual viewpoints which can be lost in a group discussion.  Team managers were not involved in the study and on reflection; their inclusion may have added a useful dimension to the study due to being an important influence in the practice setting.   A further limitation is that the research was carried out by one researcher using a single method of data collection, so the study can only represent one facet of the bigger picture of the subject matter.


The aim of this research study was to explore occupational therapists’ views and experiences of using evidence-based practice to develop their professional knowledge in a local authority setting. Occupational therapists did not draw on research evidence in their day-to-day practice due to time pressures, lack of relevant research, the tension with the client-centred ethos of occupational therapy and its limitations when working with people who have complex needs.  Occupational therapists relied on the evidence of the lived experience of clients, their own knowledge and experience, the knowledge of others, including the perceived evidence-based knowledge of health colleagues.  Knowledge using these particular sources of evidence was developed through reflection and participation in wide communities of practice which were shaped by the individual client’s needs and situation.  Occupational therapists looked to others to lead on developing evidence-based practice in the local setting.  Key individuals may help to develop an evidence-based culture, by modelling evidence-based practice and facilitating peer learning approaches that enable all occupational therapists to become evidence-based practitioners. Further research into how occupational therapists construct their knowledge and strategies that can enable them to develop professional knowledge that has a stronger evidence-base is required.

key findings







what the study has added







Debbie Ryan Learning and Development Officer OT, West Sussex County Council ; Dr Channine Clark, Principal Lecturer Occupational Therapy, Academic Lead University of Brighton


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Podoconiosis: A guide for farmers

podoconiosis: A guide for farmers posterClick on image to download























Pennie Mills BSc (Hons) Podiatry



Systematic Review on the Effectiveness of exercise and Physical Activity on Quality of life Measures in knee Osteoarthritis.



Osteoarthritis (OA) is the most common degenerative joint disorder. Sufferers of this condition find that it impacts on the quality of their lives (QoL). Exercise is thought to be an important non-pharmacological approach for symptom management.
Aim and Objectives: The purpose of this systematic literature review was to examine the effectiveness of exercise (both land and water based), in improving the QoL of individuals with knee osteoarthritis.


A systematic search was undertaken of AMED, The Cochrane Library, CINAHL, MEDLINE and PEDro along with the Google Scholar databases. The timing of these searches was from September to November 2014. Studies were selected based on pre-set eligibility criteria. Two independent reviewers appraised the selected studies using the PEDro scale and collaborated in order to establish a rigorous perspective on the quality of the research.


From 782 papers initially, 12 studies were included in the review; 10 high quality and 2 moderate quality primary studies and involving a total of 687 participants. The three most common outcome measures used were KOOS (Knee Injury and Osteoarthritis Outcome Score), Nottingham health profile and SF 36. There was strong evidence supporting exercise and physical activity as effective in improving the QoL for people with knee OA based on 8 high and 2 moderate quality studies. The review did not draw any conclusions on the effects of aquatic exercise on QoL due to conflicting evidence. Also noted was conflicting levels of significance under different exercise conditions; significant difference was high when exercise was compared to a non-intervention or education control group and less so when exercise was compared with drug therapies such as NSAID.


Exercise and physical activity, either combined with appropriate drug therapies, or as a single intervention is effective on improving QoL in people with knee OA. However, the most effective exercise dose prescription, the individual aspects of a multicomponent programme, or the additional benefit of a home exercise and walking programme remain uncertain.


Osteoarthritis (OA), a degenerative joint disease, is one of the most common musculoskeletal disorders and represents a major, global public health problem (Alkan et al., 2013). The cause of the disease remains unknown; however, current evidence suggests that it is a result of an interplay of intrinsic and extrinsic risk factors such as old age, female gender, ethnicity, genetic factors, obesity, previous trauma, repetitive use of joints and occupation, which lead to the development of the disease particularly in weight-bearing joints like the knee (Iwamoto et al., 2011). It presents with progressive structural alterations to the joint which includes loss of articular cartilage, osteophytes formation, muscle weakness, and ligamentous laxity (Bennell et al., 2012).

Knee osteoarthritis is the most commonly encountered type, affecting about 18% of women and 9.8% of men globally and its incidence is projected to double by the year 2020, largely due to increased obesity and old age (Johnson and Hunter, 2014; Akinpelu et al., 2009). The disease progression is usually slow and characterised by stiffness, pain, muscle weakness, joint instability and reduced physical functions such as difficulty in walking, stair climbing and squatting, moving from sitting to standing (Yilmaz et al., 2012; Heidari, 2011; Chaipinyo, and Karoonsupcharoen, 2009). In advanced stages pain becomes continuous, muscle atrophy and limb deformity result (Micheal et al., 2010). All such complaints give rise to physical disability which could ultimately lead to restrictions in QoL with time (Yilmaz et al., 2012).

Background and literature review

The burden of knee OA does not only include physical problems, but also high economic and social burden largely attributed to the effects of the disability, comorbid diseases, treatment expenses (Bitton, 2009; Woolf and Pfleger, 2003). It also brings with it detrimental psychological effects such as helplessness, coping difficulties and depression, all experienced at higher levels than the general population in people with the condition (Litwic et al., 2013; Cook et al., 2007).

QoL is described as a global construct which includes all aspects of life such as an individual’s perceived position within societal systems and in relation to their expectations and concerns. QoL is reported to be low in people with knee OA with a correlation existing between disease progression and QoL levels dropping significantly compared with other chronic diseases (Farr II et al., 2013; Alves and Bassitt, 2013). It is evidenced that people with OA experience major changes in daily life influenced by the severity of symptoms and impact on functional capacity, affecting their QoL (Chan and Chan, 2011; Egan and Mantes, 2010).

In recent years, QoL has become an important outcome in chronic conditions such as OA where health involving living with and managing one’s condition becomes important (Bernad-Pineda et al., 2014; Phillips et al., 2013; Hoptman et al., 2009). Although not fatal, patients with knee OA are at risk of developing cardiovascular disease due to obesity (Pietrosimone et al., 2014) which could be linked to physical inactivity resulting from chronic pain and restricted joint mobility. Thus, with a progressive disease of multiple risk factors and symptoms, with no known cure and management of patients depending on relief of symptoms, the importance of improving QoL as an endpoint for management needs to be emphasised (Kao et al., 2012; Dias CR et al, 2003).

Management of osteoarthritis has been a combination of different therapies of both pharmacological and non-pharmacological nature. In physiotherapy, a wide range of treatments including exercise and physical activity are used. The treatment of OA is focused on reducing physical disability, controlling pain while lessening the potentially harmful side effects of medicines (Beckwee et al, 2009; Zhang et al., 2007). Exercise is considered as an effective conventional therapy for knee OA symptoms (Fransen and McConnell, 2008). Based on the evidence of a systematic review of guidelines for physical management of osteoarthritis, exercise was among the strongest recommended interventions as first choice conservative treatment particularly for knee OA (Beckwee et al, 2009; Hootman et al., 2003; Larmer et al., 2014; Royal Australian College of General Practitioners, 2009; Veenhof et al., 2012 and Zhang et al., 2008). Systematic reviews have established the benefits of exercise and physical activities in patients with knee OA on outcomes of pain and function (Smith et al., 2014a; Smink et al 2011., Zhang and Jordan, 2010; Fransen and McConnell, 2009a; Fransen and McConnell, 2008b). However, the effects of exercise and physical activity on QoL are not well established and no review undertaken to date.

Primary studies have assessed the effectiveness of exercise and physical activity on QoL in knee OA; some studies report beneficial effects regarding improving general health (Sheth et al., 2014; Multani, 2005; Thorstensson et al., 2005; Dias CR et al., 2003) while other studies established that exercise is ineffective (Ravaud P et al., 2004; Lund et al., 2008). Due to the varying primary evidence it seemed important that a systematic review was conducted with the aim of summarising the evidence of relevant literature and providing more reliable and generalizable conclusions which could be used in clinical practice. Furthermore, identifying therapies that improve quality of life in patients with knee OA may lessen the clinical, economic and social burden of the disease (Farr II et al., 2013).

Methods, Data sources and Literature Search

The review was based on the Center for Reviews and Dissemination guide (CRD 2009) in order to remain focused on the research question and ensure consistency across all aspects of the review, and thereby reduce the risk of bias (Boland et al., 2014; Young and Solomon, 2009). A literature search of AMED, The COCHRANE LIBRARY, CINAHL, MEDLINE and PEDro was conducted in the middle of November 2014. To ensure a comprehensive search, Internet sources of Google Scholar were conducted to make sure that unpublished papers with registered databases were retrieved (CRD, 2009). While the review attempted to minimise publication bias (Greenhalgh et al., 2014), two non-English studies could not be included due to a lack of resources for translation.

Study selection

To ensure reliability of the decision process, a second reviewer was involved S.M. (CRD, 2009). To minimise selection bias selection criteria was clearly established and studies were included based on their eligibility. The criteria included; quantitative primary studies conducted in English, adult participates with clinically diagnosed knee OA, studies that investigated both knee and hip osteoarthritis, but reported the results separately for each area in order to extract data for knee OA and intervention that included exercise and or physical activity with a control group of alternative interventions. To ensure reliability of the results across studies (Fawcett 2007), only standardized scales were included; SF 36, Short Form SF-36, KOOS (Knee Injury and Osteoarthritis Outcome Score); Nottingham Health Profile (NHP); and other QoL scales. While the review aimed to include different types of quantitative studies other than RCTs in order to ensure a comprehensive review of available evidence, however, only RCTs and one quasi-experimental study met the requirement. In total 12 studies were reviewed as outlined in the flow chart below.

Quality Assessment

Quality assessment is important to ensure that included studies provided sufficient robustness for the results to be trustworthy and generalisable (Boland et al., 2014). Eleven RCTs and one quasi-experimental study met the inclusion criteria. The PEDro scale (available at was used to assess the methodological quality (Verhagen et al., 1998). Levels of scores were based on those outlined in a study by Abiebr (2011); study scoring below 4 was low quality, a score of 4-5 was moderate quality and 6-10 was high quality.

Table 1: Flow Chart for Literature Filtering Process.

literature review flow chart

Data extraction

Data extraction was undertaken by the author and a reviewer independently. Depending on evidence provided, results on QoL outcomes measures were extracted at two time points; post-treatment and follow-up results and were recorded as short-term (within three months) and long-term follow up (above three months) as shown in tables 2, 3a to 3d below. The reviewers discussed the findings and disagreement was resolved through dialogue.

To comprehensively assess QoL which is a influenced by variables such as age, physical and social functioning, emotional well-being, role activities, perceived health (Rejeski and Mihalko, 2001, Shumaker et al., 1990), results for each subscale were considered as they address these different aspects which ultimately determine QoL for an individual with a chronic disease such as knee OA.


The literature search identified 782 studies; duplicates, unrelated studies were removed and remained with 88 potential studies for initial screening; 9 RCTs and 1 quasi-experimental study with 2 RCTs from reference search were included in the final review. 78 studies did not qualify, thus excluded.

Table 2: Characteristics of included studies
Table 2: Characteristics of included studies

Key: Nottingham Health Profile questionnaire (NHP), verse (vs.), weeks (Wks.). Exercise (Ex), Quasi-Experimental study (Quasi-E)

3.1 Methodological Quality and risk of bias in the included studies

The quality of the studies is reported in table 2 above, the PEDro score ranged from 4 to 8 and the most common weakness were blinding (therapist, subjects and assessors) and intention to treat analysis. 10 high quality studies scores ranged from 6 to 8 and 2 moderate quality studies scored 4 and 5 respectively.

3.2. Study characteristics

To further understand the evidence, enhance transparency and prevent errors in interpretation, extracted data for study characteristics and results were tabulated as shown in table 3, 4a, 4b, 4c and 4d below. A total of 687 participants were included. The sample size ranged from n=31 (Aglamis et al 2008) to n=191 (O’Reilly et al., 1999).

3.3 Outcomes

The outcomes in tables 4a and 4b show statistical significance found by the authors of the different studies in p-values indicating either significant difference in support of the experimental group or no significant difference between the groups and confidence intervals (95%) with positive values in favour of the experiment group. They are reported according to short- or long-term follow-up for each outcome measure. The duration of interventions ranged from six weeks to six months respectively.

Studies were grouped into physical activity, exercise, aquatic exercise and exercise and physical activity when the interventions were combined, As per protocol, when two interventions were assessed with a control group, the results of one intervention in relation to the control group were reported, thus studies by Wang et al. (2011) and Lund et al. (2010) aquatic exercise were reported, and Evick and Sonel’s (2003) a walking programme instead of exercise was reported. This ensured that the review was inclusive for the type of exercise intervention.

Multicomponent strengthening exercise versus a non-intervention

The efficacy of multicomponent strengthening exercises in the management of OA was directly addressed in two high quality studies; Fransen et al., (2001) compared supervised group exercise supplemented with walking to a non-intervention group found significant improvement as reported on the SF 36 scale with the mental component score of CI 2.1 (0.8, 3.4) indicating a narrower confidence interval, and this was without the physical component score reaching statistically significant improvement. Similarly, Thorstensson et al. (2005) conducted a supervised multicomponent exercise complemented with a walking program and found on the SF 36 mental component score (p<0.04) in favour of the intervention.

Table 3a: Outcomes Results: SF 36 – mean percentage difference (95% confidence interval CI), P-value; Short term effects of exercise and physical activity < 3 months
Table 3a: Outcomes Results

Key: Combined Results for physical Mental and components (PC + MC), PEDro Score (PS), Exercise (Ex), Verses (vs), standardized response mean (SRM), Results not provided as a combined score









Table 3b: Outcomes Results: SF 36 – mean percentage difference (95% confidence interval CI), P-value; long term effects of exercise and physical activity < 3 months
Table 3b: Outcomes Results

Combined Results for physical Mental and components (PC + MC), PEDro Score (PS), Exercise (Ex), Verses (vs)








Table 3c: Outcomes for KOOS-QoL measure – mean percentage difference (95% confidence interval) and p=values where given
Table 3b: Outcomes Results: SF 36 – mean percentage difference (95% confidence interval CI), P-value; long term effects of exercise and physical activity < 3 months

Combined Results for physical Mental and components (PC + MC), PEDro Score (PS), Exercise (Ex), Verses (vs)








Table 3d: Outcomes Results: Nottingham Health Profile questionnaire and p=values where given

Table 3d: Outcomes Results: Nottingham Health Profile questionnaire and p=values where given




Home based exercise and walking program versus non-intervention

Dias CR et al., (2003) evaluated the combined effects of walking with supervised progressive concentric-eccentric exercise to a non-intervention group. This moderate quality study reported statistically significant improvement in favour of exercise with functional capacity (p<0.000), physical role (p<0.0004) and general health (p<0.02) on the SF 36 scale. Similar findings were observed in a high-quality study by Aglamis et al., (2008) who reported significant improvement on most subscales of the SF 36 (p<0.001) with effects maintained at both 6 and 12 weeks’ follow-up after a supervised multicomponent functional exercise and walking programme.

Physical activity alone

Walking versus non-intervention

A moderate quality study by Evcik and Sonel (2002) compared the effects of a 3-month walking programme with a non-intervention group and found statistical and clinical improvement on all subscales of the Nottingham health profile (P<0.001) except for the social isolation dimension.

Exercise alone

Jorge et al. (2015) compared a supervised progressive strengthening programme with a no treatment group and found statistically significant improvement on SF 36 PCS; physical function and physical role (p-value 0.002, p-value 0.002) in favour of the exercise group. The MCS showed no improvement and the control group remained unchanged. While Salli et al. (2010) found that subjects receiving supervised concentric–eccentric exercise showed improvement on outcomes; SF36  PCS (P<0.001) at both 8 and 20 weeks follow-up while on the mental component of the scale, improvement above significant levels showed at 20 weeks follow-up.

Home based strength training

Three high quality studies; investigated the effectiveness of a home based strengthening exercise programme; Baker et al., (2001) compared progressive strengthening with a nutrition education group and evidenced statistically and clinically meaningful improvement in physical function, physical role, social function and mental health (p=0. 01, p<0.009, p<0.012 and p=0. 001) on the SF36 scale. However, the control group showed deterioration in QoL. Similarly, O’Reily et al (1999) conducted home based progressive isometric-isotonic exercises. While improvement was apparent in favour of the exercise, however the results were not significant as shown in table 4b. Doi et al. (2008) assessed home based quadriceps strengthening against non-steroidal anti-inflammatory drugs. Improvement was observed in both groups with positive results in favour of exercise (p<0.001) compared to NSAID (p, 0.023) however the significance difference appeared small. Some of this difference perhaps lies in the issue of motivation to undertake unsupervised exercise involving painful joints.

Aquatic Exercise Versus a non-intervention

High quality studies by Wang et al. (2011) and Lund et al. (2008) compared the effects of aquatic exercise involving strength training to non-intervention groups. Outcomes were reported using the KOOS, Wang et al. (2011) found statistical significant improvement on subscales; pain, symptoms, recreation, QoL (p<0.001). Other subscales showed less improvement and the control group remained unchanged.  On the contrary, Lund et al. (2008) found no clinical benefits compared with the control group as shown in table 4c, however, the study reported significantly less adverse effects in the aquatic group.

3.5 Summary of evidence

Established on levels of evidence by Tulder et al. (2003) and the incorporated study quality to help interpret results (CRD 2009), findings of 8 high and 2 moderate quality studies provided strong evidence that exercise and physical activities are effective in improving QoL in knee OA. There is inconsistent evidence provided by two high quality studies on the efficacy of aquatic exercise. Overall, evidence from the majority of the studies demonstrated that the interventions could improve QoL with short term effects. Provided below is the table for the level of evidence.

Table 4: Level of evidence (Van Tulder et al., 2003).

Table 4: Level of evidence (Van Tulder et al., 2003).

4.0 Discussion

This systematic review summarised evidence from ten high and two moderate quality studies investigating the effectiveness of exercise and physical activity on QoL in knee OA. A number of potential studies were excluded mainly because they were a multimodal management. The review has provided strong evidence from eight high and two moderate quality studies that the interventions could be effective at improving QoL in knee OA. This evidence has established that regular, moderate levels of exercise do not aggravate symptoms in the majority of patients (Messier, 2010; McCarthy and Oldham, 1999). Further, a qualitative study by Wilcox et al. (2006) conducted on perceived exercise benefits, showed improvement, not only on pain and mobility, but also meaningful psychological benefits and enhanced QoL. This could be seen consistent with other studies that found the effects of exercise and physical activity improve self-efficacy and depression, which consequently resulted in improved QoL (Hartman et al., 2000; Penninx et al., (2002); Penninx et al., 2001; Singh et al., 2005; Beckwee et al., 2013)

The effects of strength training on the symptoms of knee OA are supported by wider literature, both of primary and systematic review studies. This is consistent with evidence from other studies that established the benefits of progressive strength training on symptoms in knee OA such as muscle atrophy and weakness which contribute to functional limitations and thereby restrict QoL (Jenkinson et al., 2009; Topp et al., 2002; Jan et al., 2008; Mikesky et al., 2005). Regular supervision as shown in Barker et al. (2001) and Evick and Sonel (2002) seemed to have positively influenced treatment outcome.

Activity is superior to all other treatments in the short term. This review observed that when exercise was compared with a non-intervention group, exercise results were significantly better. Whether this is most effectively performed on land or water remains unclear as included studies provided contradictory evidence. However when activity compared with other treatment groups (e.g. acupuncture), significant differences were small indicating some potential Hawthorne or placebo effects. However it could not be established if the interventions had long-term effects because of the limited number of studies that assessed long-term outcomes.

Overall, studies that included a supervised progressive multicomponent strengthening exercise, supplemented with a home exercise and walking programme found significant improvement in QoL (Jorge et al., 2015; Wang et al., 2011; Aglamis et al., 2008; Thorstensson et al., 2005; Dias CR et al., 2003. Baker et al., 2001; Fransen et al., 2001). This could suggest that physical activities not only provide relief of pain, but also those of psychological and general well-being as well as QoL (Aglamis et al., 2008; Dias CR et al 2003). Which activities are most effective remains uncertain however as Smith et al. (2014b) compared the effects of walking with cycling on QoL in OA knee and found that both groups improved with no statistically significant difference. This may indicate that exercise, although effective, may not be superior to other active interventions in terms of the impact on general wellbeing.

4.1 Strengths and limitations of this review

The review included primary studies of high quality and thoroughly reviewed the evidence provided. Publication bias could not be avoided as studies in other languages were removed and studies from less well-known databases may have been missed.

4.2 Strengths and limitations of included studies

The studies used standardised outcome measures to assess QoL but because they are not specific for measuring QoL in knee OA, they may not adequately assess the area. Based on the PEDro scale, quality studies from moderate to high were included on which evidence was drawn, however, common limitation in the studies was the lack of blinding of participants, therapists and assessors. Some studies had small sample size while some had drop-outs, but did not use intention to treat analysis, which could have impacted on the treatment effects (Joseph et al., 2014) and as a result, may not reflect a true clinical situation.

4.3 Implications: Clinical practice and Education

Clinically this suggests that exercise programmes designed to enhance QoL in knee OA patients ought to target specific impairments such as weakness, as presented in patients (Focht, 2012). This review observed a correlation between pain and QoL. A reduction in pain consequently resulted in improved QoL, thus, knowledge of the interplay of knee OA symptoms on QoL might help in understanding and management of patients. However biopsychosocial factors play a role and related co-morbidities may further complicate the situation (Chan and Wu 2012).

Treatment exercise plans, reinforced with a home exercise/walking programmes could help sustain the effects gained and consequently improve QoL. There is substantial evidence that physical activity has beneficial effects on QoL in knee OA, therefore, could be recommended for patients either as a facility or a home-based programme depending on the patient’s symptoms and preferences. In addition, included studies reported no serious adverse events indicating that moderate regular exercise and physical activity could be safe.

Future research may invest in developing a standardised outcome measure for QoL in knee OA and also developing a knee OA questionnaire assessing facilitators and barriers to exercise as increased understanding of the factors influencing exercise performance in people with OA could help physiotherapists and other health professionals support patients in initiating and maintaining an exercise routine and subsequently improve QoL post initial treatment.


Based on the available evidence, exercise and physical activity appear to be effective in improving knee OA symptoms and QoL. Land based exercise, well supervised home based exercises plus complemented with a walking programme provide significant improvement. Strength training exercises such as eccentric-concentric training provided better results. while exercises alone have short term effects, however, it could be established that these effects could be sustained when exercise and physical activity are incorporated into one’s lifestyle.


Dr Steven May and Mr Mahmoud Saad: Sheffield Hallam University – for guidance and support.

SM as the second article reviewer, many thanks.

Mambwe Mupeta MSc BSc (Hons) and Dr. Hazel Horobin Ed D

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Editorial – Issue 1

This 2nd edition of the BJRHS contains research from two methodological perspectives: narrative inquiry and comprehensive, sometimes called systematic, review methodology; and one essay on the cultural construction of body image.

Kristina Usaite and Dr Josh Cameron describe how narrative data analysis is used in a study about promoting young people’s resilience through enjoyable structured activities. This allows them to discuss the importance of the resilience concept from an occupational perspective, and the relationship of resilience with flow theory. Their study is interesting both in terms of the growing significance of the resilience paradigm in contemporary discourses of empowerment in tacking individual, structural and social inequalities,.

My experience over the years of co-teaching the dissertation module for final year nursing students has helped me realise that many of them embark on their literature reviews with fear and trepidation. This results in low self-efficacy beliefs such as ‘everyone else can write and do well in their dissertation, but I can’t’, and also the view that comprehensive literature reviewing does not constitute proper research. It is therefore perhaps timely that this edition of the BJRHS contains four successful undergraduate SHS literature review dissertations submitted by students from very recent cohorts, and a literature review from a nursing lecturer. All showcase different styles and topics and constitute review exemplars – not to be copied but to guide readers of the journal who may be approaching and working on their own dissertations.

The topic of Amy Barlow’s review is the under-discussed role of exercise in helping people who are experiencing extreme psychological distress, and the emergent implications for a mental health nursing profession that arguably needs to reimagine itself in more creative, embodied ways.

Neil Molkenthin, like Amy a recent mental health nursing graduate, examines interpersonal relationships, arguing that the power held by mental health nurses impacts on their therapeutic relationships with service users. This is a constant problem for mental health nurses who are torn between humanistic educational principles and structural and institutional workplace factors that militate against the realisation of these principles.

Edward Liscott, a recent graduate of the paramedic undergraduate degree, explores the causes of inappropriate and avoidable uses of accident and emergency care. His review discusses clearly important and currently highly topical implications for the efficient and cost-effective use of our ambulance services.

Vinny Curtis, who graduated recently from the adult branch nursing degree, argues in his review that maggot therapy is an effective tool in the debridement of necrotic foot wounds. Despite this, due to the lack of rigorous random controlled trials available, there remains a lack of published evidence that supports its use. He concludes that maggot debridement therapy will one day be accepted alongside the current set of conventional debridement therapies rather than just being used as a treatment of last resort.

As part of his professional doctorate in education, the focus of Darren Brand’s literature review is around practice placements undertaken by student nurses in their BSc (Hons) in Nursing degrees. The author has an interest in the way in which students learn in the clinical setting. This is significant, not least because of the under-discussed tensions between the explicit undergraduate curriculum, the so-called ‘null curriculum’ (knowledge that doesn’t appear on this curriculum but arguably should) and the ‘way things are done around here’ service curriculum that nursing students are gradually and inevitably socialised to.

Systematic review methodology is also represented in the paper by Yvette Wagner and Dr Josh Cameron, within which the provision of social support from co-workers during the return-to-work process is explored. The authors argue that work is understood to generally benefit health and well-being, while absence from work bestows costs to the health of the individual and to the economy. Return-To-Work plans are implemented in many workplaces to allow individuals to recommence their duties.

Finally, Simon Whiffin’s essay on the relationship between shifting cultural discourses around the meaning of body image and what constitutes ‘ideal’ types across history and cultures, and the ways in which these shape national ideology, is of great relevance for scholarship and pedagogy in the health sciences. From a critical perspective, all normative healthcare practices are shaped by broader cultural discourses, as can be seen currently in, for example, the emergence of obesity as pathology, and so it is important that healthcare professionals are reflexively attuned to this.

On behalf of the editorial team – Dr Theo Fotis, Dr Chris Morriss-Roberts, David Bauckham and Simon Whiffin – we hope you enjoy and are helped by this current edition of the BJRHS.

Dr Alec Grant

Reader in Narrative Mental Health

Lead Editor, Brighton Journal of Research in Health Sciences

School of Health Sciences


How does exercise affect people who experience extreme states of mind and what impact might this have on mental health nursing practice?


People whose experiences are classified by the medical model as schizophrenia, bipolar affective disorder or psychosis, die 16-25 years sooner on average than people with no mental health diagnosis (Department of Health (DH) 2011b). It is three times more probable they will suffer premature death (DH 2011c), with increased risk of several physical illnesses, such as heart disease, diabetes, respiratory disease and infections, and obesity (DH 2006; DH 2011b,c; Rethink 2013 a, b, c; DH 2014a; NICE 2014b).
The prescribing of anti-psychotic medication may lead to weight gain, sometimes up to 5-6 kg in the first 2 months (Foley and Morley 2011; Rethink 2013a). This may be due to several factors, including a more sedentary lifestyle and a related lack of exercise. The World Health Organisation (WHO 2015) and The Department of Health (2014b) in their policy ‘everybody active every day’ stipulate that adults should be aiming to be active on a daily basis. However 27 million adults in England are not active enough to benefit their health (DH 2012), and the Secretary of State is calling for the NHS to make the promotion of active lifestyles central to all healthcare professionals work (DH 2012).

This literature review topic was chosen because in practice as a student nurse I have thought there is inadequate emphasis placed on exercise and believe that service users would benefit from its inclusion in mental health services.

The phrase ‘extreme states of mind’ (May 2014), is used to describe people in receipt of biomedical diagnoses, such as schizophrenia, bipolar affective disorder, schizoaffective disorder and psychosis. The choice of a non-medical phrase may help in the shift from a medical to a more holistic view of the experiences of people, within which mental health difficulties are described in more compassionate, less stigmatizing ways (Carless and Douglas 2008a; Moncrieff 2009; Johnstone 2014).


In order to first identify the research question, substantial reading was necessary in the field of interest, namely exercise and mental health. A Boolean search was utilised in order to search most efficiently across a range of databases. From this, a few key interests emerged. These were women’s mental health in relation to exercise, the role of the service user voice in exercise, and exercise and serious mental health issues. As there exist a significant number of papers around depression, anxiety and exercise but little on serious mental health issues, my search was made more specific by setting the inclusion and exclusion criteria to only include papers concerning serious mental health issues.
A total of 15 papers emerged as significant. These were predominantly qualitative, with four quantitative and one descriptive study. A simplified thematic analysis was performed on the papers selected (Noblit and Hare 1988; Paterson et al 2001; Rice 2008; Aveyard 2014). Three themes emerged from the papers reviewed, which go some way towards answering the research question: the social, the psychological and the physiological effects of exercise.

Social Effects

The literature signified the importance of the social effects of exercise for people who experience extreme states of mind. The peer support and friendships gained from participation in exercise (Carless and Douglas 2008a, 2008b, 2012; Hodgson et al 2011; Klam et al 2006) appear as a substantial specificeffect, as does the routine and structure it brings to people’s lives (Klam et al 2006; Crone and Guy 2008; Carless and Douglas 2008b; Hodgson et al 2011; Ronngren et al 2014; Cullen and McCann 2015). Participants also identified that exercise positively affects their social roles and highlight the value of shared experience (Crone and Guy 2008; Carless and Douglas 2012; Hodgson et al 2011; Cullen and McCann 2015).

Peer Support and Friendship

Narrative inquiry seeks to find the meaning that people make of their experiences and what it means to be human. It is a creative process that can often bring about change for the participants through the process of re telling the story, narrative re-storying (Carless and Douglas 2008a). The theme of potential benefits through the development of peer support and friendship when exercising was present in several studies. The narrative inquiry work of Carless and Douglas (2008a, 2008b and 2012) hasstrong peer support and friendship themes, and a clear service user voice is heard throughout. These three studies aimed to look at how men experiencing extreme states of mind utilise narrative re-storying through exercise and sport (2008a), how they might receive social support through exercise (2008b) and the narratives of people using physical activity programmes within mental health services (2012). For some people who experience extreme states of mind, the social role that exercise provides is helpful. One participant from Carless and Douglas’s 2012 study typically described his life before engaging in sport as lacking in friends and this meant also he experienced feelings of isolation. This study has a strong service user voice, which makes the pertinence of the statements more compelling. The work of Hodgson et al (2011), supported by Crone and Guy (2008) and Cullen and McCann (2015) also illustrate the role of exercise in alleviating some of the isolation felt by service users through meeting new people in the community.

Psychological Effects

From a psychological perspective, the literature generally revealed how exercise may assist people who experience extreme states of mind to be more motivated, be more proud, confident, have greater self esteem, have fun and alleviate symptoms.


For some, participating in exercise or physical activity led to an increase in motivation to continue exercising (Fogarty and Happell 2005) and in others, exercise increased their desire to make healthy lifestyle changes, such as reducing the intake of fast foods (Klam et al 2006). Motivation can be difficult for people experiencing extreme states of mind, and whether this is because of the impact of medication on motivation or the lack of structure in their lives is unclear (Crone and Guy 2008). In a Norwegian study, Tetlie et al (2009) discussed a mandatory exercise programme in a forensic setting. Mental health professionals participated alongside patients and found this unique approach helped decrease power imbalances on the ward, promoting ‘likeness’. The effects that exercise has on increasing motivation for this population are diverse, although some people are enabled to exercise more (Fogarty and Happell 2005; Warren et al 2011). Nurses exercising with clients may also challenge stigma (Tetlie et al 2009), and this will be explored in more depth in the discussion chapter.


For some, exercise can also be fun and pleasurable, (Klam et al 2006; Crone and Guy 2008; Tetlie et al 2009; Cullen and McCann 2015). Humour in mental health is creatively prioritized by Klam et al (2006), with the incorporation of humour workshops into their ‘personal empowerment program’. In the weeks following this intervention clients were heard sharing jokes and they described how this helped them take life a little less seriously. The fun element was something that was shared between staff and patients in the study by Tetlie et al (2009), further breaking down the barriers between them.


Having fun and experiencing pleasure in life through exercise could also be a way of distracting oneself from the negative experiences of extreme states of mind. It may, according to Cullen and McCann (2015), be a useful tool for voice hearers, as the time spent concentrating on exercise is time spent not concentrating on voices. One participant defined this as ‘it takes you out of living in your mind’ (Cullen and McCann 2015, 61).
Exercise may also counteract boredom, which is often an aspect of inpatient mental health services, and in the community is exacerbated through social isolation (Crone and Guy 2008; Hodgson et al 2011).

Confidence, Pride, Self Esteem, and Sense of Purpose

The effect of exercise on confidence, pride, self esteem and sense of purpose is reported in numerous studies (Crone and Guy 2008; Hodgson et al 2011; Cullen and McCann 2015). Confidence is crucial for participating in social activities (van Deurzen 2012), and self esteem is often interconnected with this (Crone and Guy 2008). In related terms, people who experience extreme states of mind have often lost their confidence (Carless and Douglas 2008a) and sense of purpose (Hodgson et al 2011), and exercise might be something that can help restore this.By extrapolation, the psychological effects of exercise might therefore influence how well an individual participates in society (Tetlie et al 2009) and vice versa (van Deurzen 2012). Peer support, routine and social role positively impact on people’s motivation to exercise, increasing their confidence, pride, self esteem and their ability to have fun.

Physical Affects

The majority of literature included in the review discusses the importance of maintaining good physical health for this population, especially given the negative impact medication and lifestyle can have on diabetes, weight, and the heart (DH 2006, 2011b).


Weight has been identified as a major issue in mental health difficulties (DH 2006; DH 2011c; Mental Health Foundation 2009; NICE 2011; Rethink 2013a, b; NHS 2014b; NICE 2015a). Disappointingly there was only one paper that measured weight loss as a result of exercise (Klam et al 2006). The study by Warren et al (2011) attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies. Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise (Schwee et al 2013).
Several qualitative studies found that people exercised in order to manage and control their weight. Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind – namely second generation antipsychotics (Hodgson et al 2011). Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al (2011) reported empirical information on this.

Blood Pressure, Fasting Sugar Levels and Smoking

Klam et al (2006) described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by 1445.33 over a 10 week period, which is an indicator of increased fitness (Warren et al 2011). Cullen and McCann (2015) highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving. It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al (2014). This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise. However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording (Warren et al 2011; Usher et al 2012; Scheewe et al 2013).



The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff. An important aspect of personal recovery highlighted, is personalised, individualised care. The significance of peer support was a key finding, as was staff exercising with service users.

The literature reflects the importance of exercise staff being highly skilled, especially in mental health. Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it.

It is acknowledged that there are lower participation rates in exercise for women, and also recognised that the stories that women may tell about exercise may be markedly different from men’s accounts. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women. Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available.

The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual. The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise.

The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa. Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness. The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life.

This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important. Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms. Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope.

The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans. The DH (2012) ‘lets get moving’ pathway has brief interventions already designed, but these need tailoring to this population, which would require more research for it to be evidence based. Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals.

The DH (2012) state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment. Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy (2008) highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities. For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves.

If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences. Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks. For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs. This is especially pertinent for this population, every person’s experiences are unique and require tailored support both generally and specifically in exercise interventions.

The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally. Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind (Mental Health Foundation 2012). It appears to play a key role as one of the positive effects of exercise. NICE (2014) suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink (2013c) also recommend the use of peers to aid personal recovery.

In practice as a student nurse, I have only met two peer support workers. As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al (2014) state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place. For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed.

The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship. Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole (Happell et al 2012). If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs. However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind.

The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research (Rose et al 2011). Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses. Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects (Bental 2004; Moncreiff 2009).


This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice. There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice. However, the evidence available points to the positive social, psychological and physical effects of exercise.

The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society. The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice. Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts.

Amy Barlow, former Mental Health Nursing BSc(Hons) student


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What causes inappropriate or avoidable use of urgent and emergency care services, and how far can the ambulance service reduce this through admission avoidance?


There are currently unprecedented levels of demand on urgent and emergency care throughout the UK (University of Sheffield Medical Care Research Unit 2010; Agarwal et al, 2011; NHS England 2013), with ED attendances and ambulance call outs increasing consistently every year (Nelson 2011; Newton et al, 2013). Accident and Emergency (A&E) departments are regularly missing the four-hour waiting target (NHS England 2013; BBC 2015) and there is national concern over the National Health Service’s (NHS) ability to cope with the increasing pressure (Press Association 2013; Cooper 2015).

With potentially 15% of the UK population utilising urgent and emergency care services at any one time, many accessing multiple services (Knowles, O’Cathain & Nicholl 2010), it is important to ensure appropriate use of frameworks in order to avoid any one service becoming over-burdened.Congested A&E departments have a direct and significant impact on ambulance service performance (National Audit Office 2011; NHS England 2013; Mundasad 2014), and whilst the link between ambulance and ED services should be fundamentally evident (National Audit Office 2011; Patton & Thakore 2012), often the two services are treated as isolated and even opposing entities. One example of this is the proposal of ‘forced handovers’ by ambulance crew in certain trusts (Johnston 2015; Local Ambulance Trust 2015).

The Bradley Report (Department of Health 2005) marked a fundamental recognition that ambulance services could not only reduce the amount of people admitted to A&E, but that this reduction could have a significant impact on emergency care and wider NHS services. The aim of this literature review was to establish how ambulance services can help reduce current demand on wider urgent care services and A&E departments in particular, through a greater awareness of inappropriate patient use, what causes it and how alternative care pathways can be utilised in order to reduce it. In doing so, this paper also aims to demonstrate the fundamental connection between ED and ambulance services, and how their performance is mutually dependant on one another.

Two semi-structured literature searches were conducted of CINAHL, PubMed, AMED, Cochrane Library databases and the Journal of Paramedic Practice; one exploring inappropriate use of services and one exploring prehospital admission avoidance. Twenty-seven articles were included for review and four broad themes were identified; Definition of Terms, Patient Factors, Access to Healthcare and Healthcare Frameworks.

A high number of diverse and complex contributors to inappropriate emergency department (ED) attendance and ambulance use were identified. Whilst some patient factors contributed towards this issue, problems with wider healthcare frameworks and organisational behaviours were significantly more abundant in reviewed literature. Fragmentation of services may be creating barriers to alternative care services to both patients and clinicians attempting to make referrals. Strategies to improve appropriate use of healthcare should focus on enhancing the way in which services work together.


A systematic search was performed using an adapted methodology from Moher et al (2009). CINAHL, PubMed and Cochrane Library databases were searched for key phrases in the title or abstract. A secondary search was conducted of the same databases using phrases including ‘Ambulance’, ‘Admission Avoidance’ and ‘Pathway’.
Additional keywords derived from iterative searches were added to search terms until appropriate saturation of results had been achieved. Boolean operators ‘AND’ and ‘OR’ were utilised to broaden and narrow results accordingly (Machi & McEvoy 2009).

Articles were critically analysed using a tabular matrix adapted from LoBiondo-Wood and Haber (2013). Key issues from each article where then extracted to create a thematic index (Thomas, Harden & Newman 2012).

Research conducted outside of the UK was excluded due to the internationally unique framework of the National Health Service. The exception to this was material considered in systematic reviews, where articles were included as long as they were written in the UK. Articles which focused solely on self-presentation at the ED, or which did not make any explicit differentiation between routes of attendance were also excluded. Articles published before 2010 was excluded due to changes in GP out-of-hours (OOH) services.

Material focusing upon paediatrics or specific medical complaints was excluded, with the exception of falls, and frequent users. All levels of evidence were included (National Institute for Health and Care Excellence 2006), with the exception of narrative expert opinion due to the limited quality of this evidence (GRADE Working Group 2004).

Definition of Terms

Of all reviewed material, only ten articles (Endacott et al, 2010; Agarwal et al, 2011; Jones 2011; May 2011; Patton and Thakore 2012; Booker, Simmonds and Purdy 2013; Newton et al, 2013; O’Cathain et al, 2013; O’Hara et al, 2014; Atenstaedt et al, 2014) explained how they classified inappropriate use, and of these, only a very few demonstrated significant effort to objectify definitions. Articles that did rigorously establish objectivity showed variation in their presented views. The University of Sheffield Medical Care Research Unit (2010) highlights significant inconsistency in defining appropriateness throughout healthcare research. Furthermore, Jones (2011) and Booker, Simmonds and Purdy (2013) argue that appropriateness is almost exclusively defined retrospectively by healthcare staff. This demonstrates the complexity of this particular area, and may explain conflicting views of appropriateness between ED and prehospital clinicians (Newton et al, 2011; Patton & Thakore 2012). However, whilst there exists significant challenges in objectively defining inappropriate use, clarification on what this looks like is crucial in aiding clinicians to identify and reduce it in real terms. Further research in this area would be beneficial in providing clearer guidelines for prehospital clinicians when dealing with potentially inappropriate use.

Patient Factors

A significant proportion of extracted themes related to subjective factors influencing individual patient behaviour. These could be categorised into four main sub-themes; Perception of Illness, Interpersonal Factors, Patient Demographics and Socioeconomic Factors.

Perception of Illness

Booker, Simmonds & Purdy (2013) found symptom and decision-making anxiety to be the superordinate theme of their research, often resulting in risk-averse decisions to summon the most immediate form of assistance. Whilst recognised methods were used to conduct thematic analysis, questionnaire content was derived from a previous pilot, rather than established evidence, resulting in potential content bias (Pannucci, & Wilkins 2010). However, this research was externally peer-reviewed, and several further articles provide consensus on this finding (Agarwal et al, 2011; University of Sheffield Medical Care Research Unit 2010; Edwards et al, 2014).

Conversely however, a literature review by Sheffield University (University of Sheffield Medical Care Research Unit 2010) highlights that misconceptions of symptoms can potentially cause inappropriate delay or refrain from contacting emergency services. Whilst the aforementioned makes no analysis of the ratio between inappropriate contact and non-contact, Kirkby and Roberts (2011) suggest that the majority of inappropriate classification occurs when no ambulance is required.

Patient education was highlighted as pivotal in several articles (Atenstaedt et al, 2014; Patton & Thakore 2012; Jones 2011; Kirkby & Roberts 2011). Atenstaedt et al (2014) demonstrates the effectiveness of targeted campaigns in improving patient knowledge and reducing inappropriate attendance, however provides no cost-analysis of these strategies. Perhaps a cost-effective opportunity exists for the ambulance service to deliver this type of patient education to inappropriate users. The ambulance service has previously demonstrated high levels of success in bringing health campaigns to public awareness (Association of Ambulance Chief Executives 2011). This is demonstrated by the recent stroke awareness campaign by the South East Coast Ambulance Service (South East Coast Ambulance Service 2015).

Interpersonal Factors

Similarly three articles considered interpersonal factors such as relatives and carers in the decision-making process. Booker, Simmonds & Purdy (2013) found interpersonal factors often reduced tolerance for medical risk. They found that informal carers often experienced feelings of responsibility and helplessness, prompting them to take the least risky course of action. In addition, risk-minimising behaviour was noted in patients themselves, who often felt pressured by what friends and family might think, regardless of their actual presence. Whilst a single site limits this research’s external validity (Steckler & McLeroy 2007), verbatim transcripts noted this as a reoccurring theme in interviews. The Association of Ambulance Chief Executives (2011) outlines similar risk-averse behaviour from staff in care homes, however primarily driven by misconceptions of organisational responsibility.

The Keogh Review (NHS England 2013) suggests that self-care is a crucial influencer of service demand. In many cases this is dependant on patient and carer confidence managing minor ailments and long-term conditions.

Interpersonal factors can significantly influence subsequent use of ambulance services, and therefore should be considered by the prehospital clinician when attending an incident. It is also important for clinicians to recognise how interpersonal factors and support networks can influence a patient’s ability to self-manage, as this is pivotal information when making referral or non-conveyance decisions. In addition, clinicians should be aware interpersonal pressures when assessing patient wishes and when making best interest decisions.

Patient Demographics

The Keogh Review (NHS England 2013) identifies that the patient demographics most likely to benefit from alternative healthcare support are those least likely to be aware of it, prompting increased inappropriate dependence on urgent services. Several articles studied the effect of patient demographics on healthcare usage. Whilst Kirby and Roberts (2011) found no statistically significant factors in their research, Dent, Hunt and Webster (2010) found that frequent ED attenders were more likely to be male, with a mean age of 49. In a systematic review, Scott et al (2013) finds several concurring articles identifying frequent users as predominantly male. Despite some potential bias introduced from a single initial reviewer, established methodology and quality analysis is employed.
Edwards et al (2014) and Smith and McNally (2014) both agree that elderly demographics can make up a significant portion of inappropriate and frequent users. However, Scott et al (2013) found highly mixed evidence in regards to patient age, and only one limited study suggesting that frequent use increased with age.

Reviewed literature demonstrates mixed evidence in relation to patient demographics, and caution should be taken by the prehospital clinician in stereotyping frequent or inappropriate users of healthcare (Donohoe & Blaber 2008). The majority of evidence suggests that inappropriate users are heterogeneous, presenting for a variety of health and social reasons (Edwards et al, 2014; Scott et al, 2013).

Socioeconomic Factors

In a quantitative ecological study, O’Cathain et al (2013) found that areas of social deprivation, and urban areas had significantly higher numbers of avoidable emergency admissions. Whilst many confounding variables were not considered in this research, including distance to hospital, these factors were statistically calculated as significant, with a combined predictor of 75% in admission avoidance variation. In addition, many articles support this finding (Agarwal et al, 2011; Association of Ambulance Chief Executives 2011; Scott et al, 2013; Edwards et al, 2014; Smith & McNally 2014).

Conversely to O’Cathain, O’Hara et al (2015) suggested through qualitative research that rural areas had limited access to alternative pathways, and were more likely to see increased inappropriate ambulance transport. However, this research was limited by a small sample size at risk of self-selected participant bias (Lavrakas 2008). This furthermore contradicts evidence from the National Audit Office (2011) highlighting increased ‘see and treat’ rates in rural areas.

Whilst there exists conflicting views regarding geographical influence on appropriate healthcare use, there is an overwhelming consensus of evidence suggesting social deprivation contributes towards inappropriate and frequent use of urgent services. Healthcare campaigns have demonstrated success when socioeconomically targeted (Atenstaedt et al, 2014), and strategies by ambulance services to manage inappropriate use appear well advised to be initially targeted at economically deprived areas.

Access to Community Care Services

Several articles discuss patient access to community services as an influencing factor of avoidable ED attendance and inappropriate ambulance use. The Keogh Review (NHS England 2013) highlights significant variation in GP service satisfaction levels nationally, with systemic fragmentation of community services causing further access issues. This is supported by Agarwal et al (2011), which found GP access issues to be a consistently reoccurring theme in patients attending the ED inappropriately. In similar semi-structured interviews, Booker, Simmonds and Purdy (2013) also found that previous experience accessing community services and perceived limitation of GP capabilities heavily influenced patients’ decision to access ambulance services with primary care issues. This might explain why in highly rigorous, mixed-method action research, Endacott et al (2010) found that inappropriate ED attendances increased dramatically during OOH periods. If barriers to community care increase rates of inappropriate ambulance and ED usage, this has significant implications for ambulance services in analysing patterns of demand and managing response levels geographically and at different time periods (NHS Office of Strategic Health Authorities 2008). Evidence also suggests ‘post code’ variation in access to GP services (Raleigh & Frosini 2012; NHS England 2013), and further research into this area is warranted.

O’Cathain et al (2013) found that patients’ perception of good access to GP services was initially linked to lower ED attendance rates at primary stages of analysis, however when considering further variables such as overall ED and ambulance demand, actually contributed to higher attendance rates through GP referral. Indeed, Turner et al (2013) outlines the potential for supplier-induced demand, particularly in the area of alternative community services such as NHS 111. The Keogh Review (NHS England 2013) supports this notion, and furthermore highlights that GP consultations have also been increasing, despite expansion of alternative services. Therefore the issue may be more related to general demand rather than patient access. This is supported by Edwards et al (2014), which found that frequent use of emergency services was linked to equivalent frequent use of other community services.

However, as Patton and Thakore (2012) found GP referrals via the ED were associated with lower levels of inappropriateness, it is still reasonable to suggest that better access to GP services could improve avoidable ED admission rates. This is supported by Jones (2011), which, despite limitations in external validity (Steckler & McLeroy 2007), saw on-site GPs contribute to a reduction in avoidable admissions and improved waiting times at one district hospital ED. Paramedic Practitioners are now working more closely in supporting community GP services (Association of Ambulance Chief Executives 2011), and therefore perhaps this should be an important focus by ambulance trusts in managing overall demand.

Convenience of Emergency Services

Inversely, ease of access to ambulance and emergency department services was also a reoccurring contributor to inappropriate use of these channels. Patton and Thakore (2012) surmise that the convenience of an ED providing 24-hour investigations without appointment must significantly influence patient behaviour, however this was not explicitly analysed in their research. Smith and McNally (2014) propose a similar rationale for frequent users of urgent and emergency care services, and furthermore speculate a similarity in the behaviour of ED and ambulance users; a view supported by Edwards et al (2014). The notion of access simplicity is also supported by Knowles, O’Cathain and Nicholl (2010), who found that multiple referral pathways were linked with lower levels of satisfaction in the majority of patients. Through random quota telephone surveys, this paper also found high levels of satisfaction with Ambulance and ED services in particular, despite low levels of satisfaction with GP OOH and NHS Direct services. Indeed, the Keogh Review confirms that patient experience of ‘999’ emergency services is consistently positive; “overwhelmingly” so for patients with non-urgent conditions (NHS England 2013, 26).

Agarwal et al (2011) found confusion over alternative pathways to be a main contributor to patients accessing urgent services inappropriately. Participants in this research cited familiarity of services, and perception of efficiency over GP services as important influencers on the decision to attend the ED. Similarly, Booker, Simmonds & Purdy (2013) found users quoted previous positive experience and convenience of access to be primary contributors in their decision to access urgent care.

All articles appeared to demonstrate generally high levels of satisfaction amongst patients utilising ambulance and ED services, putting these services in the predicament of generating increased demand through positive performance. This represents a significant dilemma for the NHS, as these channels are by far the most expensive routes for patients to access health services (NHS England 2013). In addition, recent declining patient satisfaction levels for ED services demonstrate the consequences of demand surpassing a service’s capacity (NHS England 2013).

However, if adequately resourced, this could be viewed as an opportunity for the NHS to give more robust signposting and referral powers to a service with which patients are already confident using (National Audit Office 2011; Booker, Simmonds & Purdy 2013; Smith & McNally 2014). Patton and Thakore (2012) find that ambulance admission avoidance could reduce demand on ED services by 11%; a view supported by established literature (Department of Health 2005; The Association of Ambulance Chief Executives 2011). In addition to improving the overall profile of the ambulance service within the NHS, the National Audit Office (2011) estimates that this would be a significantly more cost-effective response model if configured appropriately.

Healthcare Frameworks

The Francis enquiry (2013) demonstrates how an organisational culture, and clinical behaviours within that culture, can have a significant impact on the quality of healthcare delivered to patients. A large majority of articles considered organisational and clinician factors in relation to inappropriate and frequent use of emergency care. Extracted themes could be broadly categorised into four subheadings; Triage and Clinical Decision-Making, Multidisciplinary Collaboration, Specialised Roles and Service Management.

Triage and Clinical Decision-Making

Sensitive triage and risk-averse behaviour are an integral part of NHS culture (NHS England 2015), and whilst risk management is an important consideration for any healthcare system (Turner et al, 2013; O’Hara et al, 2014), it can also contribute towards inappropriate use of emergency channels.
Patton and Thakore (2012) demonstrate the potential impact of oversensitive triage from ambulance staff. They found that a third of ED attendances were transported via ambulance, and of these admissions, 30% were deemed inappropriate. Whilst a potential bias exists with the duty consultant subjectively assessing appropriateness, reviewers did rotate throughout the study, and rigorous assessment was made using both the ED notes and Patient Report Form (PRF). Further articles support the suggestion of inappropriate ED referral through risk-averse or unsuitable ambulance triage (Newton et al, 2013; University of Sheffield Medical Care Research Unit 2010; O’Hara et al, 2014). However, Newton et al (2013) and O’Hara et al (2014) highlight the complexity of prehospital decision-making, particularly with low-acuity incidents.

A recent qualitative exploration of current treat and refer guidelines (Colver, Abhyankar & Niven 2015) highlights variation in prehospital use, and suggests further education and support for clinicians. In addition, Newton et al (2013) demonstrates the moderate success of prehospital pathway finders adapted from the Manchester Triage System. However, whilst providing clinicians with support tools may improve confidence, it may be argued that such tools do not address the issue of clinician education, and furthermore may be inappropriate for clinically and socially complex situations.

Oversensitive triage was also outlined as a primary contributor to increased ambulance workload by telephone services such as NHS ‘111’ (Turner et al, 2013). The issue of over-triage through telecommunications is furthermore supported in several articles (University of Sheffield Medical Care Research Unit 2010; Knowles, O’Cathain & Nicholl 2010; NHS England 2013). In this respect, the potential of a ‘snowballing’ effect of systemic over-triage through multiple services can be observed (Department of Health and Ageing 2007).

A proposed solution to this may be the implementation of secondary triage systems (Eastwood et al, 2014) in order to decrease sensitivity whilst maintaining risk management. However there exists little evidence on the most appropriate structure or benefits of this within a prehospital framework, and further research is warranted.

Multidisciplinary Collaboration

As previously discussed there are some perceived and tangible patient access issues to community care services (Booker, Simmonds & Purdy 2013), and this is also reflected in prehospital referral pathways (O’Hara et al, 2014).

The National Audit Office (2011) highlights the importance of multi-service collaboration in reducing overall demand, and the knock on effect when one service becomes congested. This is supported by further articles (Booker, Simmonds & Purdy 2013; NHS England 2013), which suggest that fragmentation of services is a heavy contributor to inappropriate use. Indeed Edwards et al (2014) and Smith and McNally (2014) both concur that collaborative multi-level interventions are most effective in tackling frequent and inappropriate use, whilst Booker, Simmonds and Purdy (2013) call for closer collaboration between primary care and ambulance services.

In a mixed-method qualitative study, O’Hara et al (2014) identifies the lack of available care alternatives as a key contributor to inappropriate ED attendance via ambulance. Whilst this was a relatively small study, this theme reoccurred consistently throughout three individual trusts, suggesting a high level of reliability (May 2011). However, the National Audit Office (2011) highlights a paucity of ambulance trusts adequately collating directories of alternative services, suggesting that the underlying issue may be prehospital awareness, rather than availability.

Specialised Roles

In a literature review by Coates (2013), Emergency Care Practitioners (ECP) were found to significantly reduce the number of patients conveyed to hospital, with estimates of approximately £20k in annual ED cost reduction per ECP. This is furthermore supported by Mason et al (2010), which found that ECPs increased admission avoidance rates, and were most effective in a mobile setting.
However Coates (2013) rightly questions the difference between avoided admission and avoided ED attendance, highlighting a paucity of studies differentiating between the two. Since a significant cost difference is applicable, further research in this area should be considered.

Reviewed material demonstrates that specialised roles have a significant benefit on admission avoidance, concurring with established literature (National Audit Office 2011; Association of Ambulance Chief Executives 2011). However, there is still variability in the deployment of these roles (NHS England 2013), and whilst there remains such a heavy prehospital focus on targeted response times over clinical outcomes (National Audit Office 2011), it may be argued that specialised prehospital roles cannot be utilised to their fullest potential.

Service Management

O’Hara et al (2014) highlighted several organisational factors which influenced clinical decisions to transport patients to the ED when alternative care may have been more appropriate. These included availability of diagnostic equipment, availability of remote support and appropriate initial staff deployment. Clinicians also felt that lack of vehicles and resources increased the pressure to reduce on-scene times, prompting them to avoid time-consuming referral pathways. Endacott et al (2010) also identifies inconsistencies in ED management of inappropriate attenders. Despite having debatable direct impact on ambulance services, this demonstrates the difficulty of managing inappropriate use in a controlled environment, and suggests greater management complexities in the prehospital setting. Indeed, Edwards et al (2014) outlines the challenges of individual case management for frequent users.

In addition, the University of Sheffield Medical Care Research Unit (2010) outlines the difficulty of service management across boundaries, and how tensions between local and national policies can negatively affect management proficiency. This tension is reflected by the National Audit Office (2011), which highlights additional variation between trusts in resource deployment and performance measurement, and limited sharing of best practice.

The Keogh Review (NHS England 2013) demonstrates how variation in service management can lead to patient confusion, significantly reducing appropriate help-seeking behaviour. It is apparent that national standardisation of service management across ambulance trusts may improve how patients access urgent services. In addition, improving training and resource support for responding clinicians may also significantly increase use of referral pathways.


An unexpected finding of this review was the distinct lack of clear definitions outlining what constitutes avoidable attendance and inappropriate use of services. A significant number of articles did not establish how appropriateness was measured, and those that did relied almost exclusively on retrospective opinion. Few articles subsequently highlighted rationales for concluding that patient behaviour was inappropriate, and those that did mostly presented their rationales narratively through interview extracts (Agarwal et al, 2011; Booker, Simmonds and Purdy 2013).

Booker, Simmonds and Purdy (2013) argue that appropriateness is almost always defined retrospectively by the healthcare professional, which would certainly explain why such a paucity of objective definitions exists. Furthermore, as demonstrated in this review, a significant number of factors exclusive to individual patients can influence help-seeking behaviour. In this respect, appropriateness is also defined subjectively by the patient. Jones (2011) suggests that healthcare providers should seek to improve care options rather than attempt to influence patient help-seeking behaviour. Perhaps services should therefore aim to educate patients through targeted campaigns, whilst simultaneously seeking to better understand patient requirements, and align services accordingly.

Similarly, few articles outlined how admission avoidance was defined. Coates (2013) was the only study that explored this in detail, and outlined that non-conveyance of a patient might not necessarily result in an avoided hospital admission, either due to inadequate use of referral pathways or subsequent medical need. This review has highlighted a universal lack of clarity regarding how successful admission avoidance is measured, and since this assessment is pivotal in evaluating adequate use of pathways, further clarity should be sought by ambulance services.
Conversely, almost all material discussing frequent users provided clear definitions of what was considered frequent use of services (Dent, Hunt & Webster 2010; Smith & McNally 2014; Scott et al, 2013; Edwards et al, 2014).

Several factors influencing patient behaviour in the context of inappropriate use were identified. A number of articles highlighted risk-averse behaviours by both patients and carers when dealing with minor illnesses due to misconceptions of condition urgency. In relation to chronic illnesses, patients demonstrated a reluctance to temporise symptoms, and often sought out the most immediate form of assistance. Material suggested that these behaviours were driven by misconceptions over the seriousness of conditions, in addition to a perceived lack of available alternatives.

Sanctioning of help-seeking behaviours by carers and relatives was an additional reoccurring theme, and interpersonal influence was found to exacerbate inappropriate use in most circumstances. Reviewed material demonstrates that patient education, whilst an important consideration, only accounts for a partial driver of patient behaviour. A large percentage of influence can be attributed to patients’ perception of barriers to alternative care. Strategies to reduce inappropriate use should aim to improve patient access to alternative care, whilst also improving education and raising awareness of community services.

It is well established that areas of social deprivation and poorer demographics suffer with increased health issues (National Institute for Health and Care Excellence 2012; Royal College of Nursing 2012), and this review furthermore found significant evidence to suggest that patients in this demographic may also significantly contribute towards inappropriate use (Agarwal et al, 2011; Association of Ambulance Chief Executives 2011; Scott et al, 2013; O’Cathain et al, 2013; Edwards et al, 2014; Smith & McNally 2014). Whilst the individual clinician should take caution in stereotyping patients, the implications for wider healthcare services in response management and healthcare promotion appear to be evident.

In relation to healthcare access, two dichotomous issues provide equal contribution to inappropriate use of emergency services. A perceived barrier to community care services was a reoccurring theme throughout a significant number of articles (Agarwal et al, 2011; Booker, Simmonds & Purdy 2013). This was combined inversely with the ease of access to ‘999’ and ED services, as well as unanimously positive patient experience using these services. It was furthermore suggested that barriers to non-urgent community care were not limited to patients. A number of articles highlighted that prehospital clinicians often encountered problems when attempting to refer patients unsuitable for A&E transport (NHS England 2013; O’Hara et al, 2014).

Whilst barriers to GP services were not explored in detail in this review, there is reasonable evidence suggesting that demand for these services is also increasing in line with other urgent and emergency care services (NHS England 2013). A review of current community care paradigms in the UK could be beneficial in establishing whether or not reform is required to meet evolving patient needs. There has been recent political suggestion that a solution may be found by bringing OOH care into the direct control of ambulance trusts (Roberts 2015).

The importance of multidisciplinary collaboration was emphasised universally across the majority of articles. Fragmentation of healthcare services was unanimously highlighted as a significant contributor to inappropriate ED attendance. There appears to be national inconsistency in the availability of alternative services (O’Hara et al, 2014), in addition to variation in prehospital awareness of available resources (National Audit Office 2011; O’Hara et al, 2014). The National Audit Office (2011) highlights that ambulance trusts are inconsistent in keeping directories of available referral pathways.

There is sufficient evidence to suggest a significant lack of collaboration, both between multidisciplinary services and between local trusts (NHS England 2013; Edwards 2014). Since this fragmentation affects so many factors of appropriate use, including patient and clinician behaviour and organisational management, it is reasonable to consider this to be the most significant finding of this review. Further research into the causes of systemic healthcare fragmentation, and proposals for reform should be considered of the utmost importance in addressing increasing demand and appropriate use of NHS services.

Internal healthcare factors were not limited to issues accessing alternative pathways. Service culture and clinical behaviours were also found to significantly contribute to inappropriate use of services (NHS England 2013; Newton et al, 2013; O’Hara et al, 2014). Oversensitive triage was observed at multiple stages of assessment, due to a combination of organisational and educational factors. Oversensitive telephone triage was also highlighted as a potential contributor to inappropriate ambulance dispatch (Turner et al, 2013).
Studies showed that clinicians with greater experience, and specialised training, demonstrated greater levels of confidence in utilising referral pathways, and subsequently lower levels of over-triage. If the ambulance service is to continue along its current trajectory establishing itself as a signposting service (National Audit Office 2011), further investment must be made in specialised clinical roles and education of staff at all hierarchal levels. Established literature suggests that specialised prehospital roles are still nationally inconsistent (National Audit Office 2011; O’Hara et al, 2014), and standardisation would be beneficial in realising their full potential.


Appropriate usage is a poorly defined concept in healthcare, and whilst it may be argued that appropriateness is a subjective term, rationales for defining users as inappropriate are consistently omitted. Healthcare services cannot expect to observe appropriate use of channels without clarification of what this looks like. Further effort should be made to provide objective guidance to both patients and clinicians.

Patient education and socioeconomic status contributed to patient help-seeking behaviour. However, healthcare access and framework issues influenced much of this behaviour. Perceived and tangible barriers to healthcare, combined with situations of perceived urgency, prompted the use of more immediate healthcare channels, contributing heavily to inappropriate use. This was reflected in prehospital clinicians making conveyance decisions. Articles suggested that lack of confidence and organisational support also prompted disproportionately risk-averse behaviour from ambulance staff.

Fragmentation of multidisciplinary services was a superordinate and reoccurring theme throughout this study. In this respect this review has demonstrated the fundamental link, not just between ambulance and ED services, but also between all multidisciplinary healthcare services. Since many patients have a diverse and complex range of healthcare requirements (Knowles, O’Cathain & Nicholl 2010; Edwards et al, 2014), service providers are dependant on one another to ensure that users travel adequately and appropriately through channels. This review demonstrates that no single service can thrive in isolation, and that the collaboration of collective services is the most fundamental aspect of improving health services and the way patients access them. Whilst success is dependant upon the collective effort of wider multidisciplinary services, this review has shown the ambulance service to be in an ideal position to influence how patients access care, and how services interact with one another.

Edward Liscott, former Paramedic Practice BSc(Hons) student


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A focus on Placement Learning Opportunities for Student Nurses – literature review


All student nurses are allocated clinical placements throughout their three year course, in which to develop their practical skills. Whilst in practice, they are supported by a designated mentor, who is the student’s identified lead for educational support. In this context, mentor support is provided by practitioners, who have undertaken an approved mentor preparation programme, approved by the regulatory body, the Nursing and Midwifery Council (NMC) (Nursing and Midwifery Council, 2008). The Code of Professional Conduct (Nursing and Midwifery Council, 2015) outlines a responsibility for all registered nurses and midwives, known as registrants, to facilitate the education of learners in clinical practice.

I am aware from discussions with students, and overhearing their conversations in the classroom setting that they perceive their placements to vary in quality, with some feeling they have benefitted from very strong, beneficial placements, through to others who do not feel so advantaged educationally. Some students perceive that they may have had an experience that was inequitable in comparison with peers, whilst others may comment that they don’t feel they learnt as much when comparing with previous placements. As such, I am aware that a perception exists that there are “good” and “bad” placements in the eyes of students. Having been a student myself, I am fully conversant with the fact that students will compare one placement experience with another and will also discuss their experiences with peers (Foster et al., 2014). The NMC dictates that the nursing course is built on 50% theory, and 50% clinical placements – thus ensuring that students gain an opportunity to gain experience in a range of clinical settings (Nursing and Midwifery Council, 2008). A dedicated team within the university is responsible for the allocation of a broad range of placement experiences (community and hospital) to all students on a nursing course.

Placement learning opportunities vary significantly in context, and it must be noted that no two placement settings are easily comparable. It is important to note the uniqueness of students and mentors, as all have a preferred way in which to teach and learn, and as such this factor must also be considered a significant variable.

In my mind, the key features of a work placement are to provide students with an experience similar to that of qualified status, as placements allow them to immerse themselves into the clinical setting. They are able to practice, under supervision, the skills they have been taught in the classroom setting and to develop their practice in readiness for qualification. Placements should also develop confidence and provide an opportunity to demonstrate competency to mentors.

Literature Search Process

A dual approach was taken to source literature to support the identification of a suitable research problem. Initially I undertook a systematic search of a number of recognised repositories, using specific search terms and a number of initial inclusion and exclusion criteria to ensure that the literature identified was relevant to my area of focus. Search engines included Google Scholar, the British Nursing Index (BNI) and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). This process proved very fruitful in terms of the quality and quantity of literature identified. The limited word count for this article does not permit a full overview of the search terms used and resultant number of “hits”.

Alongside this process, I also undertook what can be classified as a serendipitous search. This involved using my own knowledge of the topic area to ensure that key policy and regulatory documentation was identified, along with material that I currently use within my teaching practice. I also ensured that I followed up material found in the reference listings of articles I have read. On reflection, although this process goes against the traditional process for systematic literature searching that I am used to, it was extremely beneficial in giving assurance that I had reached saturation point as the majority of literature cited in the articles I was reading had already been covered. This provided confidence that I had not missed any key literature in the field I am focussing upon.

Literature was predominantly included if it originated in the UK, and was published within the last 15 years. Nursing is regulated differently across the globe and mentoring and placement requirements vary depending upon the country you are in.

If relevant, literature from overseas was included after careful consideration was given, if it supported the identification of a research problem by offering a perspective that varied from the UK based material. Literature was only included if it originated from credible sources, which for the majority were peer reviewed journals.

Overview of the Literature

From the outset, it became apparent that there was very little literature focussed on the “poor” placement, and particularly any that discusses the potential advantages of a perceived negative placement experience. The majority of the literature sourced has a firm focus around guidance to mentors, and how to make a placement learning experience as positive as possible.

The makeup of the identified literature can also be categorised for significance. The over-riding majority of identified literature was research based, having undertaken studies examining the experience of learners in practice. This was then published in credible journals. Secondly, “policy” documents were identified – these predominantly originated from the nursing regulator, the NMC (Nursing and Midwifery Council, 2008), as well as guidance from the Royal College of Nursing (RCN) based upon the regulators document and combined with advice from existing mentors (Royal College of Nursing, 2007). Finally, a number of handbooks, or toolkits covering guidance for staff involved in supporting students are concerned with the “best practice” approach (Brockbank and McGill, 2012; Shaw and Fulton, 2012).

The literature acknowledges that although in placement settings the mentor has a lead responsibility for facilitating education, there are other factors that significantly impact on the overall educational quality of the experience.

For the purpose of this review, a total of 59 articles or sources were read, and a number of key themes were evident. I utilised a matrix as recommended by Oliver (Oliver, 2012) to summarise each piece of literature and to conduct a mini thematic analysis. Upon saturation being reached, a review of the matrix enabled the identification of a number of themes that were consistent across numerous articles and sources.

The literature that was identified, as previously mentioned, all originated from credible sources – predominantly journals that are widely recognised in the field of healthcare and healthcare education. A critical approach was taken in reading each article, with a particular emphasis around critical analysis to understand what within the source was not being said. As an example, the majority of literature focussed on good examples of placements and an emphasis on positive experiences; there was a lack of literature that specifically examined the impact of negative placement experiences.

The overriding strand that ran throughout the majority of articles was the importance of the learning environment itself (Beskine, 2009; Gopee, 2011; Stuart, 2007; Walsh, 2010; Papp et al., 2003; Willis Commission, 2012; Royal College of Nursing, 2007; West et al., 2007; Burns and Paterson, 2005). Gray (2014, p65) defines the learning environment as “an interactive network of forces within clinical settings that influence students’ clinical and professional learning outcomes”. Other key foci of the literature sourced were concerned with examining relationships between mentors and mentee (Foster et al., 2014; Andrews and Chilton, 2000; Cahill, 1996; Gray and Smith, 2000; Jokelainen et al., 2011; Butler, 2012; Henderson and Eaton, 2013), and the importance of ensuring that these were effective on a professional level.

As would be expected, a considerable amount of literature exists on the assessment element of the mentor’s role, and a number of studies have been undertaken to look at the ways in which assessment is undertaken (Beskine, 2009; Aston and Hallam, 2014; Gopee, 2011; Stuart, 2007; Walsh, 2010; Robinson et al., 2012; McNair et al., 2007).

On reflection, I was surprised that there was a minimal amount of literature with a focus around the support provided by universities to mentors supporting learners in practice (Henderson and Eaton, 2013; Foster et al., 2014). Mentoring is recognised as an often challenging role, and for new mentors in particular, supporting students in practice placements can be difficult and could potentially impact upon the experience of the learner.

The Student / Learner


As students’ progress through their course, they will naturally compare their placements with their own previous experiences (Foster et al., 2014), and also with that of other students. It is only natural that they will perceive differences to exist between one area to the next, and likewise between the educational gain they have identified. The literature states that students will emulate and role-model qualified staff who they perceive to be good examples of the nursing profession, and will compare staff in one area to the next (Beskine, 2009; Brockbank and McGill, 2012). The literature does not highlight that practice varies in terms of standards and the evidence on which it is based, and as such role modelling can be problematic if the practice demonstrated is not current and credible.


Student nurses will naturally expect every placement to be a positive experience, through which they can develop their knowledge and gain a greater understanding of the role of the nurse. Many will argue that placements are the way in which they develop competency, and that positive or “good” placements are the only way in which they can complete their training and qualify in a state ready for practice (Andrews and Chilton, 2000; Gopee, 2011; Jokelainen et al., 2011). The literature covered would agree with this in the main, however an Australian article (Green and Jackson, 2014) discusses the negative aspects of placements and associated mentoring. This negative aspect of placements is a weakness in the literature and needs further exploration, as there is a need to explore how student can be prepared to deal with placements that they feel are not conducive to learning and to explore the benefits of being placed in a setting that is not supportive.


Refreshingly, Green and Jackson (2014) acknowledge that poor mentoring and negative placements do occur regularly in practice, and for a number of reasons. This paper led me to reflect and think about what was stated within it. Most of the literature reviewed outlines the importance of effective relationships between mentors and students (Henderson et al., 2012; Henderson et al., 2010); the need for learning environments to be set up as effectively as possible to facilitate high quality education and the guiding hands of experienced clinical and mentoring staff to ensure that the clinical education pathway of student nurses is as clear of obstructions as possible throughout the three years of training.

Theoretically, such an experience sounds very beneficial, and most students would be grateful to progress in such a manner. But is a poor placement also as beneficial to the education process? In my view, it is, as it introduces the student to the complexities of life as a healthcare professional. In reality, shifts as qualified practitioners will be challenging on a regular basis (Wallace and Gravells, 2007), and by gaining experience of challenging situations as a student, it assists in the development of building resilience and coping strategies (Papp et al., 2003).

‘Poor’ placement experiences also enable students to develop skills in resilience, and through working through challenging situations, leaves them better equipped to cope with similar situations either in future placements, or in practice as a qualified nurse. The university plays a significant part in supporting students in practice (Foster et al., 2014) and has a duty to liaise with practice colleagues if a placement learning experience has the potential to cause significant harm to the development of a student (Burns and Paterson, 2005).

Past Experiences

All students enter the course from a range of backgrounds many will have previous healthcare experience gained through previous employment in a support role, whilst others commence their nurse training with no previous experience at all. In some cases, this experience can be helpful, as an existing understanding of an area can assist the student to build upon their current knowledge base. For others, they enter a placement not knowing what they do or don’t know. The literature discusses in depth the importance of mentors and placement colleagues providing a positive, conducive setting in which all students can thrive and develop their knowledge and skills (Beskine, 2009; Royal College of Nursing, 2007; Aston and Hallam, 2014).

The motivation of students to enter the profession may also be a factor to consider – as some students could be classed as “healthy” having had little or no contact with the profession and whose motivation is to help others and care for the sick. As a result, they may have very few expectations of their placements. Others may have experience of the profession through previous employment or as a patient, and may make comparisons to first-hand experience.


Critique of the NMC Standards

The NMC (Nursing and Midwifery Council, 2008a) defines a mentor as one who ‘facilitates learning, and supervises and assesses students in a practice setting.’This definition is akin to frequently quoted definitions used in healthcare mentoring texts (Shaw and Fulton, 2012; Walsh, 2010; Gray, 2014) who speak of mentoring as being closely linked to skill and practice development.

As the regulatory body, the NMC have published guidance, which is frequently referred to as the “bible” for mentoring (Nursing and Midwifery Council, 2008). Idealistically, this document would provide a succinct set of instructions to mentors around how to manage a placement experience for students, and how to deal with potentially challenging situations. Unfortunately this is not provided, and the document is based around eight domains which set out the key areas of significance for mentoring students in practice placement settings.

Supporter versus Assessor

As students’ progress through their three year programme, they become more and more aware of the split responsibilities of the role of their mentors and for many, see them primarily as somebody who will judge their practice and influence the decision as to whether they will progress in their training (Bray and Nettleton, 2007). Interestingly, the study undertaken by Bray and Nettleton (2007) highlighted that the majority of mentors see their role as being fundamentally that of a teacher or supporter. Assessment is a key, but complicated process to manage for mentors, and the consequences of a wrong decision are huge for students. Stuart (2007) speaks of the importance of assessment being conducted fairly and in the best interests of students.

An observational study undertaken in a critical care setting identified the importance of the mentor offering support to students, as this led to reduced stress levels and opened up avenues for increased learning (Cochrane et al., 2008).

It is encouraging to observe more parity in this area around the balance between literature that covers both positive and negative aspects of mentoring and the relationship students have with their qualified colleagues. I have frequently reflected upon the benefits of splitting the role and having two mentors allocated, one to support and the other to assess.

Very few articles seek the views of students, and do not address any perceived difficulties from their position.

On reflection, this dual aspect of the role has infrequently been an issue for myself in a mentoring role, nor immediate colleagues. In many situations, if the mentor has been acting as a teacher and has been working with a student to develop skills in a particular area, the assessment process naturally falls within this role. It could also be highlighted, that if a student receives poor assessment results within a placement, this may potentially cloud their perception of the overall experience – irrespective of the quality of teaching received.

Benefits of shared responsibility in a larger department

As already mentioned, there are distinct advantages to the student and mentor who are based in a larger department. The responsibility for providing the guidance to students can be shared. The NMC guidance states that qualified mentors must spend 40% of practice time directly working with their student (NMC, 2008) which leaves a considerable amount of time during which a student may work with other colleagues. “Associate mentoring” is increasingly being used in practice to facilitate the educational experiences of students – as many registered nurses may not necessarily hold the mentoring qualification, but do have extensive clinical experience that will benefit all learners. Through the involvement of the whole team, expertise will benefit all learners and pressure is taken away from the qualified mentor to facilitate all learning opportunities. The literature does not discuss who should be teaching learners in practice, and this is wholly relevant to the above point. With many expert practitioners working in the placement settings, there is huge educational potential for students through working alongside such individuals.

In smaller teams, and where practitioners work autonomously, working alongside a range of colleagues is not possible. In such situations students are limited to the one mentor and can sometimes see this as a disadvantage when making comparisons to other placements.

Integration of the literature

A commission into the future of nursing education (Willis Commission, 2012) reinforces the pivotal role mentors will continue to hold in educating the next workforce generation, but does not analyse the competing roles of supporter and assessor a mentor must undertaken when carrying out the role in practice.

The literature in existence to support all those involved in educating in practice, as previously discussed, is a combination of research and advice in the form of toolkits. This is based upon the lived experiences of authors in the field of mentoring and is not necessarily research based (Wallace and Gravells, 2007; West et al., 2007; Brockbank and McGill, 2012)

The majority of the literature sourced on the mentoring element of placements is heavily biased towards the positive experience. There is a range of books and published research that discusses the “gold” standard, and provides advice on managing an effective placement experience. There is limited material that discusses the potential benefits of a negative or “poor” placement experience from a mentoring perspective. On reflection, my experiences as a mentor and as a mentee have generally been very positive – no mentor intentionally sets out to facilitate a poor placement experience for their allocated learner.

The Learning Environment

Learning cultures

A learning culture is defined by Gill(2009) as a setting in which all barriers that prevent learning from occurring are removed, and staff are rewarded for promoting learning in the setting – ultimately education should be the rule and not the exception.

It is recognised that each placement setting will differ due to the individuals that make up the team, and to the nature of the work undertaken. By default, some areas are more stressful than others due to the un-predictable nature of the setting. However, each of the above are insignificant if there is a shared culture of learning held by the whole team – if the whole team are motivated and committed to the facilitation of learning, all students should thrive.

Beskine (2009) links the environment to the staff working in an area at all levels, and discusses the importance of role modelling positive behaviour from ward manager through to cleaner. She advocates the significance of a shared philosophy towards learning, and promotes cohesive learning across a whole team, which potentially eliminates the “toxic mentor” (Green and Jackson, 2014) situation whereby one or more individuals are not keen to teach and assess students in practice. The role-model concept is supported (Brockbank and McGill, 2012) in mentoring texts as being the difference between mentoring and simply coaching an individual.

Positive and negative impacts on learning

Whilst the literature speaks generally around the learning environment as a whole, I can breakdown the focus area into separate areas of consideration: the physical environment; the individuals working within it and the philosophy held by the individuals towards learning. The physical environment will be discussed in the next section, focussed upon the work environment.

The literature agrees that the learning environment in which students are allocated clinical placements vary considerably due to the nature of the services they provide (Andrews and Chilton, 2000). Walsh (2010) notes the limitations affecting mentors and learners in that a ward or assessment unit’s primary role is to deliver healthcare, but suggests that at regular intervals the mentor and student takes a step back to review the area from their respective role in order to suggest improvement. For example, the process of giving feedback or undertaking a knowledge assessment requires a quiet area with minimal interruptions, a commonly reported issue, and sometimes the use of office space or examination rooms can be negotiated to allow such dialogue to occur. Duffy (Duffy, 2003) identified the increasingly common issue of mentors failing to fail students, but made the link to the importance of a positive learning environment in which student nurses can thrive and excel. It must also be recognised that the healthcare settings vary significantly, which for some can mean learning on a ward setting, whilst others may be in the home of a patient, or in a clinic setting (Eller et al., 2014)

Shaw and Fulton (2012) discuss another action that students often comment on as making the difference between beneficial and disadvantageous placements – a welcome and education pack. Such documents are collected by students in advance of a new practice learning experience and provides information around the work of the ward or department and some pre-reading material to support learners when they are working with mentors.

Philosophy of the wider team

For placements to be effective there is a need for the whole team to share a philosophy that education involves everybody, no matter how closely they are to be working with a learner.
With many expert practitioners working in the placement settings, there is huge educational potential for students through working alongside such individuals – irrespective of whether they hold a formal mentoring qualification.

In recent years, there has been increasing debate around the practicalities of making all registered nurses mentors (Anonymous, 2014). This is a very contentious issue, as is the suggestion that mentors should receive additional pay. I feel that a mentor requires a number of personality traits, such as patience, resilience, creativity and an interest in education that not all nurses necessarily possess. My professional opinion is that mentoring and supporting education in practice requires specialist skills, and not all staff are cut out for the role. This view is supported by the findings of the Willis Commission (2013) into the future of nursing education and discusses the complexities and demands of the mentoring role. At the current time, there is no personal selection criteria for mentors, as there is a requirement to increase the numbers of mentors in the practice setting (Anonymous, 2014).

My current role as a lecturer involves me leading tutorial sessions that outline the expectations of students prior to entering placement settings for the first time. If placement areas can be encouraged to develop and expand upon the learning opportunities available in practice with the support of the Higher Education Institutions (HEI), the benefit to students will be far reaching.
Furthermore, each HEI will have their own approach to managing the placement element of courses – and in particular the support offered and provided to students and mentors in such settings.


Having undertaken the literature search, and been surprised around the literature leaning towards the “gold standards”, I believe that there are advantages to exploring how students benefit from a perceived negative, or poor placement experience. There is also an understanding to be gained from students as to what their perception is of good and bad placements. By this I mean that a good educational placement experience for one student may be viewed differently by the next.

Placements are a stipulation of a nurse training programme, but also need to provide the student with opportunities to learn the role they are being prepared for. As the function and outlook of a placement varies from the outlook of a student, mentor, lecturer and workplace, it is likely that some students will perceive their experience to less than ideal. It can be argued that as the body with overall responsibility for students, the HEI must much better prepare students for placement experiences.

Having undertaken a review of this literature in this area, I perceive the following to be potential researchable problems.

  1. In the eyes of nursing students, what is a good or bad educational placement experience?
  2. What are the benefits to student nurses of a perceived negative educational placement experience?
  3. What is the role of the university in preparing students for placement learning opportunities?

From a methodological perspective, there is scope for an ethnographical approach in order to undertake observations in practice. This would allow me to gain an understanding of the factors in a range of placement settings that contribute to the overall educational experience.

Darren Brand, Senior Lecturer, School of Health Sciences


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Body image and notions of nationalism and modernity


It is easy to think that our interest in what appear to be obsessions around what we look like is a current phenomenon. The contemporary popular discourse surrounding body image is firmly set against the backdrop of what has become repeatedly termed the ‘obesity epidemic’ with attendant images of bulging waistlines. The current obsession with body image and the norms of thinness and the ‘six pack’can be traced back to the 1970s and the emergence in the United States of what Crawford (1980) termed ‘healthism’. Moreover, Crawford asserts that preoccupation with what the individual needs to do to make her or himself healthy paved the way for the more wider acceptance of neo-liberalism which now dominates Western health discourse.
Crawford (1980) used the term ‘Healthism’ to describe this moralisation of health amongst middle class Americans. This marked a shift in the responsibility for ‘good health’ from the state to a position where the emphasis is placed on individual, which ignores the significant role socioeconomic factor play in determining health. Moreover, the rise of neoliberal policies, not only in the area of health but more widely in society, also creates a ‘victim blaming’ culture where sections of society regards individuals who do not conform to the norm are some way at fault or lacking self-control, potentiality leading to a position where they are marginalised.

The body, particularly body image, is layered with cultural meanings . The purpose of this short article is to explore body image in the context of nationality identity and modernity. My aim in writing it is to outline how different body images, both male and female, are used to represent how a nation wishes to be viewed by the wider world.


The body image narrative

The body image narrative is multi-factorial, encompassing among other things class, health and of course attendant pejorative and judgemental assumptions about laziness and lack of self-respect. Levy-Navarro (2010) argues that it is also important to understand the role history plays in framing the current discourse on obesity and body image more generally. Further, in an historical context it is important to recognise the significance of body image in national identity.
The current dominant male body ideal draws on the classical Greek conception of what men should look like: narrow hips, broad shoulders and a broad back – ancient Greek representation of the male nude in art. In contrast male and female participants in research by Rysst and Klepp (2012) used descriptions such as; ‘hourglass figure’, ‘slim and moderately fit’, ‘relatively straight and thin legs…and a flat stomach’ to describe the idea female body. Interestingly Rysst and Klepp reported that the majority of the male participants in their research did not use the term ‘health’ in their descriptions of a good-looking body.

Fascism and the aesthetic ideal

The adoption of the classical Greek ideal male body is not uniquely contemporary. Aesthetics and the notion of the body beautiful were central to fascism. The Nazis drew on the classical interpretation of the human form to set the standard often represented in the sculptures of Arno Breker. Conforming to this ideal was evidence of a disciplined and committed mind. Fundamental to this aesthetic ideal was the creation of stereotypes, for example the Aryan man or the ‘new’ Italian man in Mussolini’s Italy, and the notion of the outsider – in other words the individual that does not conform to the norm. Regardless of the brand or country of origin of fascism, the martial male body was used as a projection of state power. Moreover, as Mangan (1999) points out the strong body as a metaphor for security and supremacy is still a contemporary image of international aspiration. Whilst the various brands of Fascism shared similarities in their use of the male body there were also dissimilarities. Peculiar to Italian fascism, Mussolini embodied the notion of the ‘Italian Superman’ symbolising athletic dynamism amongst other attributes championed by fascism. The Germanic fascists also championed the disciplined athletic body which was regarded as superior to inferior bodies that did not match the idealised. Contrastingly Mangan (1999) describes the almost religious preoccupation with emphasising the slimness of the physique of the Francoist soldiers. Mangan (1999) refers to this characterisation as being in the style of figures depicted by El Greco and hence in stark contrast to the body image promoted by fascist movements elsewhere in Europe.

The Victorian aesthetic of the male body

The Victorian period, created standards of embodiment and a normalising discourse, coinciding with what King (2010) describes as its propensity for defining, classifying and categorising. Moreover, Levy-Navarro argues that the nineteenth century witnessed the rise of body markers as revealing something about an individual’s identity. Using H.G. Well’s short story ‘The truth about Pyecraft’ King explores the culture of reducing or dieting and the angst the Victorians felt at the end of the nineteenth century about the obese male body. King asserts that implicit in the story is the fear of racial degeneration and, concurrently, an emphasis on maintaining a physically fit, muscular appearance, symbolic of and reflecting a physically fit nation and empire. It was also at this time that images of the ‘John Bull’ character were published where his appearance had been bloated. Levy-Navarro highlights one occurrence where John Bull’s bulbous belly is partitioned into the various British colonies, this image functioning as a metaphor for a weaken nation.

The 20th century

The angst felt at the turn of the twentieth century about the fat male body in particular was not restricted to Britain. The body became a target for attention throughout Europe following the conclusion of the First World War as nations sought to rejuvenate national health (Jensen 2010). Following the constitution of the new Weimar Republic in 1919 the Berliner Illustrite published a picture of the new the German president, Friedrich Ebert, and the defence minister, Gustav Noske, in their bathing trunks whilst on a trip on the beach. Jensen (2010) notes that few Germans had seen their leaders so physically exposed. The Berliner Illustrite commented on the frail and droopy appearance of these two men drawing an analogy between the way they looked and the state of the postwar German republic. Across the political spectrum Germans reacted to the perception of a ‘soft’ and ‘fat’ German nation by calling for a new physical body, symbolic of a new body politic and body aesthetic (Jensen 2010).

In contrast to today where increasing emphasis is placed on the muscular male body, Weimar Germany judged that Athletes with their sleek and streamlined body provided the model of a modern body. Moreover, as Jensen (2010) notes, this was also in contrast to the body ideal promoted in prewar First World War Germany. Then the ideal favoured for men is described by Jensen as brawny heft and tightly corseted curves for women. In the subsequent Weimar republic both men and women were encouraged to embrace the streamlined androgynous body. Modernity and society’s embrace of notions of speed also mediated against excess weight which slowed the body down.

Riso_AmaroWhilst the slender athletic form for both men and women had established its hegemony in the Weimar Republic post world war two, Italy turned to the fuller female form, typified by Sophia Loren and Silvana Mangano, in attempt reconstruct the nation’s national identity. Carman (2014) highlights the long association in Italy between feminine beauty and national identity which she contrasts with manipulated beauty of the ‘modern woman’ as represented by Hollywood stars like Greta Garbo and Rita Haywood. With Mangano’s role in the Italian neorealist film Bitter Rice, Carman (2014) highlights how her character, Silvana’s, curvaceous body manifests health and natural beauty reflecting all the qualities of Italian regional peasant culture. Carman asserts the female body as represented by Mangano and Loren was in stark contrast to the ideal female form promoted by the Fascists. Moreover, Mangano and Loren were both contestants in beauty pageants that exploded in postwar Italy. These acted as the vehicle to select the ideal female form to represent both regional and national identity. They became a way to define Italy following the moral stain of Fascism and the postwar devastation that left Italy bereft of a national identity (Carman 2014)

In contrast Goellner (2014) highlights the different female body promoted in Brazil during the 1930’s and into the early 1940’s. During that period educating and strengthening the white woman’s body became part of a national project to strengthen the white race. Goellner (2014) points out this was not only about keeping women healthy but also the nation itself. Goellner’s analysis of articles published in Brazil’s first scientific journal of Physical Education and Sports, Revista Educação Physica, during this period reveals the remarkable emphasis placed on sculpting the female body through physical exercise. Attention was paid to symmetry and proportionality highlighting the classical aesthetic, represented by images of Greek sculptures, as examples of absolute body perfection.


It is easy to think that what you look like is fundamentally a reflection of you as an individual. However, even a brief examination of the history surrounding body image demonstrates that what we look has been used as a metaphor for the ‘heath’ of a nation. Moreover, the type of body image that is valorised is not static and is influenced by a range of factors such as dominant political and cultural ideas at a point in time.

Simon Whiffin, Senior Lecturer, School of Health Sciences


Carmen E. 2014 Mapping the body: Female Film Stars and the Reconstruction of Postwar Italian National Identity Quarterly Review of Film and Video, 31(4) 322-335
Crawford, R. 1996 Health as a meaningful social practice Health 10 (4) 401-420
Goellner S.V. 2014 Body, Eugenics and Nationalism: Women in the First Sport and Physical Education Journal Published in Brazil (1932-1945) The International Journal of the History of Sport, 31(10) 1278-1286
Jensen E.N 2010 Body by Weimar Athletes, Gender & German Modernity New York: Oxford University Press
King N. 2010 ‘The fattest Clubman in London’ : H.G. Wells’s ‘The truth about Pyecraft’ and the culture of reducing in England at the turn of the Twentieth Century. In Historicizing Fat in Anglo-American culture edited by E. Levy-Navarro Columbus: The Ohio State University Press
Levy-Navarro, E. ed, 2010 Historicizing Fat in Anglo-American culture edited by E. Levy-Navarro Columbus: The Ohio State University Press
Mangan J.A. 1999 Global fascism and the male body: ambitions, similarities and dissimilarities The International Journal of the History of Sport 16 (4) 1-26
Rysst M., I.G. Klepp 2012 Looking good and judging gazes: The relationship between body ideals, body satisfaction and body practices among Norwegian men and women Health 4 (5)

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