Correlation, Association and Causation…Is It Time for a Review?

correlationWhen I returned to higher education for my Master’s Degree, my end point was to become credentialed so I could begin my dream job as an inpatient nurse practitioner. This was a new role in 1993 and I will admit that as a single woman who  could afford only one year away from the paycheck, I was committed to getting in and out of my Master’s courses at Boston College quickly and efficiently. In particular, I had no aptitude or desire to become a researcher. My mind was clear that I would go through the “hoops” of the beginning research course (mandatory) and then “never do research again.”  I can hear your laughter now….

So, on day one of my Master’s year, I entered Research 101 for Nurses; thoroughly prepared to hate it, pretty sure I might not pass it, and very clear that it was not pertinent to my clinical life. (Yes, one can be quite naïve, even at age 35). Amazingly, I entered a classroom taught by the most wonderful teacher of my entire academic life (I’m including grade school here too). I’ve long forgotten her name but I’ll never forget her. She taught me to love and appreciate the science of science. For 18 rapid weeks, she taught a basic exercise. Each week we were given a nursing research paper to read and then in each class, we reviewed it and discussed the paper’s merits. She, of course, chose increasingly complex papers with a variety of study designs and writing skills. Some papers were good, some terrible, some stated what they did not find, some overstated conclusions….you get the idea. Our class thrived! It sounds so naïve to admit, but we were empowered to realize that just because the researchers said it, it might not be true…because of design flaw, overreaching results, and other errors, glaring and subtle.

Our professor also taught us to appreciate that while we may not be researchers, we were intelligent…and that research should not be sloppy, unreadable, or beyond our understanding. It was up to the writer to tell us what their question was, what was known about it, explain the study design, tell us how they did it, discuss their results against their question and draw some conclusions based on what they found. She demystified the process and actually taught us to critically analyze what we read….or as my Mother said, “Don’t automatically believe everything you read”. The fact that the reader of research had a responsibility in the process changed us from observers to participants. An amazing teacher with an amazing gift.

So, research became very relevant in my clinical role and subsequent professional life….if, for no other reason, than for me to critically read research and analyze its credibility. Since entering the field of obesity care, this analysis has become increasingly important. I’m not sure if is the weight bias/discrimination inherent in the specialty or the infancy of our understanding of the causes and biology of obesity…but often the “studies” that “prove” some aspect of obesity do not pass the rigor that I was taught in Research 101. Popular press articles and studies presented at conferences and professional journals that conclude association or correlation are often misinterpreted as evidence of causation.

With the flood of open access predatory publications, this issue has moved to the forefront in my mind. These journals, with their non-existent or shoddy peer reviews processes, lack of editing and oversight, and an emphasis of meeting the needs of authors, not readers, are publishing flawed articles. On a continuum these papers range from  poorly done, uninspired studies that couldn’t find a legitimate publication home, to deeply deceptive junk science reporting results that have the potential for real patient harm.

So, my thought is that it may be timely to review basic research principles at conferences, journals, and classrooms….sincerely. It has been a long time for many of us since Research 101. With so much information bombarding us daily through so many mediums, it is easy to just skim the headlines or read the conclusion of the paper. An emphasis on critical analysis of research (or what is presented as research) might remind us and our readers to take a moment to read the fine print.


Lisa Kennedy Sheldon Appointed as New Editor of Clinical Journal of Oncology Nursing

Lisa Kennedy SheldonPITTSBURGH, PA (November 3, 2014) The Oncology Nursing Society (ONS) has announced the appointment of Lisa Kennedy Sheldon, PhD, APRN, BC, AOCNP® as editor of the Clinical Journal of Oncology Nursing (CJON) effective June 1, 2015. Dr. Sheldon will serve as editor-elect under current editor Deborah K. Mayer, PhD, RN, AOCN®, FAAN, beginning January 2015. CJON, published bimonthly, is an official publication of ONS and is directed to the practicing nurse specializing in the care of patients with an actual or potential diagnosis of cancer.

Dr. Sheldon is an assistant professor at the University of Massachusetts-Boston and an oncology nurse practitioner in the Cancer Center at St. Joseph Hospital in Nashua, NH. Her program of research has focused on communication and psychosocial concerns of people living after a diagnosis of cancer. She served as a past associate editor for CJON.

“It has been my pleasure to be involved with CJON for almost 10 years as an author, peer reviewer, writing mentor, and an associate editor,” said Sheldon. “Throughout my career, I have witnessed the impact of oncology nursing practice on the outcomes of people living after a diagnosis of cancer. I am honored to follow Deb Mayer as editor and continue the important mission of CJON, delivering the information oncology nurses need to deliver the best patient care.”


XLargeThumb.01781601-201407000-00000.CVAs a member of Editorial Board for the Journal of Pediatric Surgical Nursing (JPSN) Editorial Board, my role is to mentor authors who ask for assistance. I enjoy working with colleagues on these projects and find (as always) that I learn much more than I offer. Most of the authors thus far are newer in the profession and have less clinical experience. This brings the challenge of helping them fill in the literature, clinical, and research gaps.

But, my most recent mentoring challenge is an expert clinical nurse who feels that she does not have anything “data driven” to write. This is despite the fact that for over 25 years, she has worked with a specific patient population, collaborated with the leading physician expert, earned two Master’s degrees, and is seen as the clinical expert by colleagues both novice and expert (as they tell me themselves).

When I asked her, “What do you want to say?” she was able to concisely tell me her thoughts on orthopedic pin care, take me through the full circle history of where we were, why it didn’t work, what they found worked, and now, frustratingly, a return to the original method of 25 years ago with little data to support this trend.

We strategized a bit and came up with a plan (any ideas you have are also welcome!)

But my question for the group goes beyond pin care… colleague brings up an interesting question in my mind.  How does JPSN capture her history?  Not for pin care (we’re working on that one) but her history of our profession.  In an hour of speaking with her…and then in speaking with another nurse who referred her to me from her institution, it is quite clear that this woman has a great story. She has lived, worked, and exemplified our nursing legacy. I am confident that we will capture what she wants to say about pin care.  I am worried that we will lose her story of a fabulous, devoted career when she retires.

So, my musing for all of you is how do we at JPSN document this era of nursing? And validate these nurses’ contributions? My “mentee” told me that she did not think she had anything she could write since she did not do formal research. Yet she knew her team’s infection rates (or lack thereof) from her infection control colleagues, supports data driven care, and supports nursing’s progress to maintain our place at any management table.

How do you capture these nurses’ special contributions and history at your journal? Thanks for educating me as a mentor!


“The News Sorority” by Sheila Weller….a commentary.

51s0Q+0VafL._SY344_BO1,204,203,200_As I skimmed the list of newly released books at the iStore, I was drawn to the cover of the book The News Sorority by Sheila Weller. The subtitle of the book is “Diane Sawyer, Katie Couric, Christiane Amanpour-and the (Ongoing, Imperfect, Complicated) Triumph of Women in TV News”.

I’ll be honest; I was hoping to learn more about Diane Sawyer and Katie Couric. Full disclosure, I do not watch the news and very little TV. I certainly did as a child/adolescent and young adult….but for a number of reasons (a distaste for conflict being one), I purposefully turned away from watching television news (and most television except sports and HGTV) in my thirties. I remain conversant with world, national, and local events, feel that I am a responsible citizen. But, I have long since become disillusioned by the drama and sound bites of what is currently presented on television.

This is not a critique of The News Sorority….I did enjoy the book and if you like women’s history, writing, and journalism (as I suspect most of you do), then you’ll more than likely be able to critique this book much better than me.

What I wanted to share was my awakening to the person who is Christiane Amanpour. I had certainly heard of her, seen her reports on CNN…but as is suggested in this book, her “international” reporting and “foreign” birth/heritage somehow made her less important than her colleagues, Diane and Katie, especially in the highly competitive world of American television news.

The book is divided into sections, each featuring the three women alternately several times. I expected to skim through Christiane’s sections but found that the opposite was true….I skipped the others to read more about her life.  And what a life it is! The review of her birth, upbringing, education, profession, international reporting, and “late marriage and motherhood” is the stuff produced by fiction novelists. In fact, if you were reading such a novel, you might think it too over the top!  Who lives like that?!

Well, Christiane does…..but of course, so do Diane and Katie. So, what drew me to Christiane?  I think it is her willingness to go into the danger and speak for those who can’t speak for themselves…repeatedly. Certainly, many journalists do that (and danger does not need to be purely physical). But it is her relentless pursuit because it is the right thing to do that stands out to me. How courageous is that? Her reporting can be dramatic (bullets flying) or simply reporting as a witness to a wrong. She tells the story for those who cannot.

There are many lessons, much courage, women’s rights, injustices, andmore in all three women’s stories….but for some reason this day, Christiane’s voice speaks to me above the others….she reminds me to be me. She reminds me that although my style is different than others, it is effective for me and that gives me an opportunity. In my professional life, I have the opportunity to speak for children who are affected by weight….and for their families. I have the chance to dispel some myths, offer some physiology, and show how bias, discrimination, and mockery affect my patients.

It is hard. As a pediatric nurse, I am used to the public and colleagues praising my efforts to help children (valid or not). As a nurse taking care of children affected by obesity, I have experienced a “come-up-ance” as my husband would say….and have felt in a very minor way the daily abuse that confronts these children and their parents. It would be so easy to walk away….but they can’t so I try to carry on and help as I can. Christiane seems to find the strength to be a witness and write the story…and by doing that, provide inspiration to others to do the same.

A Book Title That Caught My Attention: Little Women of Baghlan by Susan Fox

cover-for-websiteWhile surfing the net, I came across the book Little Women of Baghlan by Susan Fox. As I read more about the book, I am not sure which story sounds more interesting….the one about three American nurses working with the Peace Corps in Afghanistan in 1969 or author Susan Cox’s own story.  Both stories are a testament to the strength, courage, and tenacity of nurses. This book speaks to me because it is about women and nurses working in challenging situations…and writing their stories to enlighten us all. I have been fortunate over time to be involved with organizations that provide care to women and children in Haiti, Nicaragua, and Vietnam. While my trips have been much safer and for only for 2 weeks at a time, the reality of working in a difficult situation with motivated nurses (some trained formally, some not) and with limited access to education, equipment, and supplies resonates with me.

Little Women of Baghlan is the true account of three nurses in the Peace Corps assigned to Afghanistan in 1968. Reviews of Little Women of Baghlan suggest that readers will learn as much about 1968 Afghanistan as they will about 1968 America.

Some comments from the publisher:

Little Women of Baghlan is the true account of an ordinary young woman who answers the call to service and adventure. Her story rivals the excitement, intrigue, and suspense of any novel, unfolding against the backdrop of changing social mores, the Cold War, the Peace Corps, and a country at the crossroads of China, Russia, India, Pakistan, and Iran. When John F. Kennedy, delivers a speech in the Senate Chambers on a hot July day in 1957, a young girl named Joanne Carter listens and is inspired to join the Peace Corps.

Jo flies into Afghanistan on March 21, 1968. With co-workers Nan and Mary, Jo starts a school of nursing for Afghan girls. The students are almost non-literate. The hospital lacks equipment, trained doctors, and a reliable source of water. Babies routinely expire from poor delivery practices. Jo reflects on the paradox that is Afghanistan. The Afghans are mired in poverty, yet generous to the point of embarrassment. The men are welcoming and solicitous of the Volunteers, yet capable of turning a blind eye to the suffering of their wives, daughters, and sisters. The climate is harsh and unforgiving; the Hindu Kush starkly beautiful.

During her two-year deployment, Jo fills the pages of a small, compact diary, never dreaming her observations will eventually become a significant historical account. Nearly a half century later, her journal is a bittersweet reminder of a country that has since vanished—a country now on the brink of becoming a modern nation, moving toward the recognition of women’s rights.”


Susan Fox

Author Susan Fox has also lived a pioneering life as a nurse and writer. She lives in the greater Chicago area and has worked as a technical writer for a major consulting firm. She is a member of the Literary Writers Network and is serving as senior editorial assistant for their online publication, 10,000 Tons of Black Ink. Susan holds a bachelor’s degree in psychology, a nursing degree, and a certificate in technical writing from the Illinois Institute of Technology in Chicago. She has been a keynote speaker at The Indiana Center for Middle East Peace and regularly travels throughout the US to talk to audiences about her book. On top of all that, she works as a nurse at St. Mary’s Hospital in Kankakee, IL.

As Susan Fox exemplifies, there are many writing arenas where nurses can make a difference. Educated formally and often practicing in environments that demand intelligence, practicality, flexibility, and creativity, nurses are uniquely positioned to write in many genres. INANE 2015 will feature a nurse who has turned her writing talents to fiction….we’ll look forward to hearing her story.

Guidelines for the Portrayal of Overweight and Obese Persons in the Media

It would be difficult to find a compassionate healthcare provider who would support bias and discrimination of their patient population. But, all too often, healthcare providers (as well as writers and editors) make choices that unfortunately do just that….reinforce obesity bias and discrimination. Bias and discrimination affect all of us; our consciousness has been raised in the way we speak, write, depict, and comment on many vulnerable groups in our society. Obesity discrimination unfortunately remains a prevalent issue for many of our patients and remains legal in all states except Michigan.

The Rudd Center for Food Policy and Obesity is a data driven, policy oriented site which has several missions, one of which is to stop obesity bias and stigma through research, education, and advocacy. Dr. Rebecca Puhl has led a team of researchers at the Center in the study of obesity bias/discrimination. Her work is often cited, available to all through the site, and offers guidance on opportunities for advocacy and intervention.

Two areas on the Rudd Center website are of particular interest to the INANE membership.The first area features media resources for journalists, bloggers, editors, and film, television, and communication experts. The Rudd Center Media Gallery contains a repository of images and videos that are free for use by anyone visiting their site.  These images show people affected by obesity in a positive way, in a variety of work, school, and recreational settings. The second resource includes guidelines for the portrayal of overweight and obese persons in media or print (including professional posters and presentations). These guidelines remind us to respectfully put people first and the “condition” second. We are all familiar with the disrespectful videos that often accompany a newscast on some “obesity” news….often showing a video of a person affected by obesity walking from behind, focusing only on their body, not their shoulders and head.

As editors of nursing journals, we are in an ideal position to share this information through editorials and articles. Just as important, being mindful of modeling appropriate “people first; condition second” writing will encourage the elimination of bias and discrimination toward a population of our patients who need our support. I encourage you to visit the links above and if time permits, the entire Rudd Center site. Spreading the news of this valuable resource to your readership, students, staff, and community will go far to eradicate hurtful bias and discrimination of adults and children affected by obesity.