Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


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


Aveyard, H. 2014. Doing a Literature Review in Health and Social Care. A Practical Guide. 3rd Ed. Maidenhead: Open University Press.

Bassilios, B., F. Judd and P. Pattison. 2014. Why don’t people diagnosed with schizophrenia spectrum disorder (SSDs) get enough exercise? Australian Psychiatry. 22(1): 71-77.

Bentall, R. P. 2004. Madness Explained: Psychosis and Human Nature. Harmondsworth: Penguin

Carless, D. and K. Douglas. 2008a. Narrative, identity and mental health: How men with serious mental illness re-story their lives through sport and exercise. Psychology of Sport and Exercise. 9: 576-594.

Carless, D and K. Douglas. 2008b. Social support for and through exercise and sport in a sample of men with serious mental illness. Issues in Mental Health Nursing. 29: 1179:1199.

Carless, D. and K. Douglas. 2012. The ethos of physical activity delivery in mental health: A narrative study of service user experiences. Issues in Mental Health Nursing. 33: 165-171.

Crone, D. and H. Guy. 2008. ‘I know it is only exercise, but it’s something that keeps me going’: A qualitative approach to understanding mental health service users’ experiences of sports therapy. International Journal of Mental Health Nursing. 17: 197-207.

Cullen C. and E. McCann. 2015. Exploring the role of physical activity for people diagnosed with serious mental illness in Ireland. Journal of Psychiatric and Mental Health Nursing. 22: 58-64.

Department of Health. 2006. Choosing Health: Supporting the Physical Health Needs of People with Severe Mental Illness. Accessed online 17/04/15.

Department of Health. 2011b. No health without Mental Health. Accessed online 11/12/2014.

Department of Health. 2011c. Atypical (Second Generation) Antipsychotics. Accessed online 01/04/15.

Department of Health. 2012. Lets Get Moving. Accessed 10/04/15.

Department of Health. 2014a. Closing the Gap: Priorities for Essential Change in Mental Health. Accessed 04/04/15.

Department of Health. 2014b. Moving More, Living More. Olympic and Paralympic. Games Legacy. Accessed online 20/03/15.

Fogarty, M. and B. Happell. 2005. Exploring the benefits of an exercise program for people with schizophrenia: A qualitative study. Issues in Mental Health Nursing. 26: 341-351.

Foley, D. and K. Morley. 2011. Systematic Review of Early Cardiometabolic Outcomes of the First Treated Episode of Psychosis. Archives of General Psychiatry. 68(6): 609- 616.

Happell, B., D. Scott, C. Platania-Phung and J. Nankivell. 2012. Nurses views on physical activity for people with serious mental illness. Mental Health and Physical Activity. 5: 4-12.

Hodgson, M., H. McCulloch, and K. Fox. 2011. The experiences of people with severe and enduring mental illness engaging in a physical activity programme integrated into the mental health service. Mental Health and Physical Activity. 4: 23-29.

Johnstone, L. 2014. A Straight Talking Guide to Psychiatric Diagnosis. Ross-on-Wye: PCCS Books.

Klam, J., M. McLay, and D. Grabke. 2006. Personal empowerment program: Addressing health concerns in people with schizophrenia. Journal of Psychosocial Nursing. 4(8): 20-28.

May, R. 2014. Blog. Accessed 11/12/2014.

Mental Health Foundation. 2009. Moving on Up. Accessed online 20/02/15.

Mental Health Foundation. 2012. Need2Know Briefing: Peer Support. Accessed 22/04/15.

Moncrieff, J. 2009. A Straight Talking Guide to Psychiatric Drugs. Ross-on Wye: PCCS Books.

National Health Service. 2014b. Valuing mental health equally with physical health or “Parity of Esteem”. Accessed online 11/04/15.
NICE. 2011. Preventing type 2 diabetes: population and community-level interventions. Accessed online 25/03/15.

NICE. 2014b. Psychosis and schizophrenia in adults: treatment and management. Accessed online 23/03/15.

NICE. 2015a. Psychosis and schizophrenia in adults. Quality statement 7: Promoting healthy eating, physical activity and smoking cessation. Accessed online 20/03/15.

Noblit, G. W. and R. D. Hare. 1988. Meta Ethnography: Synthesizing Qualitative Studies. Qualitative Research Methods Series. (11). London: Sage.

Paterson, B, S. Thorne, C. Canam, and C. Jillings. 2001. Metastudy of Qualitative Health Research. Thousand Oaks, CA: Sage Publications Inc.

Rethink. 2013a. The abandoned Illness: A report by the Schizophrenia Commission. Accessed online 10/04/14.

Rethink. 2013b. Lethal Discrimination. Accessed online 25/03/15

Rethink. 2013c. 100 ways to support recovery. Accessed online 07/04/15.

Rice, M. J. 2008. Evidence-based practice in psychiatric and mental health nursing: qualitative meta-synthesis. Journal of the American Psychiatric Nurses Association .14 (5): 382-5.

Ronngren, Y. M., A. Bjork, D. Haage and L. Kristuansen. 2014. LIFEHOPE:EU: Lifestyle and healthy outcome in physical education . Development of a lifestyle intervention program for people with severe mental illness. Journal of Psychiatric and Mental Health Nursing. 2: 924-930.

Rose, D., J. Evans, A. Sweeney, and T. Wykes. 2011. A model for developing outcome measures from the perspectives of mental health service users. International Review of Psychiatry. 23(1): 41–46.

Slade, M., M. Amering, M. Farkas, B. Hamilton, M. O’Hagan, G. Panther, R. Perkins, G. Shepherd, S. Tse, and R. Whitely. 2014. Uses and abuses of recovery: Implementing recovery-orientated practices in mental health systems. World Psychiatry. 13: 12-20.

Schwee, T. W., F. J. Backx, T. Takken et al. 2013. Exercise therapy improves mental and physical health in schizophrenia: A randomized controlled trial. Acta Psychiatric Scandinavia. 127: 464-473.

Tetlie, T., M. C. Heimesnes, and R. Almvik. 2009. Using exercise to treat patients with severe mental illness. Journal of Psychosocial Nursing. 47(2): 30-40.

Usher, K., T. Park, K. Foster and P. Buettner. 2012. A randomised control trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation anti-psychotics. Journal of Advanced Nursing. 69 (7): 1539-1548.

van Deurzen, E. V. 2012. Existential Counselling and Psychotherapy in Practice. 3rd Ed. London: Sage.

van Deurzen-Smith, E. V. 1984. Existential therapy. In: Individual Therapy in Britain, edited by W. Dryden. London: Harper and Row.

Warren, K. R., P. Ball, S. Fieldman, F. Liu, R. P. McMahon, D. L. Kelly. 2011. Exercise program adherence using a 5 kilometer (5K) event as an achievable goal for people with schizophrenia. Biological Research for Nursing. 13(4): 383-390.

World Health Organisation. 2015. Physical Activity. Accessed online 03/03/15.


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


Agarwal, S., J. Banerjee, R. Baker, S. Conroy, R. Hsu, A. Rashid, J. Camosso-Stefinovic, P. Sinfield and M. Habiba. 2011. Potentially avoidable emergency department attendance: interview study of patients’ reasons for attendance. Emergency Medicine Journal 29(3) [Online] Available From: [13 April 2015]

Association of Ambulance Chief Executives. 2011. Taking Healthcare to the Patient 2: A review of 6 years’ progress and recommendations for the future. Association of Ambulance Chief Executives

Atenstaedt, R., S. Humphreys, H. Jones, and J. Newman. 2014. Choose Well: Reducing ‘inappropriate’ emergency department attendances. British Journal of Healthcare Management 20(8):392-395

Aveyard, H. 2014. Doing A Literature Review In Health And Social Care: A Practical Guide. 3rd ed. Maidenhead: Open University Press

BBC. 2015. NHS Winter 2014-15: Weekly A&E tracker. [Online] BBC. Available From: [26 April 2015]

Booker, M., R. Simmonds and S. Purdy. 2013. Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process. Emergency Medicine Journal 0:1-5 [Online] Available From: [7 April 2015]

Brunton, G., C. Stansfield and J. Thomas. 2012. Finding Relevant Studies. In: An Introduction to Systematic Reviews, edited by D. Gough, S. Oliver and J. Thomas. London: SAGE

Coates, D. 2013. ECPs: avoiding emergency department attendance or hospital admission? Journal of Paramedic Practice 2(4):158-168

Colver, K., P. Abhyankar and C. Niven. 2015. Ambulance service treat and refer guidelines: a qualitative investigation into the use of treat and refer guidelines by ambulance clinicians. Emergency Medicine Journal 32(5):e1-e11

Cooper, C. 2015. NHS A&E crisis: Hospitals struggle to keep up with festive demand. [Online] The Independent. Available From: [26 April 2015]

Dent, A., G. Hunt and A. Webster. 2010. The Impact of frequent attenders on a UK emergency department. European Journal of Emergency Medicine 17(6):332-336

Department of Health. 2005. Taking Healthcare to the Patient: Transforming NHS Ambulance Services. London: DH

Department of Health and Ageing. 2007. Emergency Triage Education Kit Triage Workbook. Canberra: Commonwealth of Australia Department of Health and Ageing

Donohoe, R. and A. Blaber. 2008. Professional Issues Affecting Practice. In: Foundations For Paramedic Practice, edited by A. Blaber. Maidenhead: Open University Press

Eastwood, K., A. Morgans, K. Smith and J. Stoelwinder. 2014. Secondary triage in prehospital emergency ambulance services: a systematic review. Emergency Medicine Journal 0:1-7 [Online] Available From: [1 May 2015]

Edwards, M., G. Bassett, L. Sinden and R. Fothergill. 2014. Frequent callers to the ambulance service: patient profiling and impact of case management on patient utilisation of the ambulance service. Emergency Medicine Journal 0:1-5 [Online] Available From: [4 April 2015]

Edwards, N. 2014. Community services: How they can transform care. London: The King’s Fund

Endacott, R., S. Cooper, R. Sheaff, J. Padmore and G. Blakely. 2010. Improving emergency care pathways: an action research approach. Emergency Medicine Journal 28(3):203-207

Francis, R. 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery office.

GRADE Working Group. 2004. Grading quality of evidence and strength of recommendations. BMJ 328(7454):1490-1494

Halter, M., S. Vernon, H. Snooks, A. Porter, J. Close, F. Moore and S. Porsz. 2011. Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study. Emergency Medicine Journal 28(1):44-50

House of Commons. 2004. GP Out-of-Hours Services: Fifth Report of Session 2003–04. London: The Stationery Office

Johnston, I. 2015. Ambulance staff told to leave patients at A&E departments if they have not been admitted after 45 minutes. [Online] The Independent. Available From: [26 April 2015]

Jones, D. 2011. How GPs can help reduce inappropriate attendance. Emergency Nurse 19(4):20-23

Kirkby, H. and L. Roberts. 2011. Inappropriate 999 calls: an online pilot survey. Emergency Medicine Journal 29(2):141-146

Knowles, E., A. O’Cathain and J. Nicholl. 2010. Patients experiences and views of an emergency and urgent care system. Health Expectations 15(1):78-86

Kyle, R., M. Banks, S. Kirk, P. Powell and P. Callery. 2013. Avoiding inappropriate paediatric admission: facilitating General Practitioner referral to Community Children’s Nursing Teams. BMC Family Practice 14(4):1-8 [Online] Available From: [27 April 2015]

Lavrakas, P. 2008. Encyclopedia of Survey Research Methods. London: SAGE

LoBiondo-Wood, G. & J. Haber. 2013. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 8th ed. Missouri: Mosby

Local Ambulance Trust. 2015. Immediate Handover – Standard Operating Procedure. Local Ambulance Trust

Machi, L. and B. McEvoy. 2009. The Literature Review. London: SAGE

MAG Online Library. 2014. Healthcare and education content from the Mark Allen Group. [Online] Mark Allen Group. Available From: [3 April 2015]

Mani, S., D. Bertfield, A. Ritchie, A. Webber and C. Lisk. 2014. Emergency admission prevention: data from 619 patients referred to a new community based admissions avoidance scheme integrating health and social care. Age and Ageing 43(2):ii1

May, T. 2011. Social Research: Issues, Methods and Process. 4th ed. Maidenhead: Open University Press

Moher, D., A. Liberati, J. Tetzlaff and D. Altman. 2009. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7):1-6

Morris, P. 2009. Leading the way in clinical effectiveness. Journal of Paramedic Practice 1(7):299-301

Mundasad, S. 2014. Patients ‘face long queues in ambulances outside A&E’. [Online] BBC. Available From: [26 April 2015]

National Audit Office. 2011. Transforming NHS ambulance services. London: The Stationary Office

National Institute for Health and Care Excellence. 2006. Methods for development of NICE public health guidance. London: NICE

National Institute for Health and Care Excellence. 2012. Health inequalities and population health. [Online] NICE. Available From: [6 May 2015]

National Institute for Health and Care Excellence. 2015. Healthcare Databases. [Online] NICE. Available From: [3 April 2015]

Nelson, J. 2011. Why patients visit emergency units rather than use primary care services. Emergency Nurse 19(1):32-36

Newton, M., E. Tunn, I. Moses, D. Ratcliffe and K. Mackway-Jones. 2013. Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder. Emergency Medicine Journal 0:1-6 [Online] Available From: [7 April 2015]

NHS England. 2013. High quality care for all, now and for future generations: Transforming urgent and emergency care services in England The Evidence Base from the Urgent and Emergency Care Review. NHS England

NHS England. 2015. Risk Management Policy and Process Guide. NHS England

NHS Office of Strategic Health Authorities. 2008. Emergency Service Review: Good Practice Guide for Ambulance Services and their Commissioners. London: Office of Strategic Health Authorities.

O’Brien, G., M. Shapiro, R. Woolard, P. O’Sullivan and M. Stein. 1996. “Inappropriate” Emergency Department Use: A Comparison of Three Methodologies for Identification. Academic Emergency Medicine 3(3):252-257

O’Cathain, A,. E. Knowles, R. Maheswaran, T. Pearson, J. Turner, E. Hirst, S. Goodacre and J. Nicholl. 2013. A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study. BMJ Quality and Safety 23(1):47-55

O’Hara, R., Maxine Johnson, A. Siriwardena, A. Weyman, J. Turner, D. Shaw, P. Mortimer, C. Newman, E. Hirst, M. Storey, S. Mason, T. Quinn and J. Shewan. 2014. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. Journal of Health Services Research & Policy 20(1):45-53

O’Hara, R., M. Johnson, E. Hirst, A. Weyman, D. Shaw, P. Mortimer, C. Newman, M. Storey, J. Turner, S. Mason, T. Quinn, J. Shewan and A. Siriwardena. 2015. Decision making and safety in ambulance service transitions. Emergency Medicine Journal 32(5):e1-e11

Pannucci, C. and E. Wilkins. 2010. Identifying and Avoiding Bias in Research. Plastic and Reconstructive Surgery 126(2):619-625

Patton, G. and S. Thakore. 2012. Reducing inappropriate emergency department attendances: a review of ambulance service attendances at a regional teaching hospital in Scotland. Emergency Medicine Journal 30(6):459-461

Press Association. 2013. Pressure on A&E departments is out of control, warns NHS regulator. [Online] Guardian News. Available From: [26 April 2015]

Raleigh, V. and F. Frosini. 2012. Improving GP services in England: exploring the association between quality of care and the experience of patients. The King’s Fund

Ridley, D. 2012. The Literature Review: A Step-by-Step Guide for Students. 2nd ed. London: SAGE

Roberts, N. 2015. GP out-of-hours could integrate with ambulances and 111 under Labour. [Online] Haymarket Media Group. Available From: [6 May 2015]

Royal College of Nursing. 2012. Health inequalities and the social determinants of health. London: Royal College of Nursing

Scott, J., A. Strickland, K. Warner and P. Dawson. 2013. Frequent callers to and users of emergency medical systems: a systematic review. Emergency Medicine Journal 31(8):684-691

Smith, D. and A. McNally. 2014. Delivering enhanced safety, productivity and experience: early results from a frequent caller management system. Journal of Paramedic Practice 6(12):634-641

Snooks, H., W. Cheung, J. Close, J. Dale, S. Gaze, I. Humphreys, R. Lyons, S. Mason, Y. Merali, J. Peconi, C. Phillips, J. Phillips, S. Roberts, I. Russell, A. Sánchez, M. Wani, B. Wells, and R. Whitfield. 2010. Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial. BMC Emergency Medicine 10(2):1-8

South East Coast Ambulance Service. 2015. Stroke Awareness. [Online] South East Coast Ambulance Service. Available From: [7 May 2015]

Steckler, A. and. McLeroy. 2007. The Importance of External Validity. American Journal of Public Health 98(1):9-10

Thomas, J., A. Harden and M. Newman. 2012. Synthesis: Combining results systematically and appropriately. In: An Introduction to Systematic Reviews, edited by D. Gough, S. Oliver and J. Thomas. London: SAGE Publications Ltd.

Turner, J., A. O’Cathain, E. Knowles and J. Nicholl. 2013. Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study. BMJ Open 3(11):1-8 [Online] Available From: [7 April 2015]

University of Sheffield Medical Care Research Unit. 2010. Building the evidence base in pre-hospital urgent and emergency care: a review of research evidence and priorities for future research. London: DH

Watters, P. 2014. Literature Searching. [PowerPoint] University of Brighton. Brighton: University of Brighton

Whitnell, J. 2008. Psychology: an introduction. In: Foundations For Paramedic Practice, edited by A. Blaber. Maidenhead: Open University Press


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


Andrews, M. and Chilton, F. (2000) “Student and Mentor Perceptions of Mentoring Effectiveness”, Nurse Education Today, 20 (7) pp. 555-562.

Anonymous (2014) ‘Should All Nurses Be Mentors?’, 110 (Generic) 22.

Aston, L. and Hallam, P. (2014) Successful Mentoring in Nursing, London: Learning Matters.

Beskine, D. (2009) “Mentoring Students: Establishing Effective Working Relationships”, Nursing Standard, 23 (30) pp. 35-40.

Bray, L. and Nettleton, P. (2007) “Assessor or Mentor? Role Confusion in Professional Education”, Nurse Education Today, 27 (8) pp. 848-855.

Brockbank, A. and McGill, I. (2012) Facilitating Reflective Learning: Coaching, Mentoring and Supervison, London; Philadelphia: Kogan Page.

Burns, I. and Paterson, I. M. (2005) “Clinical Practice and Placement Support: Supporting Learning in Practice”, Nurse Education in Practice, 5 (1) pp. 3-9.

Butler, K. (2012) ‘Benefits of a Peripatetic Support Mentor’, 108 (Generic)   23-25.

Cahill, H. A. (1996) “A Qualitative Analysis of Student Nurses’ Experiences of Mentorship”, Journal of Advanced Nursing, 24 (4) pp. 791-799.

Cochrane, J., Heron, A. and Lawlor, K. (2008) “Reflections on Student Nurse Placements in the Picu”, Paediatric nursing, 20 (1) pp. 26-28.

Duffy, K. (2003) Failing Students: A Qualitative Study of Factors That Influence the Decisions Regarding Assessment of Students’ Competence in Practice, Glasgow: Glasgow Caledonian University [online]. Available:<> [Accessed 19th December 2014].

Eller, L. S., Lev, E. L. and Feurer, A. (2014) “Key Components of an Effective Mentoring Relationship: A Qualitative Study”, Nurse Education Today, 34 (5) p. 815.

Foster, H., Ooms, A. and Marks-Maran, D. (2014) “Nursing Students’ Expectations and Experiences of Mentorship”, Nurse Education Today. 35 (1) 18 – 24

Gill, S. J. (2009) Developing a Learning Culture in Nonprofit Organisations, London: SAGE Publications.

Gopee, N. (2011) Mentoring and Supervision in Healthcare, London: SAGE.

Gray, M. (2014) Practical Skills for Mentoring in Healthcare: A Guide for Busy Practitioners, London: Palgrave Macmillan.

Gray, M. A. and Smith, L. N. (2000) “The Qualities of an Effective Mentor from the Student Nurse’s Perspective: Findings from a Longitudinal Qualitative Study”, Journal of advanced nursing, 32 (6) pp. 1542-1549.

Green, J. and Jackson, D. (2014) “Mentoring: Some Cautionary Notes for the Nursing Profession”, Contemporary nurse, 47 (1-2) p. 79.

Henderson, A., Cooke, M., Creedy, D. K., et al. (2012) “Nursing Students’ Perceptions of Learning in Practice Environments: A Review”, Nurse education today, 32 (3) pp. 299-302.

Henderson, A. and Eaton, E. (2013) “Assisting Nurses to Facilitate Student and New Graduate Learning in Practice Settings: What ‘Support’ Do Nurses at the Bedside Need?”, Nurse education in practice, 13 (3) pp. 197-201.

Henderson, A., Twentyman, M., Eaton, E., et al. (2010) “Creating Supportive Clinical Learning Environments: An Intervention Study”, Journal of Clinical Nursing, 19 (1-2) pp. 177-182.

Jokelainen, M., Turunen, H., Tossavainen, K., et al. (2011) “A Systematic Review of Mentoring Nursing Students in Clinical Placements”, Journal of Clinical Nursing, 20 (19-20) pp. 2854-2867.

McNair, W., Smith, B. and Ellis, J. (2007) “A Vision of Mentorship in Practice”, Journal of perioperative practice, 17 (9) pp. 421-430.

Nursing and Midwifery Council (2008) Standards to Support Learning and Assessment in Practice, London: Nursing & Midwifery Council.

Nursing and Midwifery Council (2015) The Code: Standards of Performance, Conduct and Ethics for Nurses and Midwives, London: Nursing and Midwifery Council.

Oliver, P. (2012) Succeeding with Your Literature Review: A Handbook for Students, Open up Study Skills, Maidenhead: McGraw-Hill.

Papp, I., Markkanen, M. and von Bonsdorff, M. (2003) “Clinical Environment as a Learning Environment: Student Nurses’ Perceptions Concerning Clinical Learning Experiences”, Nurse Education Today, 23 (4) pp. 262-268.

Robinson, S., Cornish, J., Driscoll, C., et al. (2012) Sustaining and Managing the Delivery of Student Nurse Mentorship: Roles, Resources, Standards and Debates, London: King’s College London.

Royal College of Nursing (2007) Guidance for Mentors of Nursing Students and Midwives, London: Royal College of Nursing [online]. Available:<> [Accessed 18th December 2014].

Shaw Mary E., and Fulton, J.. (2012) Mentorship in Healthcare, Keswick, Cumbria: M&K Publishing.

Stuart, C. C. (2007) Assessment, Supervision and Support in Clinical Practice: A Guide for Nurses, Midwives and Other Health Professionals, Edinburgh: Churchill Livingstone Elsevier.

Wallace, S. and Gravells, J. (2007) Mentoring, Exeter: Learning Matters.

Walsh, D. (2010) The Nurse Mentor’s Handbook: Supporting Students in Clinical Practice, Maidenhead: McGraw-Hill/Open University Press.

West, S., Clark, T. and Jasper, M. (2007) Enabling Learning in Nursing and Midwifery Practice: A Guide for Mentors, Chichester: John Wiley.

Willis Commission (2012) Quality with Compassion: The Future of Nursing Education, London: Royal College of Nursing [online].


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)


Promoting young people’s resilience through enjoyable structured activities.


Concerns about child protection and wellbeing have been increasing in the UK (Kids Company 2014) and internationally (WHO 2012), particularly for those experiencing significant adversity. Such adversity has been defined as intense and/or persistent negative life events including: neglect, abuse, poverty, mental health challenges, addictions, disability and discrimination (Hart et al 2007). Lack of appropriate supports to respond to adversity can have a detrimental impact on children’s development and adult life (Masten and Cicchetti 2010). Resilience involves a dynamic process of positive adaptation to adversity and, accordingly, a resilience frame of reference can facilitate the understanding of young peoples’ strengths and challenges (Hart et al 2007, Masten 2011). Assessing resilience requires taking into account assets and resources within an individual and their environment, and longitudinal processes that lead to resilient outcomes (Ungar 2009). Successful recovery from adversities can contribute to future resilience and debate has focused on internal factors and external factors that may promote resilience (Rutter 2012); yet an occupational perspective (Wilcock and Hocking 2014) calls attention to the potential role of human doing which involves an interaction of internal capacity with the external world.

Literature review

Current resilience research employs multidisciplinary approaches to investigate how individual and environmental factors work together to promote resilience among the most disadvantaged youth (Hart et al 2007, Masten 2011). This includes expanding the evidence base for activity-based interventions (Hart and Heaver 2013) and exploring the perspectives of the professionals involved (Teram and Ungar 2009). A resilience research project, Imagine (2015), has proposed investigating past resilience-building strategies to facilitate reflection on current practices and enhance service provision.

Some studies suggest that activity participation can enhance resilience in young people through development of positive self-identity, including improvement in self-esteem, sense of control, self-awareness, coping, taking care of themselves, confidence, belonging, satisfaction, goal-orientated behaviour and optimism (DeLuca et al 2010, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). Accordingly, Jessup et al (2010) and Grunstein and Nutbeam’s (2007) found leisure activities promoted all of the above.

Participation in leisure activities and apprenticeships has been linked to the resilience indicators of improved learning outcomes, and development of new roles and responsibilities (Hart et al 2007, Ungar 2009). A robust study (Scholl et al 2004) found that graduates with and without disabilities from a youth apprenticeship programme reported advancement in their technical, communication, problem-solving and time-management skills, and made meaningful work transitions with appropriate support. Other studies identified a positive impact of leisure or vocational activities on school performance and further education (DeLuca et al 2010, Hart and Heaver 2013, Jessup et al 2010, Woodier 2011).

Developing friendships, interpersonal skills and belonging to supportive relationships is another resilience domain (Hart et al 2007, Masten 2011) associated with activity participation (Grunstein and Nutbeam 2007, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). DeLuca et al (2010) illustrates the important role of support and guidance in facilitating these positive outcomes. Two case studies were compared and demonstrated that appropriately graded adult assistance during an apprenticeship promoted positive personal, inter-personal and work outcomes. Conversely, lack of support was found to result in gradual disengagement until help was provided.

These findings are consistent with Wilcock and Hocking’s (2014) theory that through doing people shape who they are – they become – particularly as they move into adulthood. Thus receiving professional support and belonging to a social group appears to be important in promoting occupational wellbeing and resilience. Participation in appropriately structured play/leisure, exercise and employment related activities may address occupational injustice and the resilience indicator of meeting basic needs (Hart et al 2007, Masten 2011, Ungar 2009).

Evidence suggests that activity participation can promote resilience, however, the studies reviewed have a number of methodological limitations, including the lack of detailed description of settings, participants and interventions. Only Jessup et al’s (2010) research focused on leisure activities and only one study (Woodier 2011) was UK-based. Of the studies which included practitioners’ perspectives (DeLuca et al 2010, Woodier 2011) – just DeLuca et al (2010) provided in depth description of specific practitioner support strategies used to promote resilience.

Some longitudinal studies ranging up to three years were identified, but no papers presented accounts of past practices. Historical research may help to capture the complex processes of adversity and the use of occupational strategies in adapting to life transitions, including the change in availability of adequate supports (Kirk and Wall 2010, Wiseman and Whiteford 2007). Research into past practices may illuminate changes in both individual and organisational resilience over time. The research reported below explored the role activities have played in service provision over recent decades and its impact on youth resilience.

Reviewing the current literature led to the formulation of the following research question: how did retired professionals use activities to promote the resilience of young people they previously supported?


Study design

Ethical approval for this study was granted by the relevant University Research Ethics Panel. A qualitative approach was chosen for this exploratory study (Silverman 2010) underpinned by a critical realist ontological and epistemological position (Danermark et al 2002). This methodology holds that while every vulnerable youth experiences their situation of adversity subjectively, the reality of the adverse circumstances exists independently of that experience. Therefore it is valid for critical realist research to try and identify explanations for phenomena which may be relevant to different individuals in related contexts. The impact of the researcher’s experiences and views was acknowledged in line with a critical realist perspective that interpretations of reality will vary according to the perceptions and attributes of different people (Archer 1995). In-depth interviews were conducted with retired professionals to gain accounts on how they had previously used activities to promote young people’s resilience.


Purposive (snowball and criterion) sampling was used to recruit five participants allowing gathering of rich information within limited time constrains (Silverman 2010). The participants were retired people aged over 60 who had worked in health, social care and education and who used activity-based strategies to promote resilience in young people (aged 12-18) experiencing adversity in the UK. Participants were able to give their consent, had fluent English and confirmed that the young people they discussed were over 18 at the time of the research interview. The first five respondents were interviewed.


After consent was gained, approximately 80 minutes long interviews were carried out on university premises using semi-structured open questions, examples of which participants were given in advance. The questions included ‘Could you describe how you used an activity with a young person you worked with?’, ‘Could you describe the types of adverse situations the young person was going through?’ and ‘How did the activity engagement make a difference in the life of…?’ These questions were informed by resilience literature (Masten 2011, Ungar 2009) and discussions with boingboing resilience forum members (boingboing 2013), and their utility was confirmed by a pilot interview. During the interviews further prompts were given to encourage participants to expand or clarify particular points. These interviews were audio-taped and transcribed using pseudonyms to ensure confidentiality.

Data analysis

Data were analysed using a two stage narrative analysis methodology as rich narrative accounts can help to understand the meaning and social significance of the activities in a particular context (Polkinghorne 2010). The first stage was the creation of a chronologically organised core story with a beginning, a middle, an end and contextual factors (Clandinin and Connelly 2000). This chronological picture of the events afforded the potential to suggest the difference the activity participation made (Polkinghorne 2010). The second stage was interpretative and involved looking for regularly reoccurring themes within individual narratives and across them (Clandinin and Connelly 2000). Some themes emerged from the data and some were informed by the authors’ existing understanding of wider literature thus a combination of inductive and deductive approaches were used consistent with the critical realist methodology (Danermark et al 2002).

Credibility was enhanced through member checking in which participants were invited to comment on the key themes (Silverman 2010). The researcher also used a reflective journal throughout the duration of the research to ensure the confirmability.


The five participants came from social work, family therapy and teaching professions. Their detailed narratives covered periods of up to thirty years from the present. 12-18 years old youths’ experiences of adversity were found to be related to bereavement, trauma, anger management, anxiety, poverty, social deprivation, domestic violence and disabilities. The background characteristics of participants are described in table 1 below and a summary of their reported activity-based interventions for young people are shown in table 2. (Names of all individuals and organisations have been changed to protect anonymity).

Table 1. Participant practice information

Participants reflected on the most recent 10 years before they retired.

  • Matt – began career as youth worker in 1970s subsequently qualified as a social worker and then as a family therapist. Retired in 2012.
  • Jude worked as Special Educational Needs Co-ordinator in schools and nurseries since 1980s. Alongside that she volunteered at the Sparkle – a charitable organisation that provided weekly activities and occasional trips. Retired in 2013.
  • Sam – social worker at the Rainbow – a country-side based residential place offering ‘youth in trouble’ support to engage in constructive activities over the weekends. Retired 30 years ago.
  • Pat – qualified as social worker in 1980s. Discussed experiences at The Sunshine – a centre supporting children with learning and physical disabilities. Retired in 2012.
  • Ruth qualified as a primary school teacher in 1970s. Also volunteered with various youth organisations. Retired in 1990s.

Table 2. Summary of young people’s background, interventions and outcomes.

The adversities faced by young people:

  • Antisocial behaviours: stealing, lying, aggression, violence, property damage, youth offending.
  • Poor school performance/attendance/suspended.
  • Childhood trauma, including parent’s death, divorce, illness, single parenting, drinking, unemployment, chaotic routines, abuse, domestic violence, ‘bad parenting’.
  • Physical, mental health and learning difficulties/disabilities, substance misuse.
  • Poverty and financial struggles.

Activities used:

Mindfulness, family therapy, liaising with school and parents, (international) camping trips, running hip-hop groups, cooking, making beds, looking after chickens, Qi Gong, games, roller-skating, football, ice-skating, canoeing, walking in the woods, gardening, painting, knitting, visiting theatre, volunteering, psycho-education.


– representing mechanisms and contextual factors associated with participation in structured activities which influenced young people’s resilience – were identified from the data. These were: promoting positive emotional experience and expression; developing routines, responsibility and roles; constructive relationships; and, social policy and service-level change. These themes are presented in further detail below.

Promoting positive emotional experience and expression

Most participants stated that activity engagement promoted positive emotions in youth. Special Educational Needs Co-ordinator (SENCO) Jude explained that the games they play should always be fun. “That’s the whole essence of it in my mind. If they’re fun, then the children enjoy playing them.” While most enjoyed exploring a variety of activities, gardening was the only occupation that Eva took pleasure in and benefited from. “Everybody else was at the same stage as she was. She felt more at ease, […] less tense, more amenable and interested in what would happen – to see the flowers come out, the tomatoes forming”, reflected primary school teacher Ruth.

Activity enjoyment was also linked to increased confidence and self-esteem. For example, Bob was bullied at school and was never picked to play football, one of his favourite sports, as “macho boys would pick big guys” to join their team. The staff arranged for him to beselected, and “he was good at it – very quick and agile. […] The next time the other team wanted him as well”, remembered social worker Sam. This helped to build his self-respect, confidence and maturity – “he would not accept being bullied anymore”. This shows that increased resilience can enhance youth’s ability to both cope with and challenge adversity.

Family therapist Matt considered that embodied meditative activities transformed negative energy into positive and aided emotional and physical healing. “Sara could write a book on anxiety management. But in her body she was still experiencing huge anxiety’, recalled Matt. She stopped going to school and spent her days in bed. Qi Gong helped her to use negative anxious energy in her body, gather warm calm positive energy, placing and storing it in her lower belly. A few months later Sara returned to school and was relatively free from Irritable Bowell Syndrome.

Similarly, mindfulness-based approaches helped Paul to develop awareness and management of his anger enabling him to be happier and work towards his aspirations. Mindfulness helped Paul to notice the physical sensations in his hands, and how this related to his thoughts and feelings. “If you notice your hands clenching, is that happening when you are relaxed, tense, feeling angry? If the hands are relaxed, then you are relaxed”, explained Matt. Paul had to physically release his hands when they were tensing up. “With kids, if you get them to work with their bodies, it’s much easier than getting them to work with their emotions.” Paul did not get involved in any further violence. He returned to college and did well, aspiring to enter the same skilled trade as his father. Such enjoyable and meditative activities helped promote healing, active engagement, positive self-image and confidence.

Developing routines, responsibility and roles.

Improvement in structured routines, learning, sense of responsibility and future transitions was another category of reported resilience outcomes. Some young people had difficulties with following structured routines due to “chaotic” home environments, explained social worker Sam. A countryside-based residential home ‘Rainbow’ provided them with such opportunities for up to three days a week. They had to get up at certain time in the morning, help to make beds and prepare meals (some discovered they liked vegetables).

On occasions occupational participation involved disappointments and subsequent feelings of guilt, which, when reflected upon, could foster a better understanding of the consequences of their actions and a stronger sense of responsibility. Sam explained, “The big boys would go out and make sure the fox does not get any chickens. One day the fox got some of the chickens and they were very sad about that. Next time they would make sure the fox would never get any chickens.”

Improvement in anti-social behaviours could arise from being encouraged to take responsibility. Jude described how one boy “was at his best [and enjoyed himself] when I said ‘Will you push the wheelchair?’ […] Other times, I remember at one camp where he was on the top of that dung heap swearing loudly as people were passing. Give him a bit of responsibility, and […] he could rise to the occasion and do well and be successful.”

All the professionals wondered if the resilience that the activity promoted at the time had supported future transitions. There was evidence of improved school attendance and performance as Sara’s and Paul’s stories demonstrated, and they subsequently expressed clear aspirations for the future. Primary school teacher Ruth reflected that development of interests and skills could influence career choices. “It was amazing how some children would learn to cook, get a badge and eventually become a chef.” . Sometimes small improvements were observed while other times professionals were uncertain as to whether resilience was carried into home and school environments.

For some resilience only really manifested itself in adulthood. For example, Nora presented with difficult behaviours at the youth organisation. “But her lowest time was when she wasn’t [there]. She was virtually living on the streets for a while. […] She turned up to help years later. Her mother […] was incredibly impressed with her. […] Maybe all those experiences have given her real empathy. She really has turned a corner and is a very pleasant young woman […] training to be a social worker”, stated Jude.

Constructive relationships

According to the participants, structured activities could promote collaboration, constructive role-modelling, strong friendships, autonomy and reduction in antisocial behaviours. Teamwork was considered important by Jude because, “we all do our best if we cooperate rather than be in competition.” Cooperation was promoted by encouraging youth to play without winners and losers, learning to negotiate and compromise. “If you have never had socialisation and responsibility to a group you won’t [compromise] because the child is so strong in you”, explained social worker Sam.

Many professionals reported young people learned to consider and help others through engagement in structured activities. 14 year old Ann spent “so much time thinking about her own problems, things that she didn’t like […]”, remembered Jude. When they went on a camping trip overseas “everybody was ill [and] I expected her to be one of the worst, but […] she actually rose to the occasion.” She helped the children “who were really rough. […] Seeing somebody in a worse situation helped her to see that she had to think about them. […] I saw a side to her that I hadn’t seen anywhere else.”

Sometimes helping others involved becoming a role model of how to behave, being caring and helpful. “The younger ones knew they could rely on this older girl who was there to help to look after them’, recalled school teacher Ruth. Social worker Sam reflected that supporting others allowed children to learn that everybody has different strengths. She recounted how a 12 year old boy was teaching her roller-skating. “I was petrified – ‘I’m going to fall, break my neck!’ And he would say, ‘you won’t fall’. There was roundness in the relationship – it was not just about us teaching them.”

A few participants emphasised that activities helped to establish strong friendships that continued years after they left the youth organisations. Jude remembered Simon had “a massive head injury” as a result of a serious car accident. When his friends from the Sparkle went to see him, “he realised who they were and went to speak to them. His father was almost in tears because it was the first indication that his mind was working properly.” Simon made “a remarkable recovery” and his friends from the Sparkle “have been supporting him during all this time.”

Therapeutic support

Most professionals acknowledged that they played a central role in ensuring the activities were enjoyable and successful. SENCO Jude’s experience suggests that the role of the facilitator is to ensure that activities are fun. “It’s got to remain fun. If it doesn’t, then you quickly adapt the rules or move on to a different game. You don’t want to knock their confidence. You need to be vigilant.”

Professionals reported they nurtured youth’s resilience through role-modelling, encouragement, feedback and guidance within a safe space. Jude knew Peter was able to dance hip-hop, and so consistently encouraged and supported him to run a session for the younger ones. “I think he felt very pleased with himself afterwards.” With Jude’s guidance Peter was able to encourage a boy with learning difficulties who already knew some hip-hop. “It’s the sort of double-edged success. It’s a lot to do with giving opportunities, but then support to make sure that it does work.” By contrast, according to family therapist Matt and social worker Sam, some unstructured activities with peers could promote antisocial behaviours and maladaptive coping strategies.

Helping young people to reflect on their experience was an important part of the process. Family therapist Matt enabled Paul and his family to share their experience of bereavement exploring helpful strategies in supporting each other. While Eva was supported to explore “the other person’s point of view”, according to primary school teacher Ruth.

Social Policy and Service-level change

Some participants reflected that the integration of services, including working with families as a whole can help to sustain resilience outcomes, and considered they had witnessed improvements in this over time. According to social worker Sam who retired 30 years ago “there weren’t enough communication and togetherness [between the organisation and the parents]. It was quite isolated – we took them out of that sphere and put them in another. Our job was limited to 48 hours”. However, in more recent social worker Pat’s experience, “you are supporting the family so the family can keep the child at the centre. […] Now family social workers, might suggest working with brother and sister together […]. In those days there was nothing like that.”

Continuity of funding of youth organisations was reported to be a significant challenge in both the recent and more distant past. It led to the closure of the Rainbow thirty years ago and elsewhere it was implied that limiting therapy input might have contributed to Sara’s and Luke’s relapses. Matt and Jude reflected that getting government grants, is much more difficult now, and that time-limited interventions, targets and long waiting lists have become more predominant. Matt stated that in mental health services more funding is being directed towards talking therapies, while forty-fifty years ago “activities were all we ever did”. By contrast, social worker Sam believed activity participation has become more valued in school settings.

Some participants considered the sort of resilience-building work they used to do is being challenged by increasing recording on complex computerised systems as part of a drive to evidence accountability. Pat was concerned this can reduce the direct contact of working with children and their families. Sam was apprehensive about the lack of flexibility, increased focus on materialism and negative perceptions regarding being tactile with children. She was among those who expressed a relief they are not part of the current system.


A range of different activity types were reported, often closely aligning meditative or cognitive approaches, and those based more on activity itself. Retired professionals’ descriptions of the impact activity participation had on young people facing a range of adversities revealed commonalities. Structured activities promoted competence, confidence, self-esteem, self-awareness, roles, routines, responsibility and constructive relationships as was also found by Hart et al (2007), Jessup et al (2010) and Scholl et al (2004). Sometimes this translated into long-lasting friendships, better learning outcomes and future achievements supporting the findings of DeLuca et al (2010) and Woodier (2011).

The extent to which resilience was achieved varied and appears to have depended on a number of factors. Successful outcomes were linked to positive emotional experience. This elaborates upon some findings in previous studies that have made more limited reference to role of positive emotions in building resilience through activity participation (DeLuca et al 2010, Jessup et al 2010, and Woodier 2011). More broadly, positive emotions have been proposed to be an underlying mechanism for resilient adaptation, associated with resistance to and recovery from stressful life events (Ong et al 2010). Thus some of the successful transitions undertaken by young people may have been aided by positive emotions experienced during the activities which participants described.

When enjoyment is the main reason for pursuing an activity and the level of challenge matches the existing skills, flow or optimal positive experience can occur (Csikszentmihalyi 2002). Such deep and sustained immersion in the activity can contribute to opening up to new opportunities emphasised also in resilience research (Ungar et al 2005), potentially leading to a turning point in a young person’s life. Positive emotions are also related to feeling calm, safe, connected and trust in others (Csikszentmihalyi 2002), which may have further contributed to successful resilience outcomes of the kind reported by our participants.

Because children and youth naturally enjoy play (S Bazyk and J Bazyk 2009), experience of flow may be a significant mechanism in their engagement and resilience. According to flow theory, pursuing the optimal experience is the main motivation, while skills naturally develop as the level of challenge required to enter flow gradually increases (Csikszentmihalyi 2002). Yet, rather than reflecting on the direct impact of the experience of doing, many of the participating professionals emphasised the way in which activities helped people develop transferable social, educational and life skills as was also the case with studies discussed in the literature review (DeLuca et al 2010, Grunstein and Nutbeam 2007, Hart et al 2007, Jessup et al 2010, Peck et al 2008, Scholl et al 2004, Woodier 2011).

Given that enjoyment may be central in promoting positive experience and success, a good knowledge of how to nourish such experience would seem to be important for those using activities to support young people. There was some suggestion this was more challenging when young people presented with disabilities that professionals were less familiar with. Despite Csikszentmihalyi’s (2002) indication that matching challenges and skills is a vital component of achieving flow (2002), and suggestions that it may also promote resilience (Scholl et al 2004, Ungar et al 2005, DeLuca et al 2010), there was limited discussion by the professionals interviewed in this study of the importance of adapting activities, and increasing the level of challenge. That is not to say that participants did not use strategies of adaptation and grading that are familiar to occupational therapists (Creek 2010) – rather, it may be that the participants’ professional backgrounds provided them with lenses which drew attention to other areas and a language which is better able to express them rather than occupational factors. Similarly, whilst there was little evidence of using goal setting strategies (Dawes and Larson 2010), professionals showed their expertise in rule-setting, fostering collaboration and debriefing – helping youth to consider more constructive stories about themselves and others around them. This was also recognised to be important by DeLuca et al (2010), Jessup et al (2010) and Woodier (2011).

While flow involves a deep level of enjoyment with the awareness of time and space drifting into the background, mindfulness-based activities, also highlighted in the findings, entail conscious awareness of whatever arises in one’s physical, emotional and social being, including unpleasant experience (Reid 2011). In some cases the state of mindfulness and flow may merge and more research is required to examine this. Nevertheless, the findings support Rempel’s (2012) literature review which identified an association between mindfulness and pursing positive experience, reducing problem behaviours and promoting desired outcomes. Similarly, Schonert-Reichl and Lawlor’s (2010) high quality quasi-experimental study found mindfulness can significantly increase positive emotions, social and emotional competence, particularly optimism, self-awareness, attention and concentration, in turn improving classroom learning and resilience. While their finding is consistent with the current study, Sara’s relapse suggests that following up mindfulness interventions is important.

Retired practitioners in the current study suggested that addressing a young person’s capacity to cope with adversity on an individual basis alone may not be sufficient to sustain resilience – a point advanced by resilience researchers such as (Hart et al 2007) and Ungar (2009). Many young people had a history consistent with Wilcock and Hocking’s (2014) definition of occupational deprivation involving limited opportunities to engage in meaningful occupations due to the lack of resources, poverty and fragmented families. In this context maladaptive coping strategies became attractive alternatives to meet their physical and psycho-social needs (Caldwell and Smith 2013, S Bazyk and J Bazyk 2009). The UK government is targeting child poverty (HM Government 2014), however, the proposed strategy has been critiqued as insufficient in the context of widening inequalities and more comprehensive resources, child protection and wellbeing approaches are required (Kids Company 2014).


The interpretation of data was influenced by the researcher’s unique life experience and could be interpreted differently by other researchers. Multiple factors contribute to resilience, and this study highlighted the contribution of activity participation and only from the professionals’ perspectives. Young people’s experiences might have been different and future studies could gather data from both parties. Memory bias is also possible and further research could include interviewing current professionals. Recruiting occupational therapists could provide a comparative analysis of how that profession’s use of activities across services has changed over time. Definite conclusions are difficult to draw from the study due to the heterogeneity of the professionals’ and youth backgrounds, activities, services and points in history.

Implications for practice

Structured enjoyable activities can be significant in promoting resilience. The practitioners in the current study made valuable contributions that have clear relevance to occupational therapists and other people working with children and young people in adverse circumstances. This includes nurturing the experience of fun, mindfulness applications, family-centred practice, debriefing strategies, promoting collaboration, creative interventions, and considering longer-term impact of participation in activities on young people’s resilience. Analysis also suggest there are opportunities in this area of practice for occupational therapists to offer their knowledge of a broad range of disabilities and associated functional impact, and their expertise in individualised goal setting and activity grading.


Analysis suggests that key mechanisms through which participation in structured activities promoted resilience for the young people were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; alongside this, the presence of opportunities for constructive relationships and therapeutic support were important contextual factors. Participants noticed a number of changes over time to policy and service provision. Increased integration of services were judged to have improved efforts at resilience building, whilst concerns were expressed with regard to funding constraints and that administrative monitoring of professionals’ work provided less time for active engagement with youth. Analysis also identified opportunities for occupational therapists and occupational perspectives to make a greater contribution to supporting young people in adversity.

Key findings:

  • Enjoyable structured activities can promote youths’ resilience
  • Key mechanisms were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; enabling constructive relationships and providing therapeutic support

What the study has added:

Increased understanding of how participation in structured activities can build young people’s resilience. More broadly the study has helped establish the relevance of occupational perspectives to resilience research and practice.


The authors thank: firstly, the participants for sharing their rich experiences; and secondly, Professor Angie Hart and other members of the Boing-Boing Resilience Research and Practice network and collaborators in the Connected Communities Imagine project for advice and inspiration.

Kristina Usaite, Occupational Therapist, Sussex Partnership NHS Foundation Trust; University of Brighton and Dr Josh Cameron, Principal Lecturer, School of Health Sciences, University of Brighton.

Reference list

Archer MS (1995) Realist Social Theory: the Morphogenetic Approach. Cambridge: Cambridge University Press.

Bazyk S and Bazyk J (2009) Meaning of occupation-based groups for low-income urban youths attending after-school care. American Journal of Occupational Therapy 63(1): 69-80.

boingboing (2013) Resilience forum, University of Brighton. Available at: (accessed 15 October 2013).

Caldwell LL and Smith EA (2013) Leisure as a context for youth development and delinquency prevention. In: France A and Homel R (eds) Pathways and Crime Prevention: Theory, Policy and Practice. New York: Routledge, pp. 271-297.

Clandinin DJ and Connelly FM (2000) Narrative Enquiry: Experience and Story in Qualitative Research. San Francisco: Jossey-Bass.

Creek J (2010) The Core Concepts of Occupational Therapy: a Dynamic Framework for Practice. London: Jessica Kingsley Publishers.

Csikszentmihalyi M (2002) Flow: the Classic Work on How to Achieve Happiness. New York: Random House.

Danermark B, Ekstrom M, Jakobsen L and Karlsson JC (2002) Explaining Society: Critical Realism in the Social Sciences. Abingdon: Routledge.

Dawes NP, Larson R (2011) How youth get engaged: grounded-theory research on motivational development in organized youth programs. Developmental Psychology 47(1): 259-269.

DeLuca C, Hutchinson NL, DeLugt JS, Beyer W, Thornton A, Versnel J, Chin P and Munby H (2010) Learning in the workplace: fostering resilience in disengaged youth. Work: A Journal of Prevention, Assessment and Rehabilitation 36(3): 305-319.

Grunstein R and Nutbeam D (2007) The impact of participation in the Rock Eisteddfod Challenge on adolescent resiliency and health behaviours. Health Education 107(3): 261-275.

Hart A, Blincow D, and Thomas H (2007) Resilient Therapy: Working with Children and Families. Hove: Routledge.

Hart A and Heaver B (2013) Evaluating resilience-based programs for schools using a systematic consultative review. Journal of Child and Youth Development 1(1): 27-53.

HM Government (2014) Child poverty strategy 2014-17. London: TSO.

Imagine (2015) Imagine: Work package 2: the historical context. Available at: (accessed 23 February 2015).

Jessup GM, Cornell E, and Bundy AC (2010) The treasure in leisure activities: fostering resilience in young people who are blind. Journal of Visual Impairment and Blindness 104(7): 419-430.

Kids Company (2014) How did we get here? A review and analysis of children’s services policy and practice from 1945 to 2014. London: Kids Company. Available at: (accessed on 31 July 2014).

Kirk J and Wall C (2010) Resilience and loss in work identities: a narrative analysis of some retired teachers’ work‐life histories. British for research, practice, and translational synergy. Development and Psychopathology 23(2): 493-506.

Masten AS, Cicchetti D (2010) Developmental cascades. Development and Psychopathology 22(03): 491-495.

Ong AD, Bergeman CS and Chow SM (2010) Positive emotions as a basic building block of resilience in adulthood. In: Reich JW, Zautra AJ and Hall JS (eds) Handbook of Adult Resilience. New York: The Guildford Press.

Polkinghorne DE (2010) The practice of narrative. Narrative Inquiry 20(2): 392-396.

Reid D (2011) Mindfulness and flow in occupational engagement: presence in doing. Canadian Journal of Occupational Therapy 78(1): 50-56.

Rempel K (2012) Mindfulness for children and youth: a review of the literature with an argument for school-based implementation. Canadian Journal of Counselling and Psychotherapy 46(3): 201-220.

Rutter M (2012) Resilience as a dynamic concept. Development and Psychopathology 24(02): 335-344.

Scholl L and Mooney M (2004) Youth with disabilities in work-based learning programs: factors that influence success. The Journal for Vocational Special Needs Education, 26(2): 4-16.

Schonert-Reichl KA and Lawlor MS (2010) The effects of a mindfulness-based education program on pre-and early adolescents’ well-being and social and emotional competence. Mindfulness 1(3): 137-151.

Silverman D (2010) Doing Qualitative Research: a Practical Handbook. London: Sage.

Teram E and Ungar M (2009) Not just the master discourse: a case for holistic case studies of youth resilience. In: Ungar M and Liebenberg L (eds) Researching Resilience. Toronto: University of Toronto Press, pp.103-128.

Ungar M (2009) A sample research proposal for a mixed-methods investigation of resilience: the pathways to resilience project. In: Ungar M and Liebenberg L (eds) Researching Resilience. Toronto: University of Toronto Press, pp.271-296.

Ungar M, Dumond C, and Mcdonald W (2005) Risk, resilience and outdoor programmes for at-risk children. Journal of Social Work, 5(3): pp.319-338.

Wilcock AA, Hocking C (2014) An Occupational Perspective of Health. 3rd ed. Thorofare: Slack Incorporated.

Wiseman LM, Whiteford G (2007) Life history as a tool for understanding occupation, identity and context. Journal of Occupational Science 14(2): 108-114.

Woodier D (2011) Building resilience in looked after young people: a moral values approach. British Journal of Guidance & Counselling, 39(3): pp.259-282.

World health organisation (2012) Health behaviour in school-aged children international report from the 2009/2010 survey. Copenhagen: WHO. Available at: (accessed 21 December 2014)


The Therapeutic Relationship and Issues of Power in Mental Health Nursing


Objectives: The therapeutic relationship is an important concept to mental health nurses, and many believe it to be the essence of nursing practice. However, the nurse patient relationship is one of imbalanced power. This study, completed as a BSc dissertation project, forms a scoping review, utilising a systematic approach, to examine the research on the relationship between power and the therapeutic relationship, with relevance to mental health nursing.

Methods: Literature was found online through texts available in the university library catalogue using a variety of search strategies. Literature was searched for on Cumulative Index to Nursing and Allied Health Literature, PsychINFO, ProQuest hospital collection, British Nursing Index and ScienceDirect. Additional articles were found using an ancestry and decendancy approach.

Results: Existing research gives collaborating evidence that there is a relationship between power and the therapeutic relationship. Not only is coercion related to negative evaluations of the therapeutic relationship, but the main way in which professionals influence patients to make healthy choices is through the therapeutic relationship. The context in which mental health nursing takes place also influences this relationship.

Conclusions: As there appears to be a relationship between power and the therapeutic relationship, nurses who identify with the concept of the therapeutic relationship would benefit from considering power as a pertinent theory. Nursing academics need to direct more resources towards researching power as there appears to be a dearth of nursing literature on this topic, particularly in the United Kingdom. Professionals may benefit from reflecting upon power as a concept that affects their reciprocal relationships with patients.


Although nursing is not generally considered a powerful profession (Barker 2009a), power dynamics frequently become apparent when thinking about relationships within nursing (Wilkinson and Miers 1999). Nowhere is this power more relevant than in the field of mental health, where legal powers are granted in order to detain persons who are deemed unwell and in need of assessment or treatment (The Stationary Office 2007).

Despite on-going criticism of psychiatry and its association with coercion, control and power (Szasz 2007; Foucault and Howard 1967; Goffman 1968), and continuing lack of evidence to demonstrate the effectiveness of compulsory treatment (Kisely and Campbell 2014), recent reports suggest coercive practices in the United Kingdom are increasing (Care Quality Commission 2015).

Resistance to the idea of coercion and control in psychiatry, may be found in the idea of empowerment, service user involvement and recovery, which have gained popularity in nursing literature (Barker 2001; Lloyd 2007; Caldwell et al. 2010) and in mental health policy (Department of Health 2011). However, the extent to which empowerment is possible, and its actual impact on service users true freedom and consent within a system that endorses detention and compliance, has been problematised (Grant 2009). This implies that it is important to think about empowerment in the context of the imbalanced power relationships that exist in mental health. That nurses endorse empowerment without appropriately considering the concept of power, may contribute towards ambiguity in terms of the approaches and definitions of empowerment within the nursing literature (Ryles 1999).

Perhaps the most pertinent theorist on power within mental health is Foucault due to his examination of madness (Foucault and Howard 1967), and of medical power (Foucault and Sheridan 1973). For Foucault, however, power is not something that can be held by certain groups or individuals, nor is it exclusive to intentional action. Power is essentially a positive force which permeates all levels of society and people are always simultaneously undergoing and exercising this power. Power, in this sense, is legitimised through knowledge ascertaining to what is considered true, or “discourse”. People are disciplined by discourses that work as normalising structures which guide people to understand the world and their bodies in certain ways (Foucault and Sheridan 1979). Although Foucault’s conceptualisation of power has been criticised as generalised to the extent that it loses any analytic force (McNay 1994), It also opens up ways of thinking about power differently, simultaneously avoiding specificity and reductionism.

The effects of power on relationships is pertinent to the role of mental health nurses as the “therapeutic relationship” is frequently cited as the core of nursing (Barker 2009b; Browne et al. 2012; Dziopa and Ahern 2008; O’Brien 1999).

The idea of therapeutic relationships were highlighted in nursing most notably by Peplau (1988, 16) who regarded nursing as ‘a significant, therapeutic, interpersonal process.’ This asserts the interpersonal nature of nursing, gives salience to nurse-patient relationships and highlights the need for these relationships to be therapeutic, promoting health and growth (Peplau 1988). Since Peplau, therapeutic relationships have been considered the core focus of mental health nursing (Barker 2009b; O’Brien 1999).

In order for a relationship to be therapeutic, though, it must function as more than an everyday relationship. It is a relationship in which the patient feels accepted as a person of worth, free to engage in self-expression without fear of rejection. Therapeutic relationships should involve communication that helps the nurse understand the needs and perceptions of the patient, enable the patient to learn about, or cope more effectively with their environment, and result in the reduction or resolution of the patients’ problems (Reynolds 2009).

The popularity of the therapeutic relationship in mental health nursing has not meant it is easily defined, however. In fact, it may have become more difficult to define now that it is tied into the mental health nurse’s identity (Browne et al. 2012). A literature review on what makes good quality therapeutic relationship identified nine overlapping constructs within the nurse-patient therapeutic relationship (See image 1), which require a complex interplay of skills dependent on the needs of both nurse and patient at a given time (Dziopa and Ahern 2008). Judicious use of power is implicated as one mechanism through which the development of a good quality therapeutic relationship is achieved, although the possibility of nurses abusing said power is also duly noted.

The impact of power on the therapeutic relationship has been alluded to (Dziopa and Ahern 2008; Wilkinson and Miers 1999). However, a review of the literature within this area may shed increasing insights into whether a relationship exists. This literature review, Inspired by my curiosity from practice, defines power as bi-directional, as something that can be used negatively (in coercion, compulsion, force and threat) and positively (through empowerment and legitimate authority or leadership). It also acknowledges that power can be overt (as in restraint or seclusion), or subtle (as in persuasion, approval and observation).

This literature review aims to highlight common themes in academic literature, and areas where more research is needed answering the question:

How does current primary research, with relevance to mental health nursing, explore issues of power within the therapeutic relationship?

There is potential for findings to help guide practice enabling nurses to be aware of the benefits and drawbacks of different facets of power and their use within the therapeutic relationship. It is also possible that the evidence found may confirm or deny whether these concepts are related.


The research question was developed during the process of preliminary searching around the concept of power and the therapeutic relationship. This allowed me to gain a sense of what published research existed on my chosen topic, leading to the development of a question that could be answered by the research available without becoming over or under saturated aiming for between 10 and 20 articles (Aveyard 2014).

As power can be conceptualised in different ways (Scott 2001), which may result in the exploration of different perspectives, it is important to use the appropriate terms associated with those perspectives in order to find a breadth of literature. Some synonyms of power have been mentioned in the introduction – yet preliminary searching revealed more. Authority represents the legitimate use of power while Control, coercion, restraint and restriction represent more invasive uses of power (Scott 2001). In addition, Agency and empowerment could be seen as positive elements of power whereas influence and leverage are more subtle forms of power (Wilkinson and Miers 1999). These synonyms of power were utilised as unique search terms in my preliminary search strategy.

Observations from preliminary searching demonstrated a dearth of specifically nursing literature within this topic indicating my search strategy would need to be broad. A systematic approach was adopted for the primary search strategy in order to gain a sense of the literature that already exists on this subject. Four separate search sectors were developed to ensure specificity to nursing, mental health, power and the therapeutic relationship respectively. These search sectors were combined using the Boolean logic AND so all results returned were relevant to all the search sectors (Boagy et al. 2013).

Within the search sectors, additional search operators were used informed by literature specific to performing a literature search (Aveyard 2014; Boagy et al. 2013; Jesson et al. 2011).

The extent that the search was restricted by the generic search sectors was then considered. “Therapeutic relationship” was considered as a limiting search term that may be described in other ways, for example, “therapeutic alliance” is another term that could be used. Further exploration uncovered “helping alliance” and “working alliance” but these proved to be more relevant to counselling and psychotherapy than nursing and including them did not expand results. The term “relationship” on its own was also considered, which caused the search to become too broad with an unmanageable amount of results (n=1108) from just one database.

The following databases were accessed as considered the most relevant to nursing psychiatry and sociology: CINAHL, PsychINFO, ProQuest hospital collection, British Nursing Index and Science Direct.

It was then necessary to develop inclusion and exclusion criteria (Table 1) in order to define the scope of the review (Aveyard 2014) and answer the research question: how does current primary research, with relevance mental health nursing, explore issues of power within the therapeutic relationship?

Inclusion and exclusion criteria

  • Only articles exploring power (and its synonyms) and the interpersonal relationship were included.
  • Only articles that were relevant to nursing were included. This included articles that were interdisciplinary in nature but excluded articles that were exclusive to other professions such as physicians.
  • Articles examining control and restraint as an intervention were excluded.
  • Only primary research was included.
  • Only research published after 2004 was included.
  • Only research available in English was included.
  • Research from all specialities of mental health was included.
  • Research from all countries was included.

As it is possible that searching through online databases alone may not find all relevant research, snowball sampling was used to accent this initial approach (Aveyard 2014).

When the full texts of the final articles were read, 9 did not meet inclusion criteria, leaving 10

Although similarities between findings were apparent from an early stage and fit into themes, to aid in presentation of the findings, articles were instead split into themes according to the approach used to gather data, rather than their findings. Critical analyses of each article took place using a research appraisal framework by Caldwell et al. (2011) as it is appropriate for both quantitative and qualitative research, both of which were included in the review. Critical appraisal of the articles were presented in the appropriate themes and the impact of each article was considered and synthesized for discussion.

The relationship between perceived coercion and evaluations of the therapeutic relationship

Four of the studies found through the literature search were Quantitative studies measuring service users’ perceptions of coercive practices alongside their evaluations of the therapeutic relationship to see if there is an association between these concepts. The following articles result in a fairly narrow conceptualisation of power as coercion, which, despite being often measured on a continuum, does not allow for positive conceptualisations of power. Also, a variety of measures are used to describe the therapeutic relationship resulting in some conceptual discrepancies within this area too. Despite this, the articles demonstrate that a relationship does exist between these concepts, which is significant (p<0.05) in three out of the four studies.

Stanhope et al. (2009) acknowledge case managers use of pressure in assertive community treatment of vulnerable populations in Pennsylvania, USA and seek to examine consumer’s perspectives in relation to these pressures through use of surveys delivered through face to face interviews. They recognise that introductions with consumers had to be negotiated through case managers which may result in social desirability bias.

Findings show a modest relationship between consumer-provider relationship, and perceived coercion with small effect size but no relationship between case manager’s utilisation of coercive strategies (pressure), and perceptions of coercion. It is noted, however, that case managers utilised almost exclusively low-end coercive strategies, such as verbal guidance (Neale and Rosenheck 2000). Higher perceived coercion was also related to shorter service contacts with a small effect size; more years spent in services with a medium effect size and negative service evaluation with medium to large effect size.

Sheehan and Burns (2011), from a complimentary perspective, seek to test a hypothesized association between the therapeutic relationship and the experience of coercion. A cross sectional cohort study was conducted for a consecutive sample of admissions to five acute hospitals in Oxford, England. Sheehan and Burns (2011) report a similar response rate (75%) to other articles exploring perceived coercion, but acknowledge that patients who decline to participate in research may have different views to those who did participate. How the population used in this study differs from a UK population is noted with consequences for generalizability.

Sheehan and Burns (2011) show that positive evaluations of therapeutic relationship with admitting clinician (12% identified as nurses), were significantly associated with low levels of perceived coercion; low levels of negative pressure and high levels of procedural justice, as measured by the AES. Perceived coercion was higher in participants who had been involuntarily admitted and logistic regression analysis showed the therapeutic relationship as an important factor, explaining 6% of the variance in perceived coercion. Just 21% of the variance was explained through the collected data indicating that other factors also come into play, including relationships with other staff members.

Furthermore, Theodoridou et al. (2012) use a similar approach in their study utilising a survey delivered through face to face interviews to measure the relationship between perceived coercion and the therapeutic relationship.

Theodoridou et al. (2012) show that higher levels of perceived coercion were consistently related to worse evaluations of the therapeutic relationship. Furthermore, involuntary admission, history of involuntary admission diagnosis of schizophrenia were all associated with higher AES scores.

These three articles present corroborating evidence to demonstrate that higher ratings of the therapeutic relationship are linked to lower perceptions of coercion in inpatient psychiatric populations across England (Sheehan and Burns 2011) and Switzerland (Theodoridou et al. 2012) and Assertive Community Treatment populations in the USA (Stanhope et al. 2009).

Wolfe et al. (2013), examine the relationship between coercion, motivation and therapeutic alliance in community-based drug and alcohol treatment in New South Wales, Australia. The researchers show that coercion was significantly related to external motivation and that external motivation was partially related to lower therapeutic alliance. However, no significant relationship was found between coercion and therapeutic relationship, apart from for the variable “openness”.

Patients perceptions of power and the therapeutic relationship

Further to the quantitative articles discussed previously, four articles found in the literature search were qualitative studies examining service users’ perspectives of power in various forms. While none of these studies sought to examine the therapeutic relationship, relationships with professionals emerge as an important concept from their results.

The following qualitative articles should help expand on the reductionist nature of quantitative research, enhancing understanding of how the variables of power and the Therapeutic relationship relate to each other in certain situations, as understood by service users, giving some sense of the complexity of this relationship.

Thogersen et al. (2010) aim to explore whether patients perceive Assertive Community Treatment (ACT) to be a coercive service due to ongoing academic debate about coercive aspects of the assertive provision of care. Participants were recruited, using staff as gatekeepers, from two newly formed ACT teams in Copenhagen, Denmark.

Themes were revalidated through agreement among other researchers and participants.

Lack of active participation in treatment processes and a poor alliance with case managers; not being recognised as an autonomous person and crossing the line and intruding on privacy, were recognised by Thogersen et al. (2010), as themes enhancing perceptions of coercion. On the other hand, a collaborative and mutually trusting relationship with case managers; commitment, perseverance and availability and a recognition of the need for social support and assistance with everyday activities were experiences that counteract perceptions of coercion. These themes can easily link coercion with the therapeutic relationship but also indicate other important factors, including time spent with patients; providing support; intrusion on privacy and case managers’ attitude demonstrated towards the patient. The study also demonstrates that different services invoke different experiences that relate to perceptions of coercion. Namely, ACT was considered coercive in that it was intimidating and overwhelming, whereas experiences of coercion in other services were related to lack of autonomy, lack of alliance with staff and lack of influence on treatment.

Tveiten et al. (2011) seek service users’ views and experiences of empowerment utilising data from focus group interviews. They define the concept of empowerment, relating it to concepts of advocacy, service user involvement and participation, stating that user participation allows transcendence of the power hierarchy inherent in psychiatry. The population is selected from two inpatient units in Norway, each with different acuity, but similar in relation to the services offered.

The three main themes included possibilities and presuppositions for participation, influence of the system on the empowerment process, and collaboration along a continuum of power between empowerment and powerlessness. Interesting to note for this review is that, in the possibilities and presuppositions theme, participants spoke about real acknowledgement, rather than acknowledgement as a formal claim.

Laugharne et al. (2012) aim to examine the experiences and attitudes of patients with psychosis in relation to factors that enhance or undermine trust, choice and power utilising face to face interviews. They acknowledge that, while participants found it difficult to engage with the concept of power, two overarching themes emerged. First that patients feel the need for a shifting balance of power that moves over time and is dynamic according to circumstances. Crucial to this shifting of power is improving patients’ understanding by providing them with information. Within this theme it is also suggested that threats of coercion and neglect disable patients.

Second, patients saw a trusting relationship as vital in their care. Trusting relationships are portrayed as going beyond the recognised expertise gained through training and experience, to include attributes and behaviours of patients as well as staff. The value of a personal touch was also stressed through aspects of kindness, hopefulness, friendliness, conversations about shared interests and personal disclosure from staff. There was contradictory evidence from some participants who suggest that they thought patient views should take precedence over scientific evidence and that relying on scientific knowledge was disempowering for patients.

Maguire et al. (2014) used a purposive sampling of 12 nurses and 12 patients from a forensic hospital in Australia to explore the practice of limit setting – a potentially coercive intervention, from both nurses and patients perspectives – in order to propose principles to guide practice. Limit setting is frequently used in forensic settings and it focuses upon setting boundaries in the therapeutic relationship and limiting or preventing disruptive behaviour.

Maguire et al. (2014) propose three themes. First, limit-setting is valued by patients as it sets boundaries around what are acceptable or unacceptable behaviours, promoting safety structure and control in the unit. This is also proposed as development of a therapeutic milieu.

Second, engaging patients in an empathic manner indicates that patients don’t find limit-setting as coercive in itself, but this is mediated by elements of the relationship in which patients feel understood, and understand why the limits have been set. Experiences of humiliation and disrespect contribute to coercive experiences, whereas experiences of limit-setting in a caring way did not damage the relationship or lead to negative outcomes.

Thirdly, the authoritative, rather than authoritarian style of limit setting suggests that, from a patient perspective, an authoritarian style is experienced as intimidating, aggressive and disrespectful and damages the therapeutic relationship. Conversely an authoritative style involves the nurse being knowledgeable about the patient and setting limits in a fair, consistent and respectful manner.

Nurses perceptions of power and the therapeutic relationship

Some qualitative articles found through the literature search considered power and the therapeutic relationship from a professional perspective. The professional perspectives explored appear to be more varied than the patient perspectives, some posing as a challenge to the use of power while others accepting the necessity of using power (or influence) to encourage healthy behaviours.

Maguire et al. (2014), explore nurses’ perceptions of limit setting, alongside previously mentioned patient perspectives, in forensic services. Many of the nursing perceptions are similar to patients’ perceptions, with nurses giving stories of observed poor practice resulting in aggressive responses or poor outcomes. However, separate to patients’ views, many nurses were uncomfortable with the term limit-setting as they believed it implied exerting control over patients as a coercive intervention.

Other nursing staff confirmed patient views, that limit setting was important for safety and maintenance of the therapeutic milieu. Having an understanding of the patient, and being fair, respectful and consistent was crucial to patients responding positively to limit-setting.

Cutcliffe and Happell (2009) highlight that interpersonal relationships, which are fundamental to nursing practice, are replete with issues of power. Despite discussions about empowerment being popular in the literature, Cutcliffe and Happell (2009) point out that there is a dearth of nursing literature examining power as it may be a difficult or uncomfortable subject for nurses. The study utilises examples from practice, with consideration for confidentiality, to illustrate health professionals’ use of power over consumers. Examples from practice enable naturalistic generalisations where readers gain insight through recognition of similarities in case study details and find descriptions that resonate with their own experiences.

Cutcliffe and Happell (2009) argue that these examples are tied to the use of invisible power through the dominant discourse of bio-psychiatry. They illuminate the recovery discourse as a viable alternative to this in which nurses can reconnect with Peplau’s theory of mental health nursing or, in other words, re-value the therapeutic relationship. However, this article paints an exclusively negative picture which taken alone may overemphasize the prevalence of the use of invisible power in current mental health practice.

In contrast, Gardner (2010) reports on a preliminary theory of how mental health nurses establish therapeutic relationships and maintain professional boundaries. The theory portrays the establishment of the therapeutic relationship as a gradual process, which begins with “therapeutic friendliness”, and develops through stages of “therapeutic engagement”, until a “therapeutic relationship” is developed and deepens over time.

Similar to Laugharne et al. (2012) who indicate that patients appreciate personal disclosure and conversations about shared interests, this study indicates that therapeutic engagement begins with a process of being friendly, which is not based on professional roles, but rather on getting to know each other. This is demonstrated to be particularly important in order to counteract the previous negative experiences many mental health clients have had in services before, supporting results suggesting that previous experiences of coercion might result in a higher likelihood of perceiving coercion in future (Laugharne et al. 2012; Theodoridou et al. 2012; Thogersen et al. 2010).

As a relationship progresses through the different levels of engagement it finally becomes a “Therapeutic Alliance” in which nurses can use “Therapeutic Leverage” as a form of influence that helps the client make the best decisions regarding their illness and health. It is important to recognise that “Therapeutic leverage” is different from coercion or manipulation, which would jeopardise the therapeutic relationship making it more difficult to manage. The level of influence a nurse has through their “therapeutic relationship” with a client can also be compromised when professional boundaries become blurred, resulting in confusion from the client as to whether the relationship is a friendship or a professional one, highlighting significant complexities within this framework.

Rugkåsa et al. (2014) highlight contemporary professional roles that are both empowering and controlling in light of recent changes in mental health where professionals utilise a range of “influencing behaviours”. The use of existing groups promoted discussion of professional perspectives on the use of “influencing behaviours”, to which real cases and existing relationships could be referred.

The quality of their relationships emerged as the central way in which professionals influenced patients, highlighting the need for trust within these relationships to be built over time. Honesty, curiosity, fairness, empathy, consistency and reliability were considered important to demonstrate within the therapeutic relationship, which in turn promoted engagement from patients. Providing something outside of patient expectations, such as going for coffee, or helping with practical tasks, helped to create reciprocal obligations, similar to findings by Laugharne et al. (2012) which suggest that patients also appreciate conversations about shared interests and staff personal disclosure, which is traditionally considered beyond professional boundaries. Emphasising the reciprocity of relationships, the authors describe “negotiating agreements” as another mechanism for influence. The final way of exerting influence was indicated as “asserting authority”, noting professionals’ power to compel, mainly through the use of the mental health act. This was seen as an inferior approach to others as, although it is a useful way of ensuring patient safety, it also had the potential to undermine relationships. The authors describe the difficulty navigating patients’ expectations about coercion that arrise from them having experienced coercion before. In fact, the very context of having the Mental Health Act to fall back on can be experienced as coercive in itself.

Strengths and limitations of study

As a novice researcher at undergraduate level, this review is hindered by inexperience and limitations placed by financial and time restrictions (Aveyard 2014). Publication bias may be an issue for this review as literature was only found on electronic databases which could be improved if efforts were made to search for grey literature (Polit and Beck 2014). Single author reviews might also increase the potential for subjectivity and bias, although I have consulted with my dissertation tutor, which will hopefully have helped limit my own biases where evident. I have also acknowledged my own views at the beginning of this research so that it would be evident to others if my own views did influence the results.

In contrast, I consider the broad approach to this research a strength, as it demonstrates the complexity of power relations instead of focusing on a single area. Although most articles are not exclusively relevant to nursing they acknowledge the interdisciplinary nature of working within mental health and nurses’ core role within the interdisciplinary team. Recommendations may be found as relevant to other professions working in settings alongside nurses but may also lack specificity to nursing.


Power is a complex phenomenon that may need to be broken down into other elements in order to be better understood and researched. This review was able to observe some of the current trends in research relevant to mental health nursing as to the way in which power is conceptualised.

The findings of this review mainly converge upon 4 areas: Legitimate use of power by professionals, the adverse impact of coercion, force and neglect, how are balance and reciprocity important to both power and the therapeutic relationship, and the influence of the system upon these perceptions. Mental health nurses are clearly in a position of power in comparison to service users and this review proposes that this is not inherently bad. There are examples of where professionals use their power legitimately and this is beneficial. This relies upon having a good Therapeutic relationship. However, the potential for coercion if this power is misused is apparent and perceptions of coercion are related to poor evaluations of the therapeutic relationship. Professionals should be aware that balance and reciprocity may be important concepts when thinking about building relationships in the context of unbalanced power relations and might also want to acknowledge that structural and environmental factors can influence how patients perceive actions as either legitimate or coercive.

There were only three articles exclusive to nursing (Gardner 2010; Maguire et al. 2014; Cutcliffe and Happell 2009) although two further articles had nurses involved as part of the research (Thogersen et al. 2010; Tveiten et al. 2011). The extent to which nurses can accurately reflect on and engage with the concept of power, when it has been indicated as something which they are uncomfortable discussing (Cutcliffe and Happell 2009), is highlighted by the lack of articles exclusive to nursing and the language used to signify power within those articles, such as leverage (Gardner 2010) and limit setting (Maguire et al. 2014).

It has been noted elsewhere that there is a dearth of nursing literature regarding coercion which is surprising considering that nurses are involved, directly and indirectly, in many coercive interventions (Galon and Wineman 2010). Although this review is exclusive to nursing, it was difficult to find exclusively nursing-related literature. Additionally, patients may be uncomfortable with the idea of power due to its negative connotations as noticed in certain studies exploring patients’ perspectives (Tveiten et al. 2011; Laugharne et al. 2012).

Although three studies were of UK origin (Rugkåsa et al. 2014; Laugharne et al. 2012; Sheehan and Burns 2011) none of these included a nurse in the research process. This is an important limitation as the unique culture of the UK may provide unique challenges and perspectives. Future research in the UK, including nurses in the process, would enable more specific recommendations to UK nurses in various settings and may highlight areas of power explicitly relevant to nursing. The EUNOMIA study highlights differences in coercive practices across European countries (Raboch et al. 2010), further cementing the difficulty in generalising this review between countries. Interestingly, the only centre where nurses order coercive measures more frequently than physicians was the United Kingdom (Raboch et al. 2010). The need for nurses to be involved in research about coercion in the UK, when they are the ones most frequently ordering it, is evident. However, as results in this review appear to conform across cultures and are supported by an article of international approach (Cutcliffe and Happell 2009), some implications of this review should not be discounted From a UK perspective.

Recommendations and implications for practice and research

Despite consensus in this review that many relationships might exist between power and the therapeutic relationship, further research is needed due to the quality of the current quantitative research and the tendency to focus on a single element of power: coercion. In regard to the relationship between perceived coercion and evaluations of the therapeutic relationship, longitudinal studies may help determine whether this is a causal relationship and experimental studies may be appropriate if an intervention specifically targeted at building a therapeutic relationship can be developed. Studies should continue to use face to face interviews to collect data for surveys as, although this is more time consuming, it results in a more complete data set and higher response rate. Directions in research to date appear to be interdisciplinary, reflecting the increasing interdisciplinary nature of mental health care. However, an increased nursing emphasis needs to be applied to research in order to relate findings specifically to nursing. The articles in this review were all written in what are considered high income countries (The World Bank Group 2015) reflecting the higher number of mental health professionals employed as a proportion of the population in these countries (World Health Organisation 2011).

The current research is difficult to generalise to UK culture and more research is needed in order to assess whether these findings can be generalizable across cultures, and whether unique cultures have unique differences. However, the homogenous nature of high income countries mean it would be more reasonable to generalise the findings of this review to the UK than to developing economies who do not have such a developed mental health workforce. Ethnographic studies involving participant observation may also be helpful in future in order to see if there is a difference between attitudes as gathered by interviews, and actions as seen through observation (Gobo 2011). Future research needs to make efforts to attempt to gain the views of individuals who for various reasons did not want to participate in current research. This will obviously pose practical and ethical challenges, although involving service users as part of the research team may provide new perspectives due to the potential for people to change their responses in relation to who is asking the questions. This also highlights the importance of increased nursing involvement in these research teams, which are currently overrepresented by medical staff.

Nurses may benefit from acknowledging power as a relevant concept within their practice, which appears to be strongly related to evaluations of the quality of the therapeutic relationship. Power may be an uncomfortable topic to reflect on as it may be seen as equating to coercion, but not all power is perceived as coercive and may be perceived legitimately. Relationships are clearly indicated as a factor in which perceptions of power may change. Some of the important aspects in these relationships to ensure they are empowering and not coercive are fairness, reciprocity, authenticity and a personal touch. Sharing of power involves the sharing of information and needs to be balanced appropriately throughout the relationship in order to avoid feelings of either coercion or neglect.

The need to reflect upon power has been demonstrated and there is potential for (ab)use of power to damage the therapeutic relationship. Coercion is also remembered by service users and impacts their perceptions of future encounters within services. The coercive context of mental health services may make service users more sensitive to issues of power and more prone to perceptions of coercion – and the threat of coercion through the mental health act itself may cause formation of therapeutic relationships to be more difficult. It may not be a coincidence that mental health nurses ascribe such value to the therapeutic relationship if you consider how difficult it is to build relationships in a culture where coercion is so prevalent. The influence of the system should not be ignored when thinking about power and current models of practice should be evaluated to determine their benefits and disadvantages in relation to the power relationships they can produce and, in turn, the effect this has on building trusting therapeutic relationships. In particular, the allocation of time should be considered as an important aspect of whether our relationships with service users are coercive or therapeutic.

Neil Molkenthin. Mental Health Nursing, BSc (Hons) Nursing Student


Aveyard, H. 2014. Doing a literature review in health and social care : a practical guide. Maidenhead: Open University Press.

Bale, R., J. Catty, H. Watt, N. Greenwood & T. Burns. 2006. Measures of the therapeutic relationship in severe psychotic illness: a comparison of two scales. Int J Soc Psychiatry 52 (3): 256-66.

Barker, P. 2001. The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric & Mental Health Nursing 8 (3): 233-240.

Barker, P.J. 2009a. The politics of caring. London: Hodder Arnold.

Barker, P.J. 2009b. Psychiatric and mental health nursing : the craft of caring. London: Hodder Arnold.

Bettany-Saltikov, J. 2012. How to do a systematic literature review in nursing : a step-by-step guide. Maidenhead: Open University Press.

Braun, V. & V. Clarke. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3 (2): 77-101.

Browne, G., A. Cashin & I. Graham. 2012. The therapeutic relationship and Mental Health Nursing: it is time to articulate what we do! Journal of Psychiatric & Mental Health Nursing 19 (9): 839-843.

Busseri, M.A. & J.D. Tyler. 2003. Interchangeability of the Working Alliance Inventory and Working Alliance Inventory, Short Form. Psychological Assessment 15 (2): 193-197.

Cahill, J., G. Paley & G. Hardy. 2013. What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing. Journal of Psychiatric & Mental Health Nursing 20 (9): 782-791.

Caldwell, B.A., M. Sclafani, M. Swarbrick & K. Piren. 2010. Psychiatric nursing practice & the recovery model of care. Journal of Psychosocial Nursing & Mental Health Services 48 (7): 42-48.

Caldwell, K., L. Henshaw & G. Taylor. 2011. Developing a framework for critiquing health research: an early evaluation. Nurse Educ Today 31 (8): e1-7.

Care Quality Commission. 2015. Mental Health Act Annual Report 2013/14. London: The Stationary Office.

Clark-Carter, D. 2010. Quantitative psychological research : the complete student’s companion. Hove: Psychology Press.

Cutcliffe, J. & B. Happell. 2009. Psychiatry, mental health nurses, and invisible power: Exploring a perturbed relationship within contemporary mental health care. Int J Ment Health Nurs 18 (2): 116-25.

Dancey, C.P. & J. Reidy. 2011. Statistics without maths for psychology. Harlow: Prentice Hall.

Department of Health. 2011. No health without mental health : a cross-government mental health outcomes strategy for people of all ages. Norwich: The Stationary Office.

Dziopa, F. & K. Ahern. 2008. What Makes a Quality Therapeutic Relationship in Psychiatric/Mental Health Nursing: A Review of the Research Literature. . The Internet Journal of Advanced Nursing Practice. 10 (1).

Edwards, P., R. Cooper, I. Roberts & C. Frost. 2005. Meta-analysis of randomised trials of monetary incentives and response to mailed questionnaires. Journal of Epidemiology and Community Health 59 (11): 987-999.

Elliott, R. & M.M. Wexler. 1994. Measuring the impact of sessions in process€xperiential therapy of depression: The Session Impacts Scale. Journal of Counseling Psychology 41 (2): 166-174.

Farrelly, P. 2013. Choosing the right method for a quantitative study… fourth article of a series. British Journal of School Nursing 8 (1): 42-44.

Foucault, M. & R. Howard. 1967. Madness and civilization: A history of insanity in the age of reason; Translated from the French by Richard Howard. . London: Tavistock Publications.

Foucault, M. & A. Sheridan. 1973. The birth of the clinic. An archaeology of medical perception … Translated … by A. M. Sheridan Smith. London: Tavistock Publications.

Foucault, M. & A. Sheridan. 1979. Discipline and punish : the birth of the prison. Harmondsworth: Penguin.

Galon, P.A. & N.M. Wineman. 2010. Coercion and Procedural Justice in Psychiatric Care: State of the Science and Implications for Nursing. Archives of Psychiatric Nursing 24 (5): 307-316.

Gardner, A. 2010. Therapeutic friendliness and the development of therapeutic leverage by mental health nurses in community rehabilitation settings. Contemp Nurse 34 (2): 140-8.

Gardner, W., S.K. Hoge, N. Bennett, L.H. Roth, C.W. Lidz, J. Monahan & E.P. Mulvey. 1993. Two scales for measuring patients’ perceptions for coercion during mental hospital admission. Behavioral Sciences & the Law 11 (3): 307-321.

Gobo, G. 2004. Sampling, Representativeness and Generalizability. In: Qualitative research practice. Edited by SEALE, C., G. GOBO, J. GUBRIUM & D. SILVERMAN. London: SAGE.

Gobo, G. 2011. Ethnography. In: Qualitative research : issues of theory, method and practice. Edited by SILVERMAN, D. London: SAGE.

Goffman, E. 1968. Asylums: essays on the social situation of mental patients and other inmates. Harmondsworth: Penguin.

Grant, A. 2009. Freedom and consent. In: Psychiatric and mental health nursing : the craft of caring. Edited by BARKER, P.J. London: Hodder Arnold.

Healy, D.M.R.C.P. 2009. Psychiatric drugs explained. Edinburgh: Churchill Livingstone.

Horvath, A.O. & L.S. Greenberg. 1989. Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology 36 (2): 223-233.

Kisely, S. & L. Campbell. 2014. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. . Cochrane Database of Systematic Reviews 2014, (12).

Laugharne, R., S. Priebe, R. McCabe, N. Garland & D. Clifford. 2012. Trust, choice and power in mental health care: Experiences of patients with psychosis. International Journal of Social Psychiatry 58 (5): 496-504.

Lloyd, M. 2007. Empowerment in the interpersonal field: discourses of acute mental health nurses. Journal of Psychiatric & Mental Health Nursing 14 (5): 485-494.

Maguire, T., M. Daffern & T. Martin. 2014. Exploring nurses’ and patients’ perspectives of limit setting in a forensic mental health setting. Int J Ment Health Nurs 23 (2): 153-60.

McCabe, R. & S. Priebe. 2003. Are therapeutic relationships in psychiatry explained by patients’ symptoms? Factors influencing patient ratings. European Psychiatry 18 (5): 220-225.

McNay, L. 1994. Foucault : a critical introduction. Cambridge: Polity Press.

Neale, M.S. & R.A. Rosenheck. 2000. Therapeutic limit setting in an assertive community treatment program. Psychiatr Serv 51 (4): 499-505.

O’Brien, A.J. 1999. Negotiating the relationship: mental health nurses’ perceptions of their practice. The Australian and New Zealand journal of mental health nursing 8 (4): 153-161.

Penny, K.I. & I. Atkinson. 2012. Approaches for dealing with missing data in health care studies. Journal of Clinical Nursing 21 (19/20): 2722-2729.

Peplau, H.E. 1988. Interpersonal relations in nursing : a conceptual frame of reference for psychodynamic nursing. Basingstoke: Macmillan.

Polit, D.F. & C.T. Beck. 2014. Essentials of nursing research : appraising evidence for nursing practice. London: Lippincott Williams & Wilkins.

Raboch, J., L. Kališová, A. Nawka, E. Kitzlerová, G. Onchev, A. Karastergiou, L. Magliano, A. Dembinskas, A. Kiejna, F. Torres-Gonzales, L. Kjellin, S. Priebe & T.W. Kallert. 2010. Use of Coercive Measures During Involuntary Hospitalization: Findings From Ten European Countries. Psychiatric Services 61 (10): 1012-1017.

Reynolds, B. 2009. Developing therapeutic one-to-one relationships. In: Psychiatric and mental health nursing : the craft of caring. Edited by BARKER, P.J. London: Hodder Arnold.

Royal Collage of Nursing. 2013b. Databases [Online Webpage]. London: Royal Collage of Nursing. Availableat: [Accessed 15/04/2015].

Rugkåsa, J., K. Canvin, J. Sinclair, A. Sulman & T. Burns. 2014. Trust, Deals and Authority: Community Mental Health Professionals’ Experiences of Influencing Reluctant Patients. Community Mental Health Journal 50 (8): 886-895.

Ryles, S.M. 1999. A concept analysis of empowerment: its relationship to mental health nursing. Journal of Advanced Nursing 29 (3): 600-607.

Selya, A.S., J.S. Rose, L.C. Dierker, D. Hedeker & R.J. Mermelstein. 2012. A Practical Guide to Calculating Cohen’s f(2), a Measure of Local Effect Size, from PROC MIXED. Frontiers in Psychology 3: 111.

Sheehan, K.A. & T. Burns. 2011. Perceived coercion and the therapeutic relationship: a neglected association? Psychiatr Serv 62 (5): 471-6.

Stanhope, V., S. Marcus & P. Solomon. 2009. The impact of coercion on services from the perspective of mental health care consumers with co-occurring disorders. Psychiatr Serv 60 (2): 183-8.

Stiles, W.B., S. Reynolds, G.E. Hardy, A. Rees, M. Barkham & D.A. Shapiro. 1994. Evaluation and description of psychotherapy sessions by clients using the Session Evaluation Questionnaire and the Session Impacts Scale. Journal of Counseling Psychology 41 (2): 175-185.

Swartz, M.S., H.R. Wagner, J.W. Swanson, V.A. Hiday & B.J. Burns. 2002. The perceived coerciveness of involuntary outpatient commitment: findings from an experimental study. J Am Acad Psychiatry Law 30 (2): 207-17.

Szasz, T. 2007. Coercion as cure : a critical history of psychiatry. New Brunswick, N.J. London: Transaction Publishers.

The Stationary Office. 2007. Mental Health Act 2007. London: The Stationary Office.

The World Bank Group. 2015. World Bank list of economies [Online Webpage]. Washington: The World Bank Group. Availableat: [Accessed 28/02/2015].

Theodoridou, A., F. Schlatter, V. Ajdacic, W. Rössler & M. Jäger. 2012. Therapeutic relationship in the context of perceived coercion in a psychiatric population. Psychiatry Research 200 (2): 939-944.

Thogersen, M.H., B. Morthorst & M. Nordentoft. 2010. Perceptions of coercion in the community: a qualitative study of patients in a Danish assertive community treatment team. Psychiatr Q 81 (1): 35-47.

Tveiten, S., M. Haukland & F.R. Onstad. 2011. “The Patient’s Voice-Empowerment in a Psychiatric Context”. Nordic Journal of Nursing Research 31 (3): 20-24.

Wilkinson, G. & M. Miers. 1999. Power and nursing practice. Basingstoke: Macmillan.

Wilkinson, S. 2011. Interviews and Focus Groups. In: Qualitative research : issues of theory, method and practice. Edited by SILVERMAN, D. London: SAGE.

Wolfe, S., F. Kay-Lambkin, J. Bowman & S. Childs. 2013. To enforce or engage: The relationship between coercion, treatment motivation and therapeutic alliance within community-based drug and alcohol clients. Addictive Behaviors 38 (5): 2187-2195.

World Health Organisation. 2011. Mental Health Atlas [Online pdf]. Geneva: World Health Organisation. Availableat: [Accessed 28/02/2015].



Factors influencing the use of Maggot Debridement Therapy in the Nursing management of the Diabetic Foot


Aims: This paper seeks to explore the factors that influence the use of maggot debridement therapy in the nursing management of the diabetic foot. It will examine literature relating to the beneficial attributes of the maggot and the advantages of its use. The paper will consider the perceptions of patients and health professionals regarding the therapy and also assess the barriers for its use and investigate the lack of credible evidential material available to professionals, which may hinder the therapy being used within the hospital environment and the community setting.

Background: Maggot debridement therapy has been used on wounds for hundreds of years but has come under intense scrutiny over the last 10 years. It is a method of debridement that uses the larvae of the common green bottle fly to remove necrotic and devitalised tissue from chronic ulcerated limb wounds. Maggots have excretions and secretions that cause various physiological changes within wounds that assist in faster debridement. The use of the therapy has other beneficial properties including its ability to disinfect, cleanse, reduce inflammation and repair difficult wounds.

Method: This dissertation took the form of a literature review and as such examined literature available between and 2010 and 2014. A systematic literature search was conducted using electronic databases including Cochrane, Cinahl, NICE, One Search, Pubmed, Wiley Online, British Nursing Index, Embase, NHS evidence and Google Scholar with inclusions in place. From these searches twenty four pieces of literature were identified and subsequently critiqued and appraised. Two themes were established from the appraisal and from these themes a synthesised document was produced.

Results: Evidence has shown that maggot debridement therapy does debride more quickly than conventional therapies. It has also been established that this debridement technique does not remove healthy tissue. However, this may be the case with surgical debridement. The review has also identified that there is substantial evidence supporting the fact that pain is a side effect of the therapy that needs to be addressed early on. Although there is generally a negative perception of maggots it has been found that with careful handling, good communication and education patients are willing to try the therapy.

Conclusions: Maggot therapy is an effective tool in the debridement of necrotic foot wounds but due to the lack of rigorous random controlled trials available, there remains a lack of evidence that supports its use. It is widely suggested that maggot debridement therapy will one day be set amongst the conventional debridement therapies and not just being used as a last resort treatment.


maggot1This work explores the question, “Factors influencing the use of maggot debridement therapy in the nursing management of the diabetic foot?”

A chronic wound is one of a continued problem to the affected area. Chronic wounds have very different healing behaviour to acute wounds. A foot ulcer usually results from pathological processes such as vascular disease or diabetes millitus which will produce a continued and prolonged event resulting in severe tissue damage (Nigam et al 2006).

There are many different kinds of wound debridement available to persons affected by non-healing wounds and include surgical, mechanical, enzymatic, biological and autolytic debridement (Alexiadou 2012).

Maggot debridement therapy (MDT) is a mechanical/biological debridement procedure where the live maggots of the common green bottle fly (Lucilia Sericata) are placed onto a necrotic sloughy wound (Tian et al. 2013). Maggots have jaws that assist the larvae to move through the food source using mechanical debridement (Barnard 1977). It has also been established that maggots use their mandables to secrete proteolytic enzymes (Biological debridement) that devitalises tissue in a selective manner and liquefy’s the tissue enabling the larvae to digest the material. These enzymes effectively degrade extra-cellular matrix components, including laminin and fibronectin. Therefore assisting in the digestion of the necrotic wound matrix, amounting to an effective debridement therapy (Chambers 2003).

According to Opletalova et al.(2011), maggot effects on wounds have been devided into three areas including debridement, the anti-bacterial effects and the stimulation of wound healing. The debridement of the wound assists in the repair of the defective re-modelling of the extra-cellular matrix proteins and prevents the failure of re-epithelialization. The success of MDT on wounds has now been identified to be as a result of three proteolytic enzyme catagories that have been found in larval excretions (Chambers 2003). These excretions have an inhibitory effect on both gram-positive and gram-negative bacteria (Nigam et al. 2006). Other investigations have identified that the ammonia excreted by maggots has an effect of increasing the pH value of the wound, generating an inhospitable environment for bacterial growth (Pettican 2012).

Reports relating to the properties of maggots are numerous, highlighting their abilities to debride, cleanse, disinfect, and repair stubborn non-healing wounds where conventional therapies have failed. It has been noted for centuries that maggots have the ability to prevent infection and promote healing in wounds. The battlefield surgeon of Napoleon noted that soldiers had returned to the field hospital with healing maggot-infested wounds sustained during battle. It was believed that the maggots had not only prevented infection but had accelerated the healing process (Nigam et al. 2006). During World War 1 orthopedic surgeon William Baer had witnessed for himself the attributes of maggot infested wounds and as a result subsequently pioneered the first systematic application of clinical maggots on a non-healing wound. Baers’ entire work on maggot therapy was published posthumously in 1931(Sherman 2009). The use of MDT became widespread during the 1930’s, however with the availability of antibiotics and the ability to mass produce penicillin, despite MDT’s success, by the mid 1940’s it had all but disappeared from use (Nigam et al. 2006).

More recently and as a result of bacterial resistance to antibiotics, MDT was revisited as a medical procedure to assist in the treatment of non-healing wounds that were resistant to antibiotics or when patients were unable to tolerate anesthesia (Merilyn & Russel 2004).


image012The paper was to take the form of a systematic literature review with the aim of identifying the most relevant and recently published material on the subject of a predetermined academic question. In order to do this 10 electronic databases including: Cinahl, One Search, Cochrane, Pubmed, Wiley online, British Nursing Index, Google Scholar, NICE, NHS Evidence and Embase were searched to identify the relevant literature for the review. There were 23 key word and search terms used within the search parameters and also included a detailed inclusion and exclusion criteria formed part of the overall methodology. Of the literature identified as potential sources of information, 24 papers were formally critiqued and reviewed to form the basis of this document.

Influencing Factors

Qualities that make MDT a successful tool in wound debridement

The research has identified the following authors who give a variety of findings related to this topic and this chapter will discuss these from Tian et al.(2013); Hall (2010); Menon (2012); Jones et al. (2011); Cazander et al. (2013); Pritchard (2013).

Recently, efficacy of MDT has been examined in great depth. Tian et al. (2013) conducted a meta-analysis involving four studies Markevich et al. (2000); Sherman (2003); Paul et al. (2009); Armstrong et al. (2005). Comparisons were drawn between MDT and conventional therapy using three hundred and fifty six patients. Three of the studies Markevich et al. (2000); Sherman (2003); Paul et al. (2009) were in relation to MDT and diabetic foot ulcers (DFUs). The fourth Armstrong et al. (2005) was in relation to maggot therapy in lower extremity “hospice” wound care. Of the four trials selected, Markevich et al. (2000) was a random controlled trial (RCT) and the other three were case control studies, Sherman (2003) being retrospective and Paul et al. (2009), being prospective in nature. The evidential strength provided by a prospective study is more reliable than that of other non-experimental designs because the investigator is able to determine the incidence of an issue and its possible causes (LoBiondo-Wood & Haber 2002).

The outcome measures of the analysis were the healing rate of DFU’s defined as full re-epithelialisation, time of healing, incidence of infection and rate of amputation.

The results of the meta-analysis conducted by Tian et al. (2013) suggesed that the MDT group were significantly superior than the control group in most areas. Comparison of healing rate was twenty seven percent for MDT and nineteen precent for controls. However, within the prospective case control study itself the results relating to the comparison of healing rates were fifty six percent for MDT and sixty two percent for the controls. This suggests a significant difference between the single study Paul et al. (2009) and the four study meta-analysis results identified by Tian et al. (2013).

Further examination revealed that the case control study in question had defined the concept of complete healing differently from the other trials which may have produced the error when collating the outcomes. Amputation rates were fifteen percent in the MDT group compared to thirty six percent in the control group. Regarding comparison of incidence of infection, MDT group was sixty five precent and the control group was eighty percent. Two of the four studies, Sherman (2003) and Armstrong et al. (2005) examined comparisons of time to heal and both studies showed that MDT was on average of three and a half days faster to heal than the conventional group. Tian’s et al. (2013) conclusions suggest that MDT may be more effective in increasing healing rate and anti-biotic free days and decreasing the rate of amputation and time of healing compared with control inteventions. However, due to the insufficencey of high quality evidence of relevant literature regarding the effectiveness of MDT the finding of this meta-analysis are not definitive.

Hall (2013) conducted a review of current literature to establish whether using MDT for the removal of devitalised and infected tissue in chronic wounds is a valuable tool in healing. This review identified four themes that were relevant in confirming the effectiveness of MDT, Debridement, Infection, Granulation and Cost Effectiveness. Systematic electronic searches were conducted for all themes mentioned above. From these searches a total of twelve studies were identified and discussed within the review. It was concluded by Hall (2013) that the review of the relevant literature identified that MDT was both an effective and efficient tool in the reduction of time to complete debridement of chronic wounds, when compared with conventional therapies. However, there is little significant difference regarding the time for wounds to heal, which is in conflict with the evidence of Tian et al. (2013). Some conventional therapies are more pedestrain at fully debriding a wound bed of devitilised tissue.

There is evidence to suggest that MDT does have the ability to supress and eradicate infection and may stimulate the re-granulation of vitilised tissue. Unfortunately, the trials within this review had some evidence of limitation, including very small sample groups and non-randomised selection of participants which may influence bias within the study.

Menon (2012) conducted a literature review of methods of MDT and patients experiences. An electronic database literature search was conducted and common themes were identified, namely, debridement, antimicrobial effects and psychological issues. Menon (2012) further discussed and compared the appropriate methods of application of both free range and confined maggots. The review identified that both application methods debride with similar efficiency. Menon (2012) further reviewed on the issue of both applications of MDT when compared to that of hydrogel. It was established that time to ulcer healing was not significantly different between the two groups which is a direct contradiction to the findings of Tian et al. (2013) but does corroberate the results of the review conducted by Hall (2013). However, it can be confirmed that Hall (2013); Tian et al. (2013); Menon (2012) concurs the MDT was considerably more efficient at time to full debridement than the conventional therapy. It was also stated in the review by Menon (2012) that MDT produces secretions that inhibits the bacterial load of wounds that are susceptible to infection. In doing so they are helping to eliminate meticillan resistant staphylococcus aureus (MRSA) and other antibiotic resistant bacteria. Larval secretions change the pH value within the wound making it more alkaline. This in turn makes the wound an inhospitable environment for various bacteria. MDT also disrupts and destroys the formation of colonies of bacteria, namely biofilms. Menon (2012) concludes that if used appropriately, MDT can be an in-expensive, efficient and effective debridement tool. Its properties of accelerated debridement and anti-bacterial action have been witnessed in both acute and chronic wounds alike, especially in diabetic foot ulcers. MDT has few side effects and is generally well received by patients, however, evidence suggest that some individuals, dependent on their co-morbidity, may experience pain as a side effect and this should be managed from the offset with appropriate analgesia.

Jones (2011) produced a literature review examining maggots and their role in wound care. A comprehensive search for appropriate material identified seven articles suitable for viewing. The Critical Appraisal Skills Programme (CASP) critiquing tool was used on the collated literature where four themes were subsequently established:- Infection control and Promotion of healing will be discussed in this chapter. The “Yuck” factor will be discussed in a later chapter. Cost effectiveness will not be discussed in this paper.

It was confirmed by Jones (2011) that MDT was a driving force behind the reduction of bacteria in ulcerated wounds, therefore, being responsible for the prevention of infections. Further to this, it has the added benefit of reducing malodorous wounds and reducing pain. The reduction of pain by the use of MDT may be at odds with the comments made in the review by (Menon 2012). Jones (2011) discussed the promotion of healing. It was stated MDT did accelerate necrotic tissue debridement from chronic wounds which in turn promoted rapid granulation when compared with conventional therapies. These comments were similar in nature to those of Tian et al. (2013); Menon (2012); Hall (2013).

Cazander et al. (2013) conducted a litratrure review that examined the multiple actions of the Lucilia Sericata larvae in hard to heal wounds and discusses the molecules contained within the maggot secretions that accelerate wound healing and reduce chronic inflammation and inhibit bacterial infection. His review accepts that MDT has a proven value as a debridement tool along with other benefits that have been widely reported in clinical trials, inluding anti-infection, immunomodulation, angiogenesis, tissue remodelling and regeneration.

In addition, maggot secretions contain two different molecules that are able to prevent bacterial biofilm formation and breakdown existing colonies of bacteria as previously discussed and corroberated by Menon (2012). With regard to wound healing, secretions also enchance the production of growth factors by monocytes and macrophages within the wound. Maggots secrete various enzymes that consume devitalised tissue and it may be the case that these enzymes also destroy various host molucles within the wound. It has been suggested by Cazender et al. (2013) that the larvae may produce anti-bacterial molecules enabling them to survive in a heavily contaminated bacterial environment who compete with the larvae for their nutritional source. There is potential that by reducing the bacterial load, maggots may well control the process of decay and therefore protecting themselves from harmful bacteria. Cazander et al. (2013) is of the opinion that the combined actions of molecules within maggot secretions are responsible for the beneficial effects of MDT.

Pritchard (2013) argued that larval therapy should be a primary and secondary treatment in wound healing. The debridement of the wound conducted by the primary application and the secondary applictation targeted at the debrided wound on a cellular level that promotes healing. Pritchard (2013) states there is evidence that molecules secreted by maggots can have a role in promoting tissue regeneration and accelerating wound healing. this idea is shared by the review of Cazander et al. (2013). Pritchard (2013) explains that maggot secretions play an intrinsic role in various physiological actions including perfusion; reduction in inflammation; anti-bacterial effect; promoting cell signalling; fibroblast motogenesis, and angiogenesis. Maggot secretions have been shown to promote fibrinolysis therefore interacting with and influencing perfusion. Secretions are believed to interact directly with aspects of the inflammatory response, modulating its performance to aid and contribte to wound healing. They destroy and prevent the formation of biofilms that cause infection. Maggot secretions in low doses have been shown to induce changes in cell morphology which stimulate fibroblasts into the wound . In conclusion Pritchard (2013) states that the growth promoting activities of maggots and their secretions has been demonstrated effectviely, and the investigations conducted within the subject strongly indicates that maggots are capable of much more that just wound debridement. The reapplication of MDT onto a debrided wound will not only assist in the healing process but also closure of the wound.

This theme has shown to some degree that maggots and their secretions have several primary and secondary benefits that supports the argument that MDT is a very useful tool in the management of ulcerated wounds.

Factors that present barriers for the use of MDT

The research has identified authors who have findings relating to this topic, namely Mudge et al. (2014); Davydov (2010); McCaughan et al. (2013); Menon (2012); Jones et al. (2011); and Gilead et al. (2012).

Mudge et al. (2014) conducted a randomized controlled, open, observer blind, parallel group study relating to a trial of larval therapy for the debridement of leg ulcers. The study compared the clinical effectiveness of a larval therapy dressing with a standard debridement treatment, namely Hydrogel. According to the BNF (2014) hydrogel dressings are recommended for dry sloughy wounds and donate liquid to the wound enabling autolytic debridement of the necrotic tissue to take place. The dressings are best avoided in cases of infection of heavily exuding wounds. The study aim was to identify the time of debridement of venous leg ulcers and mixed arterial leg ulcers. Sixty four patients completed the full study. There were thirty two patients in each group of which thirty one patients of the larval group and eleven patients in the hydrogel group fully completed the study. Mudge et al. (2014) explained that previous research conducted by Dumville et al. (2009) intimated that pain associated with larval therapy should be anticipated. For this reason throughout the trial participants experience of pain was monitored during each treatment visit. It was subsequently identified that the larval therapy group experienced ulcer related pain or discomfort on a more regular basis than that of the hydrogel group. More participants withdrew from the study as a result of pain than for any other reason. The review of Davydov (2012) corroborates the findings of Mudge et al. (2014) and further adding that pain is indeed a common side effect of larval therapy and develops within two or three days from commencement of treatment and according to the findings within Sharman (2002); Sharman (2003); Courtenay (2000) between four percent and thirty three percent of patients experienced pain that ranged between mild to severe in intensity. McCaughan et al. (2013) in her qualitative study identifies a small qualitative study by Kitching (2004), who’s findings within his own study suggested that patients experienced a reduction in the level of pain experienced when using larval therapy. It can be seen that this statement directly conflicts with those of Davydov (2012); Mudge et al. (2014); McCaughan et al. (2013).

McCaughan et al. (2013) is a qualitative study regarding patients’ perceptions and experiences of venous leg ulcers and their attitudes towards larval therapy. Eighteen patients took part in the study twelve men and six women. Five people in the study were treated with larval therapy. McCaughan et al. (2013) comments that two of the five patients treated with larval therapy experienced severe pain and were withdrawn from the study. Menon (2012) in her literature review reiterates the comments made by all the above authors that there was significantly more pain in groups of patients that had undergone larval therapy as opposed to Hydrogel therapy. Gilead et al. (2012) adds that the conclusions of a review they conducted of their experiences of treating four hundred and thirty five patients with a combined number of seven hundred and twenty three wounds over a period of thirteen years, revealed that although eighty two point one percent of wounds fully debrided, there was a significant increase in the level of pain and discomfort reported by thirty eight percent of the patients. This agrees with the comments made by Menon (2012); McCaughan et al. (2013); Mudge et al.(2014); Davydov (2010).

Jones et al. (2012) discusses the “Yuck” factor, which for the purpose of this dissertation has been interpreted as the clients distaste or mental aversion to the whole concept. Jones et al. (2011) draws on the phenomenological study of Kitching (2004) whereby six patients were monitored over a twelve week period. The initial pre-conceived feelings of the group regarding maggot therapy were feelings of disgust and not wanting to have the maggots crawling around in their wound. However, following a period of education and subsequent therapy five out of six of patients were subsequently un-phased by the thought of maggot therapy and that their wounds had improved somewhat. According to Jones et al. (2011) further studies from Steenvorde (2005); Courtenay (1999) established that providing all patient issues are addressed through appropriate, up to date, honest and accurate information regarding the therapy and its perceived outcomes, concerns regarding this issue can be eliminated. Encouraging practitioners and patients alike to accept and work with the therapy will go a long way in dealing with the barriers and issues associated with maggot debridement therapy. When these problems arise nurses are best placed to promote and influence patient choice with good quality transparent communication.

Davydov (2014) commented that some patients may feel repulsed by the idea of live organisms within their wounds which may lead to a refusal to have this therapy administered. McCaughan et al. (2013) identified that participants in their study believed that the feelings of squeamishness in relation to maggots would be short lived if they witnessed an improvement in the wound. It was also acknowledged that patients had built their own knowledge database regarding the treatments and abilities of MDT.

The evidence clearly shows there are some issues regarding the use of maggot debridement therapy and this chapter has highlighted a couple of the most prominent issues. These issues are easily resolved by planning for pain and having full, honest, open discussions with patients regarding the treatment prior to its application (Jones et al. 2011).


Chronic wounds are notoriously difficult the treat especially in patients with failing health. Evidentially, conventional debridement therapies have been shown to work, however, research suggests that MDT is more effective and efficient at debriding chronic ulcerated leg wounds (Sun et al. 2014).

Diabetic patients generally suffer peripheral vascular changes and as a result of poor perfusion tend to suffer with severe septic lower limb wounds (Pettican 2012). Surgical debridement and other debridement techniques can be used where appropriate. However, with surgical debridement there is the potential of removing healthy tissue alongside devitalized matter (Pettican 2012). Maggots on the other hand have been shown not to damage healthy tissue but remove devitalised necrotic matter leaving healthy tissue and granulating wound bed material undamaged (Pettican 2012).

The evidence has suggested that MDT offers the clinician a debridement tool that has a faster time of healing, fewer amputations, fewer incidence of infection therefore a higher rate of antibiotic free days (Tian et al.2013). Maggots have shown an ability to remove sloughy, devitalised tissue from the wound bed more quickly than other conventional therapies including hydrogel (Menon 2012). It has been established that excretions and secretions from maggots contain proteoltyic enzymes which devitalise selective tissue effectively degrading extracelular matrix components and digesting the matter in a liquid form (Pettican 2012). Maggots have also been shown to inhibit the bacterial load within the wound and also altering the pH value of the wound creating an inhospitable atmosphere for bacteria such as MRSA to survive. Maggots disruprt, destroy and prevent the formation of biofilms or bacterial colonies associated with wounds, Therefore, preventing and eradicating infection (Jones 2011). There have been suggestions that MDT has further microbiolical properties including anti-imflamatory abilities and immunomodulation, angiogeneis, tissue remodelling and regeneration (Cazander et al. 2013).

This review has illustrated that the use of MDT has many beneficial effects and advantages over conventional therapies on the debridement of diabetic chronic ulcerated wounds. Where there is a need for speedy debridement or where a patient cannot undergo surgical debridement (Sun et al. 2014). MDT should be considered by health care professionals as a primary tool in the treatment of chronic infected wounds within the hospital environment or community setting rather than an after thought or a last resort (Pettican 2012). However, there are issues that must be considered and addressed when using MDT. It has been identified by several authors including Mudge et al. (2014); Dumville et al. (2009); Davydov (2012); Sharman (2002); Sharman (2003); Courtaney (2000); Menon (2012); Gilead (2012) that ulcer ralated pain is a side effect of MDT treatment and that it can be between mild to severe in nature. The onset of pain is normally within the first two or three days and can affect between four percent and thirty three percent of patients. Only one author Kitching (2004) claimed that the majority of the patients in his study had a reduction in pain. Patients have been known to withdraw from studies as a result of associated pain.

Pettican (2012) makes the connection between pain and the alteration of the pH balance within the wound caused by maggot secretions and excretions and believes for MDT to succeed pain management is critical. Within this study there is overwhelming evidence to suggests pain is an overriding factor that should be monitored during treatment and having analgesia available from the outset may ensure that the therapy is tolerated by patients who would remain pain free. Should the issue of pain not be addressed early on in the process, pain may present itself as a barrier for the use of MDT.

The aversion to maggots is not uncommon, Jones et al. (2012); Kitching (2004) Steenvorde (2005); Courtenay (1999) all highlight issues concerning the distaste and aversion both patients and clinicians have regarding MDT. Interestingly, it has been established that the majority of persons who were given appropriate and transparent education regarding the therapy tolerated it well. Educating clinicians and patients alike in the treatment and its application is essential for the fears and feeling of repulsion to be eradicated.

From the study of McCaughan et al. (2013) it can be seen that patients with chronic leg ulcers were willing to try alternative therapies in order to rid them of their wounds as their quality of life had been blighted by this condition. Feelings of squeamishness were soon forgotten on visualising the improvement within the wound. McCaughan et al. (2013) How the treatment was presented to the patients was also a factor as to whether the treatment would be accepted by the patient.

One of the most discussed topics was the lack of research findings regarding the credibility of the use of MDT. Most authors within the review make comment regarding that fact that research for the use of this therapy is simply at this time not strong enough. The reasons for this lack of rigorous evidence has been identified as a lack of random controlled trials on the subject, poor description controls, non-blinded assessment outcomes, poor description of control and inadequate sample sizes (Gottrup 2012) and (Tian et al. 2013).

For MDT to be taken seriously, a more intensive evidential programme needs to be undertaken. It can be seen that very few random control trials have been carried out on the efficacy of MDT. Jones et al. (2011) identifies more healthcare professionals than ever before are reliant on evidence based practice when making clinical decisions regarding treatment. As a result of this, it is felt that more indepth research relating to MDT must take place in order to encourage and support the use of this debridement tool. Random controlled trials are the essence of research and offer the strongest evidential platform from which to stand when trying to prove the strengths or weaknessess of a particular subject (Ellis 2010). RCT’s explore the relationship between two variables therefore creating an RCT for the efficacy for MDT is going to be difficult to prepare because of the nature of MDT designing prospective randomised and placebo-controlled trials may prove difficult (Davydov 2011).


This work has examined what factors influence the use of maggot MDT in the nursing management of diabetic foot ulcers. It has established through detailed examination of current available literature that MDT could be a valuable tool in the treatment of necrotic wounds despite there being very few credible random controlled trials relating to its efficacy and use.

Obstacles such as the lack of strong evidential literature, associated pain and the feelings of revulsion and disgust have been highlighted within the paper and are believed to be elements within the subject that may have hindered the success and use of this therapy within the medical profession.

However, with detailed, specific, in-depth random controlled trials and thorough meta-analysis investigations of the current literature, well directed education for clinicians and patients alike and honest, transparent communication with clients, MDT may in time secure itself amongst the existing debridement tools that assist in the nursing management of diabetic foot ulcers within the hospital environment or community setting.

Vincent H Curtis, Adult Nursing, BSc (Hons) Nursing student


Alexiadou, K. & J. Doupis. 2012. Management of diabetic Foot Ulcers. Diabetes Therapy, pp. 3:4, 1-15.

Armstrong, D., P. Salas and B. Short. 2005. Maggot therapy in lower extremity hospice wound care, fewer amputations and antibiotic free days. Journal of American Podiatry , pp. 95: 254-257.

Armstrong. D., V. Kanda and L.A. Lavery. 2013. Mind the Gap: Disparity between research funding and cost of care for diabetic foot ulcers. Diabetes Care, pp. 1815-1817.

Barnard, D. R. 1977. Skeletal muscular mechanisms of the larva of Lucilia Sericata in relation to feeding habit. Pan-Pac Entomology, pp. 53, 223-229.

Blueman, B. 2012. the use of larval therapy to reduce the bacterial load in chronic wounds. Journal of Wound care, pp. vol 21, no 5.

British National Formulary, 2013/14. BNF 66 September 2013 – March 2014. London: BMJ.

Cazander,G., D.Pritchard., Y.Nigam., W.Jung., and P.H. Nibbering. 2013. Multiple Actions of Lucilia Sericata lavae in Hard to Heal Wounds. Bioessays 35, pp. 1083-1092.

Chambers, S., S.Woodrow. and A.P. Brown. 2003. Degredation of extracallular matrix componenets by defined proteinases from the green bottle larva Lucilia Sericata used for the clinical debridement of non healing wounds. British Journal of Dermatology , pp. 148, 14-23.

Courtenay, M. 1999. The use of larval therapy in wound management in the UK. Journal of Wound care, pp. 8: 177-180.

Courtenay, M., J.Church. & T. Ryan. 2000. Larval therapy in wound management. J R Soc Med , pp. 93(2) 72-74.

Cutliffe, J. and M. Ward. 2007. Critiquing nursing research ( second edition). London: Quay books.

Davydov, L. 2011. Maggot Therapy in wound management in modern era and a review of Published Literature. Journal of Pharmacy practice, pp. 24(1) 89-93.

Driver, V. and P. Blume. 2014. Evaluation of wound care and health carem use costs in patients with diabetic foot ulcers treated with negative pressure wound therapy versus advanced moist wound therapy. Journal of the American Podiatric Medical Association, pp. Vol 104 , No 2, pages 147-153.

Dumville, J.C., G. Worthy, and J Bland. 2009. Larval Therapy for Leg Ulcers (VenUS II) randomised controlled Trial. British Mdeical Journal , p. 338; b773.

Ellis, P. 2010. Understanding Research for Student Nurses. Exeter: Learning Matters.

Gilead, M. I. 2012. the use of maggot debridement therapy in the treatment of chronic wounds in hospitalised and ambulatory patients. Journal of Wound care, pp. vol 21, no 2.

Gottrup, F. and B. Jorgensen. 2011. Maggot Debridement, An alternative method of debridement. Open Access of the Journal of plastic Surgery, pp. 290-302.

Hall, 2010. a review of maggot debridement therapy to treat chronic wounds. British Journal of nursing, pp. Vol 19, no15.

Jones, G., J Green. and K. Lillie. 2011. March. Maggots and their role in wound care. Wound care, p. S 24.

Kitching, M. 2004. Patients perceptions and experiences of larval therapy. Journal of wound care, pp. 13: 25-29.

Lo-Biondo-Wood, G and J. Haber 2002. Nursing research, methods, critical appraisal and utilization. St Louis: Mosby.

Margolin, L. and P. Gialanella. 2010. Assessment of the anti-microbial properties of maggots. international Wound Journal, pp. 7: 202-204.

Markevich, Y.O.,J. Mcleod-Roberts. & Melloy, E., 2000. Maggot therapy for diabetic neuropathic foot wounds. Diabetlogia, p. 43 (supp 1)A 15.

McCaughan, D., N. Cullum. and J. Dumville. 2013. Patients perceptions and experiences of venous leg ulceration and their attitudes to larval therapy, an in depth qualitative study. Journal of Health Expectations, pp. 1-15 .

Menon, J. 2012. Maggot Therapy. British Nursing JournaL, pp. vol 21, No 5.

Merilyn, G. and R. Russel. 2004. Fly Larvae for Wound Management, A maggot Makeover. Institute of Clinical Pathology and Medical Research, pp. Vol 15, no 11-12, Pages 218-219.

Mudge, E., P. Price., N Walkley. and K. G Harding. 2014. A randomised controlled trial of larval therapyfor the debridement of leg ulcers: results of a multi center randomised controlled open observer blind parellel group study. wound healing society, pp. 43-51.

Nigam, Y., Alison, B., Steven, T. & Norman Arthur, R., 2006. Maggot Therapy: The Science and Implication of CAM. Part 1- History andbacterial resistance. Open Access Publication – eCAM, pp. 3 (2) 223-227.

Nigam, Y., A. Bexfield., S. Thomas., and N. Ratcliffe. 2004. Detection and partial characterisationof two antibacterial factorsfor the excretions of medical maggots Licilia Sercata and their activity against methicillin-resistant staphylococcus aureus MRSA. Microbes Infect, pp. 6: 297-304.

Opletalova, K., X. Blaizot., B. Mourgeon., Y. Chene., C. Creveuil., P. Combemale., A.L Laplaud., I. Sohyer-Lebreuilly. and A. Dompmartin. 2011. Maggot therapy for wound debridement a randomized multi-center trial. Arch dermatol, pp. Vol 148 no 4, 2012 April.

Paul, A.G., N.W. Ahmad., H.L Lee., A. M. Ariff., M Saranum., A.S. Naiker. and Z. Osman. 2009. Maggot debridement therapy with Licilia Cuprina: a comparison with conventional debridement in diabetic foot ulcers. International Wound Journal, p. Vol 6: no 1.

Pettican, A. and C. Baptista. 2012. Maggot debridement therapy and its role in Chronic wound management. Singapore nursing journal, pp. Vol 39, no 1, Jan to March.

Polit, D.F. and C.Tatano-Beck. 2010. Essentials of nursing research, appraising evidence for nursing practice. Philadelphia: Wolters Kluwer/lippincott Williams and Wilkins.

Pritchard, N. and Y. Nigam. 2013. Maximising the secondary beneficial effects of larval therapy. Journal of Wound Care, p. Vol 22 no11.

Sherman, R. 2002. Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound repair and regeneeration, pp. 10: 208-214.

Sherman, R. 2003. Maggot therapy for threating diabetic foot ulcers unrespobsive to conventional therapy. Diabetes Care, pp. 26: 446-451.

Sherman, R. 2009. Maggot Therapy Takes Us Back to the Future of Wound Care: New and Improved Maggot Therapy for the 21st Century. Journal of Diabetes Science and Technology, pp. Volume 3, Issue 2, 336-344.

Sherman, R. & K.Shimoda. 2004. Pre-surgical maggot debridement of soft tissue wounds is associated with decreased rates of post operative infection. Clinical Infection Dif, pp. 39: 2067-70.

Sherman, R., Wyle, F. and M. Vulpe. 1995. Maggot Debridement therapy for treating pressure ulcers in spinal cord injury patients. Journal of Spinal Cord Medicine, pp. 18: 71-4.

Singh, N., D. G. Armastrong. and B.A. Lipsky. 2005. Preventing Foot Ulcers in Patients with Diabetes. American Medical Association, pp. Vol 293, no 2.

Steenvoorde, P., T. Budding, and J. Oskam. 2005. determining pain levels in patients treated with maggot debridement therapy. Journal of wound care, pp. 14(10) 485-488.

Sun, X., K. Jaing., J. Chen., L. Wu., H. Lu., A. Wang. and J. Wang. 2014. A systematic review of maggot debridement therapy for Chronically infected wounds and ulcers. International journal of infectious diseases.

The National Diabetes Information Service, 2013. What is the cost of the diabetes service?. [Online]
Available at:
[Accessed 11th June 2014].

Tian, X., X.M. Liang., G.M. Song., Y. Zhao. and X.L. Yang. 2013. Maggot debridement therapy for the treatment of diabetic foot ulcers a meta analysis. Journal of Wound care, pp. vo l22, no 9..

Wayman, J., V. Nirojogi., A.walker., A. Sowinski. and M.A. Walker. 2000. The cost effectiveness of larval therapy in venous ulcers. Tissue viability, pp. 10: 91-94.

Wilasrusmee, C., M. Marjareonrungrung., S. Eamkong., J. Attia., N. Popram., S. Jirasisrithum. and A. Thakkinstain. 2013. Maggot therapy for chronic ulcer: a retrospective cohort and mata-analysis. Asian Journal of Surgery.

Zarchi, J. and G.B.E. Jemec. 2012. the efficacy of maggot debridement therapy a review of comparative trials. International Wound Journal, pp. 469-477, no9.


A systematic review of the factors affecting the provision of social support from co-workers during the return-to-work process


Work, in the majority of cases, has been shown to have greater benefits to health and well-being than unemployment. Waddell and Burton (2006) found that for most people work provides resources necessary for economic well-being. Furthermore they reviewed strong evidence that work also allows individuals to meet their psychosocial needs for identity, self-esteem, and social status. Correspondingly, unemployment was found to be consistently associated with poor mental and physical health (Waddell and Burton 2006). Sickness absence is estimated to cost employers in the UK £9 billion per year and to cost the state £13 billion (Black and Frost 2011). Long term absence from work due to sickness can therefore be very costly both financially and in terms of health and wellbeing. It is important that efforts be made to increase the ease with which people are able to return-to-work (RTW) in a sustainable and timely manner.

The availability of social support from colleagues has consistently been found to have an effect on RTW success (e.g. Norlund 2013), and this is likely to be related to the benefits to well-being that result from feelings of belonging within a supportive work environment (Inman 2007). In the pursuit of improving current understanding, a body of research has begun to investigate the conditions under which social support is more, or less likely to be provided. A number of factors have emerged such as whether work accommodations entail extra work for co-workers, whether the returning worker’s claims of illness are trusted (Eakin et al 2003) and whether the illness suffered by the returning worker carries stigma (Brouwer et al 2010). Furthermore, Dunstan and MacEachen (2014) have developed a model of co-worker responses to work accommodations provided for an injured colleague. They suggest that factors such as attributes of the injured worker (e.g. gender, race, competence) and features of the injury affect social support behaviours via the co-worker’s judgement of the fairness of the work accommodations. This model presents a coherent and plausible account of the process however the studies which informed its creation did not specifically consider the RTW process but rather supported employment for a disabled employee. The following review of studies, which have considered factors affecting social support during the RTW process, allows further development and validation of this model.

The increasing number of qualitative studies investigating social support in the RTW process provided an opportunity to collate and synthesise these findings in order that a comprehensive and coherent understanding of the factors affecting social support could be reached. Once synthesised, the findings presented may allow RTW specialists, including occupational therapists, to better understand the optimal conditions for a successful return to work in order that they can best support returning workers.

The aim of this systematic review using meta-ethnography was therefore to investigate the factors influencing provision of social support by co-workers to a colleague returning after sickness absence.


In January 2014 (08/01/14), several databases were searched for articles relating to the factors affecting social support given to colleagues returning from sickness absence. Databases searched included PubMED, Web of Science, CINAHL, Business Source Premier, and AMED. The search terms used were: co-worker OR colleague “return-to-work” OR “sickness absence” AND “social support”. Only articles published since 2000 were included to ensure study findings were relevant to today’s workplaces.

Following retrieval, records were screened using the inclusion and exclusion criteria as follows:

  • Considers factors affecting social support
  • Considers RTW following long term sickness absence
  • Qualitative data
  • Primary data
  • Does not exclusively consider social support given during absence from work.

The Journal of Occupational Rehabilitation was also hand searched for further relevant articles as were the references and citations of selected studies. Studies published between January 2014 – November 2014 which cited the selected studies were further screened on 01/12/14. Fig. 1 (below) depicts the articles retrieved at each stage of the systematic search.


A data extraction form that included criteria from the CASP checklist for qualitative research (Critical Appraisal Skills Programme 2013) was used to record key findings and methodological details. Methodological quality ratings were then assigned to each study by comparing the results of the CASP checklist with Cesario et al’s qualitative levels of evidence (2002). Critical appraisal of study quality was performed in order to improve understanding of the methodological processes of the studies, and to ascertain how much confidence should be placed in the findings of certain studies. No studies were excluded as a result of this appraisal.

Data analysis

Relevant data from the selected studies were synthesised using meta-ethnography, as developed by Noblit and Hare (1988).

Meta-ethnography represents a means of synthesising qualitative studies in order that the end-product is not merely an aggregation of findings but a synergy that offers new understanding and prompts further research. Key concepts are identified within each study through a process of induction and these are compared and contrasted in order to generate novel interpretations. Meta-ethnography attempts to maintain the original terminologies used by participants and primary authors throughout the synthesis in order to improve the validity of the resulting synthesis. There are a series of phases that make up the meta-ethnography process.

Noblit and Hare (1988) describe the first three phases as involving selecting the studies for review and becoming familiar with them. Phase four involves the determination of relationships between each study. Key concepts are identified for each study and entered into a table through which the similarities and differences between studies begin to appear. In phase five the studies are translated into one another. This is done by attempting to locate each study’s unique concepts and metaphors within the other studies in order to identify similarities and differences between studies. Common concepts are categorized into themes.

The sixth phase concerns synthesizing translations: A decision is made about whether the concepts arising from each study can be described as relating to one another reciprocally, in a refutational sense, or as components of a line of argument. Reciprocally related concepts are those that are so similar they could encompass one another. Concepts related in a refutational sense are those that oppose each other. Finally, concepts that relate to one another in a Line of Argument are those that describe different aspects of a single phenomenon and combine to provide a fuller understanding of that phenomenon. The final phase involves expression of the synthesis, which in this case, will be in written form.

Statement of researcher’s interests

This research is underpinned by a constructivist epistemology, which Paterson et al (2001) claim is compatible with attempts to synthesise qualitative literature. In line with this epistemology, it is accepted that the interpretations made herein reflect the first author’s individual worldview and alternative interpretations are plausible. A reflexive diary and research supervision with the second author was maintained throughout the research process in order that any personal assumptions or expectations could be monitored.


Sixteen articles met the inclusion criteria for this review. Of these articles, seven were assigned a good quality rating, and nine were assigned a medium quality rating using Cesario et al’s qualitative levels of evidence (2002).

Factors related to individual workplace actors

Characteristics of the returning worker

In several studies, the returning worker’s character or perceived character was influential to the provision of social support. A key attribute was the worker’s attitude; Participants in several studies spoke of social support that was dependent on the returning worker having the ‘right’ attitude which involved willingness to work hard towards making the return successful and being honest.

One participant in Dunstan and Maceachen’s study (2013) who worked in a military camp reported:

…as long as they [the returning worker] don’t have an attitude to give up or whatever, we kinda look after them as one of our own. (p.48)

Values of co-workers

In several studies, participants reported personal factors that encouraged them or others to provide social support, such as enjoying helping people or having a good pre-existing relationship with the returning worker. Furthermore participants in Sager and James’ study (2005) study discussed how having been through the RTW process was often a pre-requisite for social support:

… people don’t understand unless they experience it themselves. (p.133)

Influence of the supervisor

Four studies discussed the role of the supervisor in either facilitating or hindering the provision of social support among employees. The support behaviours they modelled were particularly influential. In a study conducted within the competitive electrical sector (Kosny et al 2012), managers were reported to have made attempts to prevent social support being given to returning workers, and one participant even reported workers had been rewarded for harassing a returning worker.

If a guy’s worked for a company and he’s really giving it to [the injured worker]…he made it so bad that this guy quit when he was injured, well the company is going to say…hey come on, I’ve got a job for you. (p.446)

The presence of the supervisor in RTW planning also appears very influential; participants in two studies reported feeling that without the guidance of a supervisor, misunderstandings and conflict were more likely to occur.

Factors related to the condition

History of illness

The returning worker’s illness history had an influence on provision of social support in several studies; the duration of a worker’s recovery and the number of previous absences led to reports of impatience on the co-workers’ part in several studies. Participants in Tjulin et al’s study (2011a) felt ‘drained of goodwill’ as time went on (p.1984).

Mental Health Problems

The existence of a mental health problem led to feelings of unease in several studies. Participants in Dunstan and Maceachen’s study (2013) reported feeling nervous of ‘provoking the workers’ mental condition’ (p.50) and therefore refrained from providing social support. A similar lack of knowledge about mental illness was reported to cause prejudice and discrimination in a separate study.

Another factor related to the returning worker’s condition that was reported as influential to the provision or withholding of social support was the visibility of their condition; several studies reported that a visible injury was more likely to be accepted and accommodated by co-workers than invisible conditions which led to doubt and distrust.

Lack of trust in the veracity of sickness absence claims

The validity of a condition was often called into question if it was not immediately visible and also if negative stereotypes were held about injured workers.

These stereotypes typically concerned ideas that the worker was irresponsible and had carelessly caused their injury, was lazy, or was trying to take the “easy way out” (Stergiou-Kita et al (2014a), p.16). Participants in Kosny et al’s study (2012) described being harassed at work by co-workers who believed them to be “milking the system” (p.443) while negative stereotypes led returning workers in two studies to actively restrict social contact with their co-workers. Participants in Choi et al’s study (2014) sought to avoid the rumours that were often spread about returning workers who were perceived as “malingerers” (p.4).

I was really self-conscious. ‘What do other people talk about in whispers when they see me doing exercise in the gym?’ […] So I did exercise alone and secretly”. (p.4)

Furthermore another study (Lysaght and Larmour-Trode 2008) reported that when co-workers trusted the injured worker and believed their claims to be true, they were more likely to provide support. One worker reported feeling he could rely on his co-workers to provide support as he felt they trusted him.

People here know me quite well and know that I work hard and I’m reliable and I don’t abuse the system, so when I’m injured, I’m injured, despite whether the injury is ‘invisible’ or not. (p.263)

Factors related to the culture of the workplace

Supportiveness of workplace culture

Several studies discussed the culture of the work environment in terms of how social support was facilitated. A participant in one study (Dunstan and Maceachen 2013) discussed the difference in her willingness to support colleagues in a supportive compared to a non-supportive workplace. She felt responsible to ‘pitch in’ in the former workplace whereas in the latter workplace she did not feel the need to help;

Quite frankly, I didn’t really care about the person with issues […] I came, I filled in my hours, I got paid, and I left. … The toxic environment didn’t lead to good relationships. (p.48)

Similarly, participants in another study (Kosny et al 2012) felt that the competitive culture of the electrical sector, where worries about job security were rife, and workers were divided into segregated teams, hindered the provision of social support. One co-worker reported ‘They want us to out-work one another’ (p.443). In this environment, helping another colleague would put one’s own job security at risk and therefore was not feasible; co-workers needed to prioritise their own well-being and job security before considering others.

Individualistic versus collectivistic workplace cultures

In addition to these findings that the individualistic priorities of workers in the electrical sector precluded social support, two studies discussed individualistic vs collectivistic workplace cultures, although with contrasting findings. Participants in one study (Dunstan and Maceachen 2013) reported feeling happier to put in extra work or allocate the lighter tasks to a returning worker if they felt their work group had a collective identity while participants in Tjulin et al’s (2011a) study who worked within a collectivistic culture were keen to simply replace the injured worker rather than provide special work accommodations for them. Another study (Tjulin et al 2011b) found that within workplaces where the workload was seen to belong to the worker, there was less tension in the workplace and workers were keen for their colleague to return to his own workload and reduce the stress on them.

Factors related to the quality of the organisation of the RTW plan

Quality of formal communication

One factor that appears to underlie several others in the provision of social support is the quality of formal communication within the workplace. In several studies, the lack of sufficient communication about the returning worker’s condition, limitations, and entitlements led to the proliferation of rumours, gossip, and misunderstandings, which hindered the provision of social support. The lack of social support was not necessarily malicious; a lack of formal information led to participants feeling ‘unequipped to give the support that was needed’ in Dunstan and Maceachen’s study (2013; p. 49) while participants in another study provided inappropriate support when they lacked understanding of the workers’ condition. In accordance, Tjulin et al (2011a) found that implicit communication about a worker’s return caused anxiety to be felt regarding how to act around the returning worker while a participant in Stergiou-Kita et al’s study (2014b) reported receiving “extensive support from coworkers who were educated by management about precautions to take to ensure effective wound healing” (p.503). However, contrary to the majority of studies included in this review, Stergiou-Kita et al (2014a) found that reduced communication concerning the returning worker’s condition prevented harassment and exclusion;

We have a strict privacy [policy]. Nobody else will know who is on a claim other than the immediate supervisor. Because in construction when you’re dealing [with] a predominantly male environment, he’ll [the worker will] be labelled, excuse my language, the dog f*****. He’ll be harassed. He will be ostracized by his co-workers (p.16).

Lack of understanding of RTW plans

A lack of understanding of the RTW process or of the co-worker’s role in the RTW process was often cited as a reason that social support had been inhibited. For example, co-workers who were unsure of the returning worker’s entitlements in line with the RTW scheme made health service workers returning from sickness absence in one study feel as if they were an aggravation if they attempted to attend medical appointments (Sager and James 2005).

Participants in two studies reported feeling social support may have increased if co-workers were more involved in planning the RTW process. They would then be aware of the rights of the returning worker, would be allowed input as to how they managed any additional work load, and could identify how best to support their colleague. However, co-workers interviewed in another study held quite different ideas about their involvement in planning the return; co-workers did not feel they should be involved in the process and stated they would rather be left to manage their own workload.

Allocation of work load

A common theme among eight of the studies was that the provision of modified work to a returning worker could incur resentment from co-workers, particularly if it was seen to be easy, or a duty reserved for more superior employees, in which case workers were believed to be receiving special treatment. Participants in Kosny et al’s study (2012) reported ‘sensing contempt from co-workers who felt they were now doing ‘cushy’ work’ (p.445).

Resentment also occurred if co-workers were expected to do extra work in order that the returning worker could receive accommodations. Participants in two studies saw this as a particular problem if the returning worker continued to be paid the same amount for doing less work.

Synthesis of findings

The factors discussed in this meta-ethnography combine to form a line of argument synthesis whereby the findings of the studies complement one another in order to generate new understanding, as defined by Noblit and Hare (1988). Many factors seem to interact with one another to influence the provision of social support. Furthermore, as in the model proposed by Dunstan and MacEachen (2014), it appears that the relationship between identified factors and social support may be mediated by the co-workers’ judgement of fairness of work accommodations. Although this concept of fairness was not specifically discussed in any of the studies it does seem to dominate many of the participants’ quotes and the primary authors’ interpretations.

Judgements of a lack of fairness made by co-workers have been observed to lead to restriction of support in a number of cases in the selected studies, for example:

  • Where co-workers were not allowed input into the allocation of work tasks.
  • Where co-workers believed they were being asked to do too much extra work.
  • Where co-workers perceived the returning worker to be receiving special treatment.

Judgements of fairness might lead to provision of social support when these antecedent factors are reversed e.g. co-workers are allowed input into allocation of work tasks. One quote that demonstrates the importance of judgements of fairness is taken from Dunstan and Maceachen’s study (2013):

It’s going to cause resentment, like when they […] can only perform fifty percent of their tasks and they’re still getting paid. (p.50)

This participant predicts that resentment will occur when the amount of work performed by the returning worker and the amount of pay they receive, are not in proportion. This unfair situation is expected to lead to a restriction of social support.

It therefore appears that situational and dispositional factors within the RTW process may often be subject to a judgement of fairness in determining whether those factors will result in the provision of social support.

Discussion and Implications

Nature of Synthesis

Many factors have been identified in this review as contributing to the provision of social support or lack thereof, and generally the studies are in agreement regarding these factors i.e. they present as reciprocal translations. On three occasions there was a conflict between studies in their findings – with regard to whether individualistic or collectivistic workplace cultures best facilitate support, whether co-worker input in the RTW plans facilitates social support, and whether reduced communication about the worker’s communication hinders support or impedes bullying. These disagreements may be related to contextual differences between studies such as the nature of the work tasks or the culture of the country in which the workplace was located. For example, participants in Stergiou-Kita et al’s study (2014) who reported that limitations on communication reduced the harassment of returning workers, acknowledged that this was due to the workplace being male-dominated and hostile. In this setting, formal communication regarding the returning worker’s illness may not have reaped the same benefits as in more supportive workplace cultures.   It is important, in taking the findings of this review forward, to recognise that measures taken to improve social support in one workplace may not be successful in another. Many of the included studies provided little information regarding the workplaces in which their participants worked and it would be valuable for future research to clearly document this in order that comparisons can be made between workplace contexts.

A line of argument was developed as a result of the synthesis of studies whereby the primary factors identified within the studies appear to both directly influence provision of social support and to indirectly influence it via the co-worker’s judgement of the fairness of work accommodations.

Factors that influence social support provision

This review draws together similar findings across a number of contexts regarding the factors affecting co-worker social support. Four over-arching categories of antecedent factors were found to consistently affect the provision of co-worker support in varied workplaces and cultures and this consistency of findings allows for greater confidence to be placed in the resulting recommendations for policy and development of theory.

The studies included in this review were mixed with regard to whether they investigated social support that was perceived by the returning worker or social support that co-workers reported providing. However remarkably similar factors were reported by both returning workers and co-workers. The one exception to this was that returning workers appeared to discuss negative stereotypes held about them more frequently than their co-workers reported them. This may have been due to co-workers being affected by a social desirability bias whereby they choose not to report undesirable, stereotypical beliefs to the researchers (as discussed by Krumpal, 2011), or it may be that in the state that returning workers in two studies described as ‘paranoid’ (Kirsh et al 2010, Sager and James 2005), stereotypical views present in broader societal discourse (e.g the media) were perceived where they were not existent in the specific workplace, reflecting the concept of internalised stigma (Brohan et al 2010).

Perceptions of fairness as a mediator

The line of argument developed through the process of meta-ethnography has found an increased body of evidence which broadly substantiates the model proposed by Dunstan and MacEachen (2014) in suggesting that co-workers’ judgements of fairness mediate the relationship between factors in the RTW process and support behaviours.

Fairness in the workplace is more commonly referred to in organisational research as organisational justice (Greenberg and Colquitt 2013). Further, perceptions of organisational justice have been found by Messer and White (2006) to positively affect organisational citizenship behaviours (OCBs). These are actions performed by employees that go beyond their job description for the benefit of either the organisation itself or for individuals within the organisation including co-workers e.g. re-arranging one’s work hours to allow another colleague to take annual leave. While OCBs performed for the benefit of co-workers have not directly been described as social support, there do seem to be a number of similarities in their definitions and thus Messer and White’s research (2006) further supports the line of argument that judgements of fairness affect social support provision.

Implications for practice and policy

There are a broad range of situations discussed in this review in which a perception of unfair work accommodations may be made and consequently lead to the restriction of social support. From these examples, it is possible to make some suggestions as to how co-workers’ perceptions of fairness may be changed. Of key importance to many instances in which unfairness was perceived, was a lack of understanding of the RTW plans, and of the returning worker’s condition. It appears essential therefore that formal communication is improved in the workplace; communication of the RTW plans ought to be explicit rather than spread through rumours which restrict the provision of appropriate social support (Dunstan and MacEachen 2013), and include a focus on encouraging support and tackling negative stereotypes. Co-workers can be included in the discussion of elements of RTW plans in order that they have a say regarding any extra work they are required to take on.

Although it may be reasonable to recommend supervisors improve formal communication regarding RTW plans, it is the employee’s right to decide whether to disclose information about their health to their employer and co-workers (Equality Act; Great Britain 2010). Furthermore it is unclear whether concealing or revealing a health problem, particularly a stigmatizing one, is more conducive to social support (Dunstan and MacEachen 2013, Kirsh et al 2012).

An additional recommendation would be to ensure supervisors are aware of the importance of their role both in promoting clear communication and also in modelling supportive behaviours. This may support the cultivation of a workplace culture in which social support is the norm and is fairly exchanged in times of need. As the supervisor appears to have such an influential role in developing a culture of support it may be fruitful for future reviews to seek to synthesise understanding of the factors affecting social support provided by supervisors in the RTW process.

The findings of this review and recommendations developed on their basis may additionally influence the work of practitioners in England and Wales’ new Fit for Work Service (Department for Work and Pensions, 2015) which the College of Occupational Therapists (2014) has identified as an emerging area in which occupational therapists may gain employment. The Service will allow companies and GPs to refer employees who have been absent due to sickness for an occupational health assessment in which a RTW plan will be developed so that both employee and employer can receive the support they need. The current review emphasises the need for employers to improve communication within the workplace, encourage co-worker support and include co-workers in RTW planning. Occupational therapists in work-support positions will have an important role in advising employers to adopt such changes.

The findings of this review also reinforce the importance of anti-stigma mental health campaigns and those that aim to improve awareness of mental health problems such as the UK’s Department of Health funded Time to Change campaign (Henderson et al 2012) as a lack of understanding of mental health conditions was a key factor identified as restricting the provision of social support within the workplace.


All studies were appraised to be of either medium or good quality. However there was an absence in many studies of a consideration of the researcher’s assumptions, or relationship with the research. Reflexivity is of great importance when conducting qualitative research, particularly within a constructivist paradigm, as it allows the reader to fully appreciate how the interpretations presented have been constructed (Gough 2003). This lack of reflexivity may reduce the credibility of the initial authors’ interpretations on which this review is based and highlights the need for more reflexivity in this field of qualitative research.

An additional limitation is that most of the studies included in the review discussed social support as a one-dimensional concept yet many academics adopt House’s notion of a multifaceted social support (House 1981) comprising at least four different types of support. Accordingly the use of the blanket term social support in the selected studies could be seen as a weakness of this review, as the findings lack specificity and the rich detail that could be gained through the division of social support into its component parts. Future research would benefit from specifying the particular types of support that are affected by factors in the RTW process.


This review offers a detailed and extensive account of the factors consistently found to affect social support in the RTW process of individuals who have been absent due to sickness. These factors can be categorised into those relating to individual workplace actors, the condition, the culture of the workplace, and the quality of the organisation of the RTW plan. The review also offers new understanding regarding the association between perceptions of organisational justice and social support behaviours. A line of argument synthesis was used to demonstrate that the factors identified affect social support both directly and indirectly via the co-workers’ judgement of the fairness of work accommodations. Occupational therapists and other professionals involved in RTW planning could enhance the social support provided by co-workers, and consequently the success of an employee’s return by addressing the factors that may lead to a judgement of unfair work accommodations.

Yvette Wagner, MSc Health through Occupation; and Dr. Josh Cameron, Principal Lecturer in Occupational Therapy


Articles selected for inclusion in review

Baril R, Clarke J, Friesen M, Stock S, Cole D, the Work Ready group (2003) Management of return-to-work programs for workers with musculoskeletal disorders: a qualitative study in three Canadian Provinces. Social Science and Medicine, 57, 2101-2114.

Choi M, Kim H-R, Lee J, Lee H-E, Byun J, Won JU (2014) Workers’ experiences with compensated sick leave due to musculoskeletal disorder: a qualitative study. Annals of Occupational and Environmental Medicine [online], 26(33). Available at: Accessed on: 10.01.15.

Corbiere M, Renard M, St-Arnaud L, Coutu M-F, Negrini A, Sauve G, Lecomte T (2014) Union Perceptions of factors related to the return to work of employees with depression. Journal of Occupational Rehabilitation [online]. Available at: Accessed on: 10.01.15.

Dunstan DA, MacEachen E (2013) Bearing the brunt: co-workers’ experiences of work reintegration processes. Journal of Occupational Rehabilitation, 23(1), 44-54.

Kirsh B, Slack T, King CA (2012) The nature and impact of stigma towards injured workers. Journal of Occupational Rehabilitation, 22, 143-154.

Kosny A, Lifshen M, Pugliese D, Majesky G, Kramer D, Steenstra I, Soklaridis S, Carrasco C (2012) Buddies in Bad Times? The Role of Co-workers After a Work-Related Injury. Journal of Occupational Rehabilitation, 23(3), 438-449.

Lysaght RM, Larmour-Trode S (2008) An exploration of social support as a factor in the return-to-work process. Work, 30(3), 255-266.

Mansfield E, Stergiou-Kita M, Kirsh B, Colantonio A (2014) After the storm: The social relations of return to work following electrical injury. Qualitative Health Research, 24(9), 1183-1197.

Nordqvist C, Holmqvist C, Alexanderson K (2003) Views of laypersons on the role employers play in return to work when sick-listed. Journal of Occupational Rehabilitation, 13(1), 11-20.

Norlund S, Fjellman-Wiklund A, Nordin M, Stenlund T, Ahlgren C (2013) Personal resources and support when regaining the ability to work: an interview study with exhaustion disorder patients. Journal of Occupational Rehabilitation, 23(2), 270-279.

Sager L, James C (2005) Injured workers’ perspectives of their rehabilitation process under the New South Wales workers compensation system. Australian Occupational Therapy Journal, 52, 127-135.

Stergiou-Kita M, Mansfield E, Dalter L, Colantonio A (2014a) Good Intentions? Employer representative conceptualizations and, challenges to the workplace accommodation process: The case of electrical injuries. Employee Responsibilities and Rights Journal [online]. Available at: Accessed on: 10.01.15.

Stergiou-Kita M, Mansfield E, Bayley M, Cassidy JD, Colantonio A, Gomez M, Jechke M, Kirsh B, Kristman V, Moody J, Vartanian O (2014b) Returning to work after electrical injuries: workers’ perspectives and advice to others. Journal of Burn Care and Research, 35(6), 498-507.

Tjulin A, MacEachen E, Edvardsson Stiwne, Ekberg K (2011a) The social interaction of return to work explored from co-workers experiences. Disability and Rehabilitation, 33(21-22), 1979-1989.

Tjulin A, MacEachen E, Ekberg K (2010) Exploring workplace actors experiences of the social organization of return-to-work. Journal of Occupational Rehabilitation, 20(3), 311-321.

Tjulin A, MacEachen E, Ekberg K (2011b) Exploring the meaning of early contact in return-to-work from workplace actors’ perspective. Disability and rehabilitation, 33(2), 137-145.

Other references

Bisiker J, Millinchip K (2007) Developing a work rehabilitation project: ‘Equal pathways to work’. British Journal of Occupational Therapy, 70(6), 259-263.

Black DC, Frost D (2011) Health at work – an independent review of sickness absence. Norwich: The Stationary Office.

Brohan E, Elgie R, Sartorius N and Thornicroft G (2010) Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study. Schizophrenia Research, 122(1-3), 232-238.

Brouwer S, Reneman MF, Bultmann U, van der Klink JJ, Groothoff JW (2010). A prospective study of return to work across health conditions: perceived work attitude, self-efficacy and perceived social support. Journal of Occupational Rehabilitation, 20(1), 104-112.

Cesario S, Morin K, Santa-Donato A (2002) Evaluating the level of evidence of qualitative research. Journal of Obstetric, Gynecologic and Neonatal Nursing, 31(6), 708-714.College of Occupational Therapists (2014) Health and Work Service heralds new job opportunities for OTs. Available at: Accessed on: 27.07.14.

Coole C, Drummond A, Watson P, Worthington E, Hammond A (2013) Supporting workers with musculoskeletal conditions: a survey of United Kingdom occupational therapists’ communications with patients and their employers. British Journal of Occupational Therapy, 76(11), 478–486.Critical Appraisal Skills Programme (2013) Qualitative Research Checklist. Available at: Accessed on: 26.07.14.

Department for Work and Pensions (2015) Fit for Work: guidance for employers. Available at: Accessed on: 27.05.15.Dunstan DA, MacEachen E (2014) A Theoretical Model of Co-worker Responses to Work Reintegration Processes. Journal of Occupational Rehabilitation, 24(2), 189-198.

Eakin J, MacEachen E, Clarke J (2003) ‘Playing it smart’ with return to work: Small workplace experience under Ontario’s policy of self-reliance and early return. Policy and Practice in Health and Safety, 1(2), 20-41.

Gough B (2003) Deconstructing reflexivity. In: Finlay L and Gough B, eds. Reflexivity: A practical guide for researchers in health and social sciences. Oxford: Blackwell Science Ltd. 2003. 21–35

Great Britain. Parliament (2010) Equality Act 2010. London: The Stationery Office.

Greenberg J, Colquitt JA (2013) Handbook of Organizational Justice. Oxford: Psychology Press.

Henderson C, Corker E, Lewis-Holmes E, Hamilton A, Flach C, Rose D et al (2012) England’s Time to Change Antistigma Campaign: One-Year Outcomes of Service User-Rated Experiences of Discrimination. Psychiatric Services, 63(5), 451-457

House JS (1981) Work, stress and social support. Reading, MA: Addison-Wesley.

Inman J, McGurk E, Chadwick J (2007) Is Vocational Rehabilitation a Transition to Recovery? British Journal of Occupational Therapy, 70(2), 60-66.Messer BAE, White FA (2006) Employees’ mood, perceptions of fairness, and organizational citizenship behaviour. Journal of Business and Psychology, 21(1), 65-82.

Noblit GW, Hare RD (1988) Meta-Ethnography: Synthesizing Qualitative Studies. London: Sage publications. Paterson BL, Thorne SE, Canam C, Jillings C (2001) Meta-Study of Qualitative Health Research. London: SAGE Publications.Waddell G, Burton AK (2006) Is work good for your health and well-being? London: The Stationary Office.




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