International Journal of Nursing Studies RSS feed: Current Issue. The International Journal of Nursing Studies provides a forum for publication of original papers of the highest standard that report research findings and research-based reviews and analysis of interest to an international readership of nurses, midwives, educators, administrators and researchers in all areas of nursing and health care sciences. It aims to contribute to the advancement of the science and practice of nursing and interrelated disciplines worldwide by the international dissemination of sound information based on rigorous methods of research and scholarship. The journal welcomes submissions of original research papers, protocols of controlled intervention studies, short reports of scale development, reviews (including systematic reviews, literature reviews and policy reviews), discussion papers and commentaries on previously published papers. Guidelines for authors can be accessed at http://ees.elsevier.com/ijns . Authors should highlight the significance of their work to nursing and midwifery theory, practice and education and the organisation of care. They should also identify how this might have relevance to countries other than their own, including other disciplines. All published papers are peer-reviewed.http://www.journalofnursingstudies.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. All rights reserved. International Journal of Nursing Studies0020-7489472February 2010 © 2010 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.journalofnursingstudies.com/article/PIIS0020748910000118/abstract?rss=yesEditorial Board10.1016/S0020-7489(10)00011-8International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5CO2CO2http://www.journalofnursingstudies.com/article/PIIS0020748909003587/abstract?rss=yesI was privileged this month to have a preview of the papers in this issue of the journal. The last time I read a journal from beginning to end was in the dim past when I still had personal subscriptions and liked to read in the bath after a shift – it needs little imagination to picture said journal slipping in as I slipped off … There is no impressive collection of back issues in my office because the copies were barely readable post dip! The benefit of reading every paper in the journal is the broad spectrum of information to be gained – a suite of specialist knowledge, a multiplicity of methodologies, a diversity of data collection instruments and much food for thought – things missing and missed as the modern art of electronic literature searching is perfected and we need only to read what is essential in our limited field of specialisation. This week I have given information about these papers to nurses and midwives in the hospital and the university, thereby increasing my reputation as a well read, finger on the pulse, professor for all seasons. Hopefully the dissemination will result in evidence based actions and higher standards of nursing, midwifery and research – because that is the potential. My thanks and congratulations go to each of the contributors.An exceedingly good readMary FitzGerald10.1016/j.ijnurstu.2009.11.002International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Editorial133135http://www.journalofnursingstudies.com/article/PIIS0020748909001989/abstract?rss=yesAbstract: Background and objectives: The physical health of people with serious mental illness is a cause of growing concern to clinicians. Life expectancy in this population may be reduced by up to 25 years and patients often live with considerable physical morbidity that can dramatically reduce quality of life and contribute to social exclusion. This study sought to determine whether the serious mental illness health improvement profile [HIP], facilitated by mental health nurses [MHNs], has the clinical potential to identify physical morbidity and inform future evidence-based care.Design: Retrospective documentation audit and qualitative evaluation of patients’ and clinicians’ views about the use of the HIP in practice.Setting: A nurse-led outpatient medication management clinic, for community adult patients with serious mental illness in Scotland.Participants: 31 Community patients with serious mental illness seen in the clinic by 2 MHNs trained to use the HIP. All 31 patients, 9 MHNs, 4 consultant psychiatrists and 12 general practitioners [GPs] (primary care physicians) participated in the qualitative evaluation.Methods: A retrospective documentation audit of case notes for all patients where the HIP had been implemented. Semi-structured interviews with patients and their secondary care clinicians. Postal survey of GPs.Results: 189 Physical health issues were identified (mean 6.1 per patient). Items most frequently flagged ‘red’, suggesting that intervention was required, were body mass index [BMI] (n=24), breast self-examination (n=23), waist circumference (n=21), pulse (n=14) and diet (n=13). Some rates of physical health problems observed were broadly similar to those reported in studies of patients receiving antipsychotics in primary care but much lower than those reported in epidemiological studies. Individualised care was planned and delivered with each patient based on the profile. 28 discreet interventions that included providing advice, promoting health behavioural change, performing an electrocardiogram and making a referral to professional colleagues were used. Qualitative feedback was positive. Our observations support the use of the HIP in clinical settings to enhance mental health nursing practice; however, we strongly recommend that training is required to support the use of the HIP.Using the serious mental illness health improvement profile [HIP] to identify physical problems in a cohort of community patients: A pragmatic case series evaluationFrancis Shuel, Jacquie White, Martin Jones, Richard Gray10.1016/j.ijnurstu.2009.06.003International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Practice136145http://www.journalofnursingstudies.com/article/PIIS0020748909001734/abstract?rss=yesAbstract: Background: Reporting of known and suspected child abuse and neglect is a fundamental responsibility of health professionals in many countries including Australia. Nurses’ duties to report child abuse and neglect are expressed in legislation, or in occupational policy documents. In this paper factors influencing nurses’ compliance with mandated reporting are examined.Objective: The purpose of this study was to examine the relationship between nurse characteristics, training, knowledge of legislative reporting duty and attitudinal factors on the reporting by nurses of different types of child abuse and neglect.Methods: Logistic regression analyses were conducted to examine relationships between variables.Design, setting and participants: A cross-sectional survey using the Child Abuse and Neglect Nurses’ Questionnaire (CANNQ) was conducted. The respondents were 930 Registered Nurses (RNs) currently working across metropolitan, rural and remote locations throughout the state of Queensland, Australia.Results: Nurses were confident and knowledgeable in their obligation to report physical [CPA] and sexual [CSA] abuse. They were less confident and knowledgeable about emotional abuse [CEA] and neglect [CN]. Recognition of the extent of harm to abused and neglected children was poor. Positive attitudes to mandatory reporting influenced better recognition of all forms of abuse and neglect and the likelihood of reporting CSA, CEA and CN; parenting experience influenced intention to report child sexual abuse, and CAN training predicted reporting of child neglect.Conclusions and practice implications: Results indicate that with training, nurses are a key choice for mandating child abuse and neglect reporting. Educational preparation and training for nurses should emphasise the serious impact of child abuse and neglect on children and families to improve recognition of the extent of harm and the likelihood of reporting. From a perspective of increasing compliance with the legislative duty, particular attention needs to be paid to recognition and reporting of CEA and CN. Further research is needed to determine whether factors influencing sound reporting can be successfully modified.Factors influencing child abuse and neglect recognition and reporting by nurses: A multivariate analysisJennifer A. Fraser, Ben Mathews, Kerryann Walsh, Linping Chen, Michael Dunne10.1016/j.ijnurstu.2009.05.015International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Practice146153http://www.journalofnursingstudies.com/article/PIIS0020748909001801/abstract?rss=yesAbstract: Background: There is increasing emphasis on person-centred care within the literature and the health care context. It is suggested that a person-centred approach to medication activities has the potential to improve patient experiences and outcomes.Objectives: This study set out to examine how nurses and patients interact with each other during medication activities in an acute care environment with an underlying philosophy of person-centred care.Design: A qualitative approach was used comprising naturalistic observation and semi-structured interviews.Setting: The study setting was an acute care ward with a collaboratively developed philosophy of person-centre care, in an Australian metropolitan hospital.Participants: Eleven nurses of varying levels of experience were recruited to participate in observations and interviews. Nurses were eligible to participate if they were employed on the study ward in a role that incorporated direct patient care, including medication activities. A stratified sampling technique ensured that nurses with a range of years of clinical experience were represented. Patients who were being cared for by participating nurses during the observation period were recruited to participate unless they met the following exclusion criteria: those less than 18 years of age, non-English speaking patients, and those who were unable to give informed consent. Twenty-five patients were observed and 16 of those agreed to be interviewed.Results: The results of the study generated insights into the nature of interactions between nurses and patients where person-centred care is the underlying philosophy of care. Three major themes emerged from the findings: provision of individualised care, patient participation and contextual barriers to providing person-centred care. While the participating nurses valued a person-centred approach and perceived that they were conducting medication activities in a person-centred way, some nurse–patient interactions during medication activities were centred on routines rather than individualised patient assessment and management. These interactions were based on nurses’ perceptions of what was important for the patient and did not provide opportunities for patient participation. Two main contextual barriers in relation to a person-centred approach to medication activities were identified as multidisciplinary communication and time constraints.Conclusions: While some nurse–patient interactions during medication activities were consistent with the principles of person-centred care, the study results highlighted factors that influence the nature of these interactions, and identified opportunities to improve nursing practice. To ensure person-centred care is applied to medication activities, nurses should undertake ongoing assessment of patients’ needs in relation to their medications and encourage opportunities for increased patient participation.Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: Qualitative observation and interview studyDanielle Bolster, Elizabeth Manias10.1016/j.ijnurstu.2009.05.021International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Practice154165http://www.journalofnursingstudies.com/article/PIIS0020748909001746/abstract?rss=yesAbstract: Background: Perceptions of exercise benefits and barriers affect exercise behavior. Because of the clinical course and treatment, dialysis patients differ from the general population in their perceptions of exercise benefits and barriers, especially the latter. At present, no valid instruments for assessing perceived exercise benefits and barriers in dialysis patients are available.Objectives: Our goal was to develop and test the psychometric properties of the Dialysis patient-perceived Exercise Benefits and Barriers Scale (DPEBBS).Methods: A literature review and two focus groups were conducted to generate the initial item pool. An expert panel examined the content validity. Then, 269 Chinese hemodialysis patients were recruited by convenience sampling. Exploratory and confirmatory factor analyses were used to test construct validity. Finally, internal consistency and test–retest reliability were assessed.Results: The expert panel determined that the content validity index was satisfactory. The final 24-item scale consisted of six factors explaining 57% of the total variance in the data. Confirmative factor analysis supported the six-factor structure and a higher-order model. Cronbach's alpha was 0.87 for the total scale, and 0.84 for test–retest reliability.Conclusion: The DPEBBS was a valid and reliable instrument for evaluating dialysis patients’ perceived benefits and barriers to exercise. The application value of this scale remains to be investigated by increasing the sample size and evaluating patients undergoing different dialysis modalities and coming from different regions and cultural backgrounds.Development and psychometric evaluation of the Dialysis patient-perceived Exercise Benefits and Barriers ScaleJing Zheng, Li-Ming You, Tan-Qi Lou, Nian-Chang Chen, De-Yuan Lai, Yan-Yi Liang, Ying-Na Li, Ying-Ming Gu, Shao-Fen Lv, Cui-Qiu Zhai10.1016/j.ijnurstu.2009.05.023International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Methodological developments166180http://www.journalofnursingstudies.com/article/PIIS0020748909001783/abstract?rss=yesAbstract: Background: Preventing tobacco consumption and promoting cessation among health professionals are of great significance as their habits can influence their patients’ attitudes. Knowledge of the prevalence and characteristics of tobacco use in a specific population is important for the design of efficient strategies for preventing people from acquiring the habit and persuading them to stop. Self-administered questionnaires are a very common method for determining tobacco use, but assessment is needed of their validity for specific groups, such as occasional smokers or students of health sciences.Objectives: The aim of this study was to determine the sensitivity and specificity of a self-administered questionnaire for determining tobacco use among a population of young female students of health sciences. As a gold standard, we used a measure of the concentration of cotinine in saliva with different cut-off points. We also analysed the influence on sensitivity and specificity of the questionnaire of nicotine dependence and exposure to secondary smoke.Design: This is an internal validity study (sensitivity and specificity) of a self-administered questionnaire.Settings: The study was carried out in the School of Health Sciences of the University of León, at its centres in León and Ponferrada.Participants: Data were collected on 432 of a total of 480 women aged under 25 who were studying Health Sciences at the University of León in 2007.Methods: The self-administered questionnaire included data concerning demography, education, tobacco habits and exposure to environmental smoke. Saliva cotinine concentration was determined with an EIA kit.Results: The questionnaire used showed high values of sensitivity and specificity (85.3% and 95.3%) and a very good correlation (Kappa=81.0%) with cotinine values of 10ng/ml or higher. Discrepancies in the test results for those who declared themselves to be smokers only occurred in women with a low nicotine dependency. Among those who did not declare themselves smokers, those exposed to second-hand smoke were 7 times more frequently classified erroneously as smokers than those who had not been exposed.Conclusion: The self-administered questionnaire used showed a very good internal validity and a good correlation with cotinine levels of 10ng/mg, and therefore seems to be a good instrument for measuring tobacco use in this population. The availability of information on passive smoking and nicotine dependence is essential for the correct interpretation of the discrepancies.Sensitivity and specificity of a self-administered questionnaire of tobacco use; including the Fagerström testAntonio J. Molina, Daniel Fernández, Miguel Delgado, Vicente Martín10.1016/j.ijnurstu.2009.05.022International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Methodological developments181189http://www.journalofnursingstudies.com/article/PIIS0020748909001771/abstract?rss=yesAbstract: Background: Expressed emotion is a construct that has been used for the past three decades to describe family members’ criticism, hostility and emotional involvement with a mentally ill relative within the context of family interactions and caregiving. In Western countries this construct is used as an outcome measure of interventions for families of people with schizophrenia or other psychotic disorders, but the use of this construct in Chinese populations is somewhat limited.Objective: To test the reliability and validity of a refined Chinese version of the 52-item Level of Expressed Emotion Scale (LEE).Methods: A convenience sample of 405 outpatients with psychotic disorders in Hong Kong and one of their family caregivers were recruited. Patients were asked to complete a set of questionnaires twice over a 6-month period, including the Chinese version of the LEE, the Specific Level of Functioning scale and the Brief Psychiatric Rating Scale; while their caregivers completed the Family Assessment Device twice and a demographic data sheet at recruitment. This study was aimed at establishing the internal consistency, reproducibility, responsiveness, and construct validity of the LEE.Results: Results indicated that the refined 50-item Chinese version of the LEE and its subscales demonstrated a high internal consistency and satisfactory correlations with patient and family functioning scores. Principal component analysis revealed the presence of four factors, explaining 70.8% of total variance and indicating high factor loadings as well as item-factor inter-correlations. The Chinese version not only indicated a satisfactory reproducibility in assessing change in patients’ symptom severity and family functioning but also showed an adequate responsiveness to the changes in patients’ symptoms over 6 months, especially for detecting symptom improvement.Discussion: The findings of the psychometric evaluation of the Chinese version of the LEE established its potential as a research instrument in measuring the level of expressed emotion of family members as perceived by Chinese patients with psychotic disorders. Further testing of its psychometric properties is recommended, using larger samples from diverse socio-economic backgrounds and mental illnesses.Further validation of the Chinese version of the Level of Expressed Emotion Scale for research and clinical useWai-Tong Chien, Sally W.C. Chan10.1016/j.ijnurstu.2009.05.019International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Methodological developments190204http://www.journalofnursingstudies.com/article/PIIS0020748909001692/abstract?rss=yesAbstract: Background: Nursing is considered as a risk profession with high levels of stress and burnout, and these levels are probably increasing.Objectives: This study assessed temporal and cross-sectional relationships between job stressors, hardy personality and coping resources on burnout dimensions among nurses.Design: Temporal and cross-sectional effects were evaluated. A sample of 98 nurses from Portugal completed the Nursing Burnout Scale at two time points. The data were analysed using descriptive statistics, Pearson correlations, and hierarchical linear regression analyses regressing Wave 2 burnout dimensions.Results: The study confirmed the specific contribution of control and challenged hardy personality dimensions as the explanation of burnout. However, commitment did not show any effects in this study. Social support and active coping were also relevant predictors of burnout dimensions. Specifically, active coping had an inverse temporal effect on depersonalisation and lack of personal accomplishment. In relation to the burnout process, depersonalisation appeared as an antecedent of lack of personal accomplishment.Conclusions: The present study is an initial step to comprehend the link between job stressors, hardy personality, coping resources and diminishing burnout.The relationship between job stressors, hardy personality, coping resources and burnout in a sample of nurses: A correlational study at two time pointsEva Garrosa, Conceição Rainho, Bernardo Moreno-Jiménez, Maria João Monteiro10.1016/j.ijnurstu.2009.05.014International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Professional's experience of healthcare205215http://www.journalofnursingstudies.com/article/PIIS0020748909001667/abstract?rss=yesAbstract: Background: Fatigue is a complex phenomenon associated with multiple antecedents and detrimental consequences. Although this symptom is prevalent in the older population, it is not easily recognized by nurses and has been under treated.Aim: The purpose of this review is to describe the existing research on fatigue on older adults with focus on the lived experience of fatigue, factors related to such fatigue experience and the impact of fatigue on overall health.Methods: A systematic search of the literature was undertaken to identify research evidence on fatigue among the older population. Three databases (i.e. OvidMedline, CINAHL and PsycINFO) were searched, resulting in 15 eligible studies. Three aspects about the fatigue phenomenon in older people were identified: the lived experience of fatigue, relating factors of fatigue, and impact of fatigue on overall health.Findings: The key findings suggest that fatigue is an overwhelming experience constrains physical capacity and the energy reserve required for appropriate functioning and social participation, as well as worsens their morbidity and mortality outcomes. Yet, its heterogeneous etiologies and multi-dimensional manifestations pose a huge challenge on its diagnosis and treatment. Indeed, there was inadequate research-base evidence on fatigue management for older people. This gap in literature may imply that this problem is poorly recognized and under-treated in older people.Conclusions: The findings highlight that fatigue is a substantial problem in older people that deserves early recognition and prompt treatment. Nurses need to be sensitive to the risk factors of fatigue in the older population and conduct a comprehensive fatigue assessment on the high risk case. Although this review only identified limited research-base evidence, the findings do give directions to the development of interventions for fatigue management for older people.Fatigue among older people: A review of the research literatureDoris S.F. Yu, Diana T.F. Lee, Ng Wai Man10.1016/j.ijnurstu.2009.05.009International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Reviews and Discussion Papers216228http://www.journalofnursingstudies.com/article/PIIS0020748909002314/abstract?rss=yesAbstract: Objectives: The purpose of this review was to examine the evidence of cardiovascular risk in early bereavement to identify potential risk factors and possible mechanisms for risk that may inform future research directions.Design: A comprehensive search of electronic databases PubMed Medline, CINAHL and PsycINFO, bereavement related textbooks and reviewed reference lists was undertaken on literature related to evidence of increased risk in bereavement. No limits were set on the searches in terms of date or publication type, but only English language articles were selected.Findings: Bereavement represents a time of heightened cardiovascular risk for the surviving spouse. The immediate weeks following bereavement represent the highest risk period with both men and women across all ages. Risk is evident irrespective of the nature of death, expected or unexpected, although higher level of social support at the time of death may be protective. Evidence would suggest that for many, bereavement results in a time of increased psychological stress and potential for altered behavioural health risk factors that in the presence of altered physiological state, may serve as a potential trigger of cardiovascular events, especially in those most at risk.Conclusion: The findings from this review provide insight into the impact of early bereavement on health and the recognition that bereavement is associated with increased cardiac risk. This recognition should provide an impetus for individuals to act on cardiac symptoms by seeking medical advice and for health care providers to monitor such individuals more closely.Cardiovascular risk in early bereavement: A literature review and proposed mechanismsThomas Buckley, Sharon McKinley, Geoffrey Tofler, Roger Bartrop10.1016/j.ijnurstu.2009.06.010International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Reviews and Discussion Papers229238http://www.journalofnursingstudies.com/article/PIIS0020748909001813/abstract?rss=yesAbstract: One of the key challenges for the advancement of nursing globally is the development of doctorally prepared educators and leaders in a context where there is a shortage of provision of doctoral nursing programmes. For the short term future, many nurses wishing to undertake a doctorate will need to complete this education in the USA, the UK or Australia. Very little is known however about the nature of their learning experiences in these countries. This paper presents a literature review on the international doctoral student experience, with specific reference to nursing. A thorough review of the literature from 1990 to 2009 was undertaken which yielded only three empirical studies related to nursing. The review was then expanded to include subjects other than nursing which yielded 16 studies in total. This paper presents key themes that appear to be generic to international doctoral students, and draws out specific implications for nursing.The review found that international doctoral students’ learning experiences were strongly influenced by the extent to which they could engage with three key elements of doctoral programmes:The first months represented a critical time of transition and most international students seemed to want and expect considerable support and structured in-put during this period. Most studies concluded that there was a need for greater institutional support and supervisor training. The three nursing-specific papers were entirely consistent with these themes.The existing evidence is extremely heterogeneous and of variable methodological quality. In order to ensure that doctoral nursing students are getting a high quality and appropriate PhD experience, there is a need for more research specifically with this group. There is also a need to investigate the different stages of the doctoral process in nursing, including, for example, writing up and examination processes and post-doctoral career outcomes.The learning experiences of international doctoral students with particular reference to nursing students: A literature reviewCatrin Evans, Keith Stevenson10.1016/j.ijnurstu.2009.05.025International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Reviews and Discussion Papers239250http://www.journalofnursingstudies.com/article/PIIS0020748909001795/abstract?rss=yesAbstract: Background: Theoretical and empirical overlaps between the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence have earlier been described as some kind of inner strength, but no studies have been found that focus on what attributes these concepts have in common.Objectives: The objective of this study was to perform a theoretical analysis of the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence, in order to identify their core dimensions in an attempt to get an overarching understanding of inner strength.Print method: An analysis inspired by the procedure of meta-theory construction was performed. The main questions underlying the development of the concepts, the major paradigms and the most prominent assumptions, the critical attributes and the characteristics of the various concepts were identified.Results: The analysis resulted in the identification of four core dimensions of inner strength and the understanding that inner strength relies on the interaction of these dimensions: connectedness, firmness, flexibility, and creativity. These dimensions were validated through comparison with the original descriptions of the concepts.Conclusion: An overarching understanding of inner strength is that it means both to stand steady, to be firm, with both feet on the ground and to be connected to; family, friends, society, nature and spiritual dimensions and to be able to transcend. Having inner strength is to be creative and stretchable, which is to believe in own possibilities to act and to make choices and influence life's trajectory in a perceived meaningful direction. Inner strength is to shoulder responsibility for oneself and others, to endure and deal with difficulties and adversities. This knowledge about inner strength will raise the awareness of the concept and, in turn, hopefully increase our potential to support people's inner strength.Inner strength—A theoretical analysis of salutogenic conceptsBerit Lundman, Lena Aléx, Elisabeth Jonsén, Astrid Norberg, Björn Nygren, Regina Santamäki Fischer, Gunilla Strandberg10.1016/j.ijnurstu.2009.05.020International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Reviews and Discussion Papers251260http://www.journalofnursingstudies.com/article/PIIS0020748909002260/abstract?rss=yes recently published an interesting study that set out to understand and develop the concept of care and caring culture based on an empirical/phenomenological standpoint of nurses’ lived experiences of working in different environments. Seventeen nurses were interviewed and thematic analyses revealed five themes concerning the nurses’ lived experiences of care culture. It was concluded (among other things) that care culture can be positive and enabling of good care on wards described as homelike: where nurses could act in accordance with own values. However, there are some important conceptual issues within the article that remain entangled, which is unfortunate and hence calls for a commentary.The quest for conceptual consistency: Commentary on Rytterström et al. (2009)David Edvardsson, Birgit Rasmussen10.1016/j.ijnurstu.2009.06.017International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Commentaries261262http://www.journalofnursingstudies.com/article/PIIS0020748909002077/abstract?rss=yesI welcome review which was both helpful and extremely informative. The finding that early mobilisation following a myocardial infarction (MI) may reduce mortality by up to 15% is an important evidence that reinforces what ‘expert opinion’ had been suggesting to us for many years. The benefits of early ambulation are multiple and are well reviewed in this article and I will not repeat the author's findings. I do have one comment; I was surprised to see no acknowledgement or discussion of the involvement of my profession, Physiotherapy, in the safe ambulation of patients following such an event. I am surprised about this for several reasons, but mainly because following an MI the patient may be a high falls risk in addition to probably being fearful of doing so. Falling is a leading cause of mortality and morbidity and if a fall occurs in a vulnerable patient, such as one who is post-MI, it would complicate their rehabilitation substantially. It may be tempting for clinical nurses to apply findings and start early ambulation of patients following MI. If a patient appear anxious about falling, however, or they appear to be having difficulty walking, I would advise my nursing colleagues to work with physiotherapists when considering early mobilisation to negate this falls risk. Physiotherapists are experts in this capacity; they may advice nursing colleagues on appropriate strategies to safely mobilise patients, and may also consider the value a issuing a walking aid. Failure to engage the ward physiotherapist may have tragic consequences, should a patient fall due to lack of physiotherapy guidance of the clinical team on appropriate aids and specialist advice. I welcome nurses to take a proactive approach in early patient mobilisation but urge them to consult physiotherapists for guidance on this when patients appear anxious and/or appear to be having difficulty ‘getting going’!.Early ambulation—Consider working with physiotherapists. A comment on Cortes et al. (2009)Brendon Stubbs10.1016/j.ijnurstu.2009.06.018International Journal of Nursing Studies 47, 2 (2010)2010-02-01International Journal of Nursing Studies2010-02-01472S0020-7489(10)X0002-5Commentaries263263