[Show abstract][Hide abstract] ABSTRACT: Adapting educational tools to meet user needs is a critical aspect of translating research evidence into best clinical practices. The objectives of this study were to evaluate usability and effectiveness of educational tools about infant vaccination pain management directed to postnatal nurses.
Mixed methods design. A template pamphlet and video included in a published clinical practice guideline were subjected to heuristic usability evaluation and then the revised tools were reviewed by postnatal hospital nurses in three rounds of interviews involving 8 to 12 nurses per round. Nurses' knowledge about evidence-based pain management interventions was evaluated at three time points: baseline, after pamphlet review, and after video review.
Of 32 eligible postnatal nurses, 29 agreed to participation and data were available for 28. Three overarching themes were identified in the interviews: 1) utility of information, 2) access to information, and 3) process for infant procedures. Nurses' knowledge improved significantly (p < 0.05) from the baseline phase to the pamphlet review phase, and again from the pamphlet review phase to the video review phase.
This study demonstrated usability and knowledge uptake from a nurse-directed educational pamphlet and video about managing infant vaccination pain. Future studies are needed to determine the impact of implementing these educational tools in the postnatal hospital setting on parental utilization of analgesic interventions during infant hospitalization and future infant vaccinations.
Full-text · Article · Dec 2015 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: Introduction
In many developing countries, children with CHD are now receiving surgical repair or palliation for their complex medical condition. Consequently, parents require more in-depth discharge education programmes to enable them to recognise complications and manage their children’s care after hospital discharge. This investigation evaluated the effectiveness of a structured nurse-led parent discharge teaching programme on nurse, parent, and child outcomes in India.
Materials and methods
A quasi-experimental investigation compared nurse and parent home care knowledge before and at two time points after the parent education discharge instruction program’s implementation. Child surgical-site infections and hospital costs were compared for 6 months before and after the discharge programme’s implementation.
Both nurses (n=63) and parents (n=68) participated in this study. Records of 195 children who had undergone cardiac surgery were reviewed. Nurses had a high-level baseline home care knowledge that increased immediately after the discharge programme’s implementation (T1=24.4±2.89; T2=27.4±1.55; p<0.005; 30 point scale), but decreased to near baseline (T3=23.8±3.4; ns) 4 months after the programme’s implementation. Nurse teaching documentation increased by 56% after the programme’s implementation. Parent knowledge scores increased from 1.76±1.4 for Cohort 1 to 3.68±0.852 for Cohort 2 (p<0.005; 0–4 scale) after the discharge programme’s implementation. Surgical-site infections decreased from 27% in Cohort 1 to 2% in Cohort 2 (p>0.05) after the programme’s implementation.
Nurse, parent, and child outcomes were improved after implementation of the structured nurse-led parent discharge programme for parents in India. Structured nurse-led parent discharge programmes may help prepare parents to provide better home care for their children after cardiac surgery. Further investigation of causality and influencing factors is warranted.
No preview · Article · Nov 2015 · Cardiology in the Young
[Show abstract][Hide abstract] ABSTRACT: This comparative focus group study explored nurses' experiences and perceptions regarding parental participation in infant pain management in the neonatal intensive care unit (NICU). A total of 87 nurses from 7 NICUs in Finland, Sweden, and the United States participated in focus-group interviews (n = 25). Data were analyzed using deductive and inductive thematic analysis. Nurses' experiences and perceptions varied considerably, from nurses being in control, to nurses sharing some control with parents, to nurse-parent collaboration in infant pain management. When nurses controlled pain management, parents were absent or passive. In these cases, the nurses believed this led to better pain control for infants and protected parents from emotional distress caused by infant pain. When nurses shared control with parents, they provided information and opportunities for participation. They believed parent participation was beneficial, even if it caused nurses or parents anxiety. When nurses collaborated with parents, they negotiated the optimal pain management approach for an individual infant. The collaborative approach was most evident for the nurses in the Swedish NICUs and somewhat evident in the NICUs in Finland and the United States. Further research is needed to address some nurses' perceptions and concerns and to facilitate greater consistency in the application of evidence-based best practices.
Full-text · Article · Oct 2015 · The Journal of perinatal & neonatal nursing
[Show abstract][Hide abstract] ABSTRACT: Results:
Parents (n=68) and nurses (n=63) participated in this study. After the discharge programme implementation, parents had less uncertainty (M=93.3 SD=10.7 versus M=83.6 SD=4.9, p=0.001) and ambiguity (M=40.8 SD=6.8 versus M=33.4 SD=3.7, p=0.001) about their child's illness; however, they rated themselves as being less able to cope with the transition to home (M=24.3 SD=4.1 versus 23.1 SD=2.2, p=0.001) and as having less support at home than that required (M=31.5 SD=9.9 versus 30.9 SD=3.2, p=0.001). Parents' and nurses' perception of parental readiness for hospital discharge were more closely aligned after implementation of a nurse-led discharge programme (r=0.81, p=0.001).
The results of this study suggest that the discharge programme had positive and negative effects on parental perceptions of uncertainty and readiness for discharge. Further examination is warranted to delineate these influences and to design methods for supporting parents during the transition to home care.
No preview · Article · Oct 2015 · Cardiology in the Young
[Show abstract][Hide abstract] ABSTRACT: Objective: To characterize sedation weaning patterns in typical practice settings among children recovering from critical illness. Design: A descriptive secondary analysis of data that were prospectively collected during the prerandomization phase (January to July 2009) of a clinical trial of sedation management. Setting: Twenty-two PICUs across the United States. Patients: The sample included 145 patients, aged 2 weeks to 17 years, mechanically ventilated for acute respiratory failure who received at least five consecutive days of opioid exposure. Interventions: None. Measurements and Main Results: Group comparisons were made between patients with an intermittent weaning pattern, defined as a 20% or greater increase in daily opioid dose after the start of weaning, and the remaining patients defined as having a steady weaning pattern. Demographic and clinical characteristics, tolerance to sedatives, and iatrogenic withdrawal symptoms were evaluated. Sixty-six patients (46%) were intermittently weaned; 79 patients were steadily weaned. Prior to weaning, intermittently weaned patients received higher peak and cumulative doses and longer exposures to opioids and benzodiazepines, demonstrated more sedative tolerance (58% vs 41%), and received more chloral hydrate and barbiturates compared with steadily weaned patients. During weaning, intermittently weaned patients assessed for withdrawal had a higher incidence of Withdrawal Assessment Tool-version 1 scores of greater than or equal to 3 (85% vs 46%) and received more sedative classes compared with steadily weaned patients. Conclusions: This study characterizes sedative administration practices for pediatric patients prior to and during weaning from sedation after critical illness. It provides a novel methodology for describing weaning in an at-risk pediatric population that may be helpful in future research on weaning strategies to prevent iatrogenic withdrawal syndrome.
No preview · Article · Oct 2015 · Pediatric Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: This study is a part of an ongoing effort to address the lack of rigorous, scientific evidence to inform the prescription of adaptive seating interventions for children with neurological disorders. The aim is to investigate one aspect of the seat - the cushion, at the same time as developing a battery of tests which are objective, easy to implement and reliable with which adaptive seating interventions can be measured. Method: A total of 35 school-aged children with neurological disorders were assessed in a bespoke adaptive seating system to compare the use of a flat and a ramped, contoured cushion. The measures used were an accelerometer to measure stability, two actigraphs to measure activity, a pressure mapping system to measure weight distribution, goniometry to measure posture and activities to measure functional ability. Results: The results generally support the use of ramped, contoured cushions over flat cushions. The accelerometer and pressure mapping system show particular promise in future research. The actigraphs were unreliable, although other models may prove more suitable. The goniometry produced the best results, although it was the least reliable to implement and the seated functional activities need further work. Interpretation: The methodology showed in a number of ways that ramped contoured cushions were more effective than flat seat cushions for a heterogeneous population of children. Accelerometry and pressure mapping showed particular promise for advancing research and practice in the area of adaptive seating, with further work required in other areas. In particular, it is recommended that future efforts pursue the use of more reliable electronic measurement.
[Show abstract][Hide abstract] ABSTRACT: Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown.
To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care.
Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge.
Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care.
The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal.
Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P = .03) and fewer stage 2 or worse immobility-related pressure ulcers (<1% vs 2%; P = .001). In exploratory analyses, intervention patients had fewer days of opioid administration (median, 9 [IQR, 5-15] days vs 10 [IQR, 4-21] days; P = .01), were exposed to fewer sedative classes (median, 2 [IQR, 2-3] classes vs 3 [IQR, 2-4] classes; P < .001), and were more often awake and calm while intubated (median, 86% [IQR, 67%-100%] of days vs 75% [IQR, 50%-100%] of days; P = .004) than control patients, respectively; however, intervention patients had more days with any report of a pain score ≥4 (median, 50% [IQR, 27%-67%] of days vs 23% [IQR, 0%-46%] of days; P < .001) and any report of agitation (median, 60% [IQR, 33%-80%] vs 40% [IQR, 13%-67%]; P = .003), respectively.
Among children undergoing mechanical ventilation for acute respiratory failure, the use of a sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relationship among wakefulness, pain, and agitation.
clinicaltrials.gov Identifier: NCT00814099.
No preview · Article · Jan 2015 · JAMA The Journal of the American Medical Association
[Show abstract][Hide abstract] ABSTRACT: The objectives of this scoping review were to: (1) identify publicly available educational videos on needle pain management and; (2) evaluate the content of these videos.
Reviewers screened publicly available educational videos on pediatric needle pain management available on YouTube and Google using a broad-based search strategy. Videos were categorized using the CRAAP Test: Current, Relevant, from a trustworthy source (Authority), Accurate and evidence-based and for what Purpose does the source exist.
Twenty-five relevant, educational videos were identified. The intended audience for most videos was parents (n=16, 64%), followed by clinicians (n=6, 24%) and children (n=3, 12%). Common examples of needle pain included immunizations or IV insertion, with interventions appropriate for infants through school aged children. The most frequently described techniques were parent-guided distraction and behavioral factors such as comfort holds and parent demeanor. Most videos were Current (96%), Relevant (100%), created by a trustworthy source: Authority (76%), and all were Accurate, with Purpose relating to needle pain management. None of the videos addressed the unique needs of children with a pre-existing diagnosis of needle phobia.
Publicly available educational videos offer clinicians, parents and children evidence-based techniques to manage pediatric needle pain. Further evaluation is needed to determine whether this form of education meets the needs of target audiences, and whether this type of content can lead to improved management of pediatric needle pain.
No preview · Article · Dec 2014 · Clinical Journal of Pain
[Show abstract][Hide abstract] ABSTRACT: Objective
To investigate the relationship between frequency of ultrasounds and birthplace preference.
Retrospective case-control study with the number of ultrasounds as the exposure and the pregnant woman's preference to give birth in a low-technology setting (midwifery-led unit or home) or a high-technology setting (obstetric unit) as the primary outcome.
Sample and Setting
Low-risk primigravid women receiving prenatal care at a central London academic medical centre.
Prenatal ultrasound frequency; birthplace preference at the initial pregnancy appointment (T1) and at the commencement of labour (T2); demographic data including ethnicity, index of multiple deprivation, age, and body mass index.
1100 cases were reviewed. Women received an average of 4.03 ultrasounds during their pregnancy (sd=1.96, range 2–14). The frequency of ultrasounds for women who had a low-technology T2 birthplace preference was significantly lower than for those who had a high-technology T2 birthplace preference (t=2.98, df=1098, p=0.003, r=0.1), and women who had a constant low-technology birthrate preference had significantly less ultrasounds than other women (F (3,644)=3.475, p=.02). However, within a logistic regression the frequency of ultrasound was not associated with T2 birthplace preference, after controlling for T1 birthplace preference.
The findings of this investigation suggests that a preference made early in pregnancy is a greater predictor of birthplace preference than exposure to prenatal ultrasounds.
Implications for practice
Further research is required to inform interventions that would encourage low-risk pregnant women to select a low-technology place of birth.
[Show abstract][Hide abstract] ABSTRACT: Objective
The aim of this study was to identify predictors of parental post-traumatic stress symptoms following child hospitalization.
In this prospective cohort study, a sample of 107 parents completed questionnaires during their child's hospitalization on pediatric non-intensive care (non-ICU) wards and again three months after discharge. Eligible parents had a child expected to be hospitalized for three or more nights. Standardized questionnaires were used to assess parent distress during the child's hospitalization, parent coping strategies and resources, and symptoms of post-traumatic stress after the hospitalization. Correlations and multiple regression were used to determine whether parent distress during hospitalization and coping strategies and resources predicted post-traumatic stress symptoms three months after the child's discharge, while controlling for relevant covariates.
Three months after the child's hospital discharge, 32.7% of parents (n = 35) reported some degree of post-traumatic stress symptoms (PTSS), and 21.5% (n = 23) had elevated (≥34) scores consistent with a probable diagnosis of post-traumatic stress disorder. In the multivariable model, parent anxiety and uncertainty during hospitalization and use of negative coping strategies, such as denial, venting and self-blame, were associated with higher PTSS scores at three months post-discharge, even after controlling for the child's health status. Parental anxiety and depression during hospitalization moderated the relationship between negative coping strategies and PTSS.
More than one quarter of parents of children hospitalized on pediatric (non-ICU) wards experienced significant PTSS after their child's discharge. Parents’ hospital-related anxiety, uncertainty and use of negative coping strategies are potentially modifiable factors that most strongly influenced PTSS. Further research is urgently needed to test the effectiveness of different methods to provide psychological, emotional and instrumental support for parents, focusing on increasing parent coping resources and reducing distress during hospitalization.
No preview · Article · Dec 2014 · International Journal of Nursing Studies
[Show abstract][Hide abstract] ABSTRACT: Self-report is often represented as "the gold standard" in assessment of pain intensity in children. We evaluate arguments for and against this claim and consider its implications for pain management.
Those in the support of the proposition argue that, when children are able to self-report, treatment decisions should be made based on these scores in line with current evidence-based recommendations. Pain is a subjective phenomenon and can be assessed only via self-report. Treating self-report scores as the gold standard is the only valid way for health care professionals to decide on appropriate treatment.Those against the proposition contend that reliance on self-reported pain scores for analgesic treatment decisions is inappropriate since they over-simplify the pain experience, yield only marginal information on which to base treatment decisions, and potentially place children at significant risk for adverse events. Self-reports of pain intensity sometimes contradict well-founded estimates based on other evidence. Wide variation between children in the meaning of pain scores precludes easy interpretation.
We conclude that self-report, when available, can be considered a primary source of evidence about pain intensity. However, it cannot be treated as an unquestioned gold standard. Instead, hierarchical or bundled approaches should be used, taking into account self-report as well as the many individual and contextual factors that influence pain including clinical history, patient preferences, and response to previous treatments. Alternate models are presented to guide further practice and research.
No preview · Article · Nov 2014 · Clinical Journal of Pain
[Show abstract][Hide abstract] ABSTRACT: Background & objectives Little is known about how parents think about neonatal intensive care unit (NICU) safety. Due to their physiologic immaturity and small size, infants in NICUs are especially vulnerable to injury from their medical care. Campaigns are underway to integrate patients and family members into patient safety. This study aimed to describe how parents of infants in the NICU conceptualise patient safety and what kinds of concerns they have about safety.
Methods This mixed-methods study employed questionnaires, interviews and observation with parents of infant patients in an academic medical centre NICU. Measures included parent stress, family-centredness and types of safety concerns.
Results 46 parents completed questionnaires and 14 of these parents also participated in 10 interviews (including 4 couple interviews). Infants had a range of medical and surgical problems, including prematurity, congenital diaphragmatic hernia and congenital cardiac disease. Parents were positive about their infants’ care and had low levels of concern about the safety of procedures. Parents reporting more stress had more concerns. We identified three overlapping domains in parents' conceptualisations of safety in the NICU, including physical, developmental and emotional safety. Parents demonstrated sophisticated understanding of how environmental, treatment and personnel factors could potentially influence their infants’ developmental and emotional health.
Conclusions Parents have safety concerns that cannot be addressed solely by reducing errors in the NICU. Parent engagement strategies that respect parents as partners in safety and address how clinical treatment articulates with physical, developmental and emotional safety domains may result in safety improvements.
No preview · Article · Jun 2014 · BMJ quality & safety
[Show abstract][Hide abstract] ABSTRACT: Abstract
A new first-trimester universal prenatal screening test for pre-eclampsia was introduced into two UK hospitals. The aim of this study was to investigate the potential psychological benefits, harms and acceptability of providing pregnant women with formal risk information for pre-eclampsia.
Cross-sectional interview study. Women were interviewed using a theoretically informed semi-structured schedule and transcripts were analysed thematically using Framework Analysis.
Setting and participants
Primigravid women receiving prenatal care at a central London National Health Service Foundation Trust found either high-risk or low-risk for pre-eclampsia.
15 primigravid women who received high risk (n=10) or low risk (n=5) results of a 12-week pre-eclampsia screening test were interviewed. Two types of coping typologies were evident from the data. The first were “danger managers” who had an internal sense of control, were focused on the risk that pre-eclampsia presented to them and exhibited information seeking, positive behaviour changes, and cognitive reappraisal coping mechanisms. The second were “fear managers” who had an external sense of control, were focused on the risk that pre-eclampsia presented to the fetus, and exhibited avoidance coping mechanisms. In addition to these typologies, three universal themes of ‘medicalising the pregnancy’, ‘embracing technology’ and ‘acceptability’ emerged from the data.
There are potential positive and negative unintended consequences following a first-trimester screening test for pre-eclampsia. A positive consequence could be self-instigated behaviour change, whereas a negative consequence could be reduced self-monitoring of fetal movements as the pregnancy develops.
Implications for practice
This study indicates that women with an increased risk of pre-eclampsia would be willing to engage in efforts to reduce their risk of pre-eclampsia, and there is a potential to use this screening test as a basis for improving health more broadly.
[Show abstract][Hide abstract] ABSTRACT: Abstract Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study's multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study's findings to other settings.
Full-text · Article · Jan 2014 · Journal of Interprofessional Care
[Show abstract][Hide abstract] ABSTRACT: Objective:
To describe the use of, and attitudes toward, complementary therapy (CT) by parents of children with moderate to severe cerebral palsy.
Parents of 32 children with cerebral palsy (age 5-12 years) enrolled in a randomized trial of cranial osteopathy prospectively participated in semi-structured interviews in the home to explore the use of CT and views regarding access to and expectations of these therapies. Interview transcripts were analyzed thematically, and content analysis was used to determine the frequency of use of different therapies.
Sixteen children (50%) had received one or more types of CT, although only three were currently receiving any CT. The primary reasons for trying CT were to reduce children's pain and improve physical function. Parents had limited knowledge of the range of, and possible indications for, CT and expressed concerns about CT safety and effectiveness. Practical considerations of time and cost were also identified. Some parents had strong beliefs about the benefits, and, overall, parents indicated a high level of commitment to finding any treatments, conventional or CT, to help their children.
Parents of children with cerebral palsy want to help their child, but they need information, guidance, and practical support to facilitate their decision-making regarding the use of CT. A clearer understanding of factors predictive of optimal outcomes will enable resources to be targeted effectively.
No preview · Article · Nov 2013 · Journal of alternative and complementary medicine (New York, N.Y.)
[Show abstract][Hide abstract] ABSTRACT: Family accommodation programs, such as Ronald McDonald House® (RMH), aim to facilitate family proximity and family-centered care during a child's hospitalization, yet little is known about how the programs influence family experience. The aim of this study was to investigate the perspectives of families regarding the impact of the RMH stay on the family and their hospital experience and to explore the influence of demographic and clinical factors on family member views about their experience and outcome of their child's hospitalization. Family members who spent one or more nights at an RMH in Southern California completed a cross-sectional, self-report survey that included descriptive information about the family and the hospital experience. The 2,081 respondents (53% mothers, 24% fathers, 7% other family members, and 15% multiple family members) generally reported positive experiences at RMH. Although effect sizes were small, families who stayed together for at least a portion of their stay believed more strongly that their ability to stay nearby improved their child's recovery and that RMH helped their family to stay together. Cultural differences were also evident, with Hispanic families believing more strongly that RMH shortened their child's hospital stay. A family's ability to stay together and in close proximity during a pediatric hospital stay is facilitated by accommodations such as RMH and provides important benefits in terms of family experience, psychosocial well-being, and perceptions of child recovery. These services also contribute meaningfully to the priority of providing family-centered care. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
No preview · Article · Jul 2013 · Families Systems & Health
[Show abstract][Hide abstract] ABSTRACT: This retrospective case study describes the sleep-wake cycles of an infant in the neonatal intensive care unit. We analyzed video-electroencephalographic recording of the term infant monitored during treatment with therapeutic hypothermia for hypoxic-ischemic encephalopathy. The continuous video-electroencephalographic recording over a 4-day period also allowed us to describe the following dimensions of daily care in relation to the infant's sleep-wake states: (1) handling by professional and parent caregivers and (2) stress, pain, and analgesia. Physical contact constituted 17% to 36% of each 24-hour period. The infant's care was fragmented, with a mean of 3 to 4 physical contacts per hour. As a result, the structure of infant sleep was altered by the increased amount of awake and quiet sleep. The number of painful procedures ranged from 5 to 24 per day. Nurses were the main care providers. Parents had more contact after the infant was rewarmed. This case study suggests that neonatal intensive care unit infants are exposed to frequent handling and stress as well as altered sleep. The cumulative negative impact of frequent handling and sleep fragmentation may go unnoticed by caregivers focused on episodes of care. Continuous video-electroencephalographic monitoring is a useful tool for longitudinal evaluation of infant sleep and responses to caregiving in the neonatal intensive care unit.
No preview · Article · Jul 2013 · The Journal of perinatal & neonatal nursing