Development and Testing of the Relational and Structural Components of Innovativeness Across Academia and Practice for Healthcare Progress Scale.

OBJECTIVE: Using data from 5 academic-practice sites across the United States, researchers developed and validated a scale to measure conditions that enable healthcare innovations. BACKGROUND: Academic-practice partnerships are a catalyst for innovation and healthcare development. However, limited theoretically grounded evidence exists to provide strategic direction for healthcare innovation across practice and academia. METHODS: Phase 1 of the analytical strategy involved scale development using 16 subject matter experts. Phase 2 involved pilot testing the scale. RESULTS: The final Innovativeness Across Academia and Practice for Healthcare Progress Scale (IA-APHPS) consisted of 7 domains: 3 relational domains, 2 structural domains, and 2 impact domains. The confirmatory factor analysis model fits well with a comparative fit index of 0.92 and a root-mean-square error of approximation of 0.06 (n = 477). CONCLUSION: As the 1st validated scale of healthcare innovation, the IA-APHPS allows nurses to use a diagnostic tool to facilitate innovative processes and outputs across academic-practice partnerships.

Using a Cascading Approach to Improve Multisite Study Procedures.

BACKGROUND: Multisite studies offer larger, more diverse samples to successfully capture populations and clinical practices of interest at the point of care. However, investigators face challenges with site recruitment and sampling, differences in clinical practices across sites, and data integrity. Addressing these issues a priori can improve the rigor and reproducibility of the research. OBJECTIVE: This article aims to describe a cascading approach to multisite research. An exemplar is provided of a study using this approach, which aimed to evaluate the prevalence of pain and the pain management practices provided to critically ill children in pediatric intensive care units in the United States. METHODS: The cascading approach includes two or more pilot study procedures with a progressively increasing number of sites prior to a full-scale study. Following each pilot, study procedures are evaluated; feedback was obtained from site personnel and content experts; procedures were revised accordingly; approvals were obtained; sites were trained; and the revised procedures are repeated with a larger, more diverse number of sites. RESULTS: In the exemplar provided, improvements in the efficiency and integrity of data collection were noted for the full-scale study following the pilots. All sites that completed the agreements and approvals for study participation were retained for the duration of the two pilots and full-scale study. DISCUSSION: Borrowing from principles of process improvement, the cascading approach allows knowledge to be gained regarding site differences and informs the revision of study procedures while potentially maximizing efficiency and data integrity, minimizing site burden, and maintaining site engagement for multisite studies.

Variability in qualifications for principal investigator status in research studies by nurses: A call for clarification.

PURPOSE: To describe existing guidance for qualifications of principal investigator s (PI s) of human subjects research and explore how they are operationalized for pediatric nurse scientists and clinical nurses in children's hospitals. DESIGN AND METHODS: After reviewing federal regulations, accreditation guidelines, and the literature, a convenience sample of members of the National Pediatric Nurse Scientist Collaborative (NPNSC). Participants completed a 33-item survey that included questions about Institutional Review Board (IRB), guidelines, and policies for PI status at their affiliated children's hospitals. RESULTS: The survey was electronically disseminated to 179 members of NPNSC through the Collaborative's listserv. Of the 39 members who responded, 90% hold a PhD and 80% practice in a free-standing children's hospital, nearly all of which (93%) are recognized as Magnet® hospitals. While the majority of respondents indicated that nurse scientists and other nurses were allowed to be PIs of research studies, educational requirements for PI status varied, with 3% requiring a PhD, 15% a baccalaureate degree, and 10% a graduate degree. 54% of respondents reported there was no degree requirement for PI status; however15% reported that even doctorally prepared nurse scientists cannot serve as PIs of research studies at their affiliated children''s hospitals. CONCLUSIONS: The survey identified substantial variability in requirements for PI status and potential barriers to pediatric nurses conducting independent research as PIs at children's hospitals. PRACTICE IMPLICATIONS: Operationalizing existing guidance will expand inclusion of nurse scientist expertise in human subjects research.

Predicting Who Receives Nonpharmacologic Pain Interventions in the Pediatric Intensive Care Unit.

AIMS: The majority of patients in the pediatric intensive care unit (PICU) experience pain daily, while nonpharmacologic interventions are indicated for pain management in children, there is limited information on which nonpharmacologic interventions are provided in the PICU and which patients receive those interventions. The aim of this descriptive correlational secondary data analysis was to determine what nonpharmacologic interventions were recorded in the electronic health record of PICU patients and patterns in use by patient demographics. SETTING/SUBJECTS: All patients hospitalized in 15 participating PICUs are located within 12 unique children's hospitals across the United States were eligible for participation. METHODS: Nonpharmacologic interventions used in the PICU were identified and differences between patients who did and did not receive those interventions were examined using Fisher's exact test. A generalized linear mixed effects model was constructed to determine patient characteristics that predict nonpharmacologic pain intervention application. RESULTS: Of 220 enrolled patients, 97 (44%) had nonpharmacologic pain interventions recorded in their electronic health record. The most frequently recorded interventions included repositioning (65%), decreasing environmental stimuli (55%), caregiver presence (37%), distraction (23%), and music therapy (20%). Children who had moderate to severe pain were most likely to receive nonpharmacologic pain interventions. CONCLUSIONS: Nonpharmacologic pain management is applied inconsistently across PICUs and may be underdocumented or underutilized. Additional research is needed to determine when nurses use nonpharmacologic pain interventions, their rationale for applying these interventions across differing groups, and the effectiveness of these interventions in managing pain in critically ill children.

Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality.

BACKGROUND: Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap. AIM: This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes. METHODS: The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice. LINKING EVIDENCE TO ACTION: Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.

Evidence-Based Practice Change Champion Program Improves Quality Care.

Nurses need training and mentoring to lead evidence-based practice (EBP) improvements. An array of roles have been reported to have a positive impact on EBP adoption. A training program was created to assist point-of-care nurses and nurse leader partners in operationalizing the EBP Change Champion role to address priority quality indicators. The program, a case exemplar, and lessons learned are described with implications for leaders responsible for promoting EBP to improve quality care.

Growth Measurement Practices from a National Survey of Neonatal Nurses.

PURPOSE: To describe neonatal nurses' growth measurement practices, attitudes, knowledge, bases of practice knowledge, and barriers and facilitators for changing practice; and to identify differences in practices and knowledge by nursing organization, unit type, education, and experience. DESIGN AND METHODS: A cross-sectional online survey of U.S. neonatal nurses was distributed through two neonatal nursing organizations. RESULTS: The survey was completed by 301 nurses. Some evidence-based practices (EBPs) were infrequently reported including recording frontal-occipital head circumference (FOC) and length using 0.1 cm increments (17.9% and 17.6%, respectively); measuring FOC, weight, and length more than once before recording (61.9%, 27.2%, and 39.6%, respectively); and for length, using a length board instead of tape measure (19.4%), with a second person assisting (25.1%), with Frankfort plane head positioning (3.3%), and measuring from crown to heels of both feet (19.1%). Most nurses perceived their measurements as accurate or highly accurate (96.7% for FOC, 99.3% for weight, and 87.1% for length). The mean percentage correct on knowledge items was 68.1%. NICU nurses scored slightly better than well-newborn nurses (mean 69.3% correct vs. 65.1% correct, p = .04). Most based measurement practices on clinical practice guidelines (86.6%) and unit policies and procedures (85.9%). Team culture (33.3%) and insufficient resources (32.6%) were the most common barriers to EBP. The support of nurse managers (70.0%) and unit educators (68.5%) were common facilitators. CONCLUSIONS AND IMPLICATIONS: Knowledge gaps and practice improvement areas were identified. Results can inform interventions to improve the accuracy and reliability of neonatal growth measurement practices.

Testing of the Nursing Evidence-Based Practice Survey.

BACKGROUND: Clinicians' knowledge and skills for evidence-based practice (EBP) and organizational climate are important for science-based care. There is scant literature regarding aligning organizational culture with EBP implementation and even less for unit and organizational culture. The Nursing EBP Survey examines individual, unit, and organizational factors to better understand registered nurses' (RN) self-reported EBP. AIMS: Establish and confirm factor loading, reliability, and discriminant validity for the untested Nursing EBP Survey. METHODS: The study employed a descriptive cross-sectional survey design and was targeted for RNs. The setting included 14 hospitals and 680 medical offices in Southern California. The 1999 instrument consisted of 22 items; 7 items were added in 2005 for 29 items. The questionnaire used a 5 point, Likert-type scale. The survey website opened in November 2016 and closed after 23 weeks. Psychometric testing and factor determination used parallel analysis, exploratory factor analysis, confirmatory factor analysis (CFA), and ANOVA post hoc comparisons. RESULTS: One thousand one hundred and eighty-one RNs completed the survey. All factor loadings in the CFA model were positive and significant (p < .001). All standardized loadings ranged from .70 to .94. The covariance estimate between Factor 1 and Factor 2 was marginally significant (p = .07). All other covariances and error variances were significant (p < .001). Final factor names were Practice Climate (Factor 1), Data Collection (Factor 2), Evidence Appraisal (Factor 3), Implementation (Factor 4), and Access to Evidence (Factor 5). Four of 5 factors showed significant differences between education levels (p < .05 level). All factors showed significant differences (p < .05) between inpatient and ambulatory staff, with higher scores for inpatient settings. LINKING EVIDENCE TO ACTION: Nurses' knowledge, attitudes, and skills for EBP vary. The 2019 Nursing EBP survey offers RNs direction to plan and support improvement in evidence-based outcomes and tailors future EBP initiatives.

A Typology of Innovations in Nursing.

OBJECTIVE: The purposes of this project were to identify innovations conceived from nurse faculty at a college of nursing and nurses in an academic medical center, examine their characteristics, and create a typology of nursing innovations. BACKGROUND: Innovation is a crucial component for progress in healthcare. Jobs to Be Done Theory suggests that to make progress in nursing, workers must be solution focused to answer problems. METHODS: This qualitative study used directed content analysis to evaluate survey responses of nurses in 1 university's academic and practice setting about solutions or innovations to achieve progress in their jobs. RESULTS: Fifty-seven examples of situations needing an innovative solution were coded and categorized by challenges to yield an 8 characteristic typology in nursing innovation. CONCLUSIONS: These findings serve as a guide for nurse executives to understand and leverage how innovations are conceptualized and translated in academia and practice.

Pain Assessment Practices in the Pediatric Intensive Care Unit.

PURPOSE: Pain assessment is the first step in managing pain; however, this can be challenging, particularly in settings such as the Pediatric Intensive Care Unit (PICU). This paper reports the current pain assessment practices from a study that was conducted describing the prevalence of pain, pain assessment, painful procedures, interventions, and characteristics of critically-ill children. Specifically, this paper addresses the child's communicative ability, pain scales, and characteristics of pain. DESIGN AND METHODS: The primary study was a cross-sectional, multi-site, descriptive design. Data from a 24-hour time period were collected from medical records and bedside nurses. RESULTS: Data were collected from the records of 220 children across 15 PICUs. The average number of pain assessments per child was 11.5 (SD 5.8, range 1-28). Seven behavioral scales and five self-report scales were used. There were times when no scale was used, "assume pain present" was recorded, or a sedation scale was documented. Twelve pain scales, including the target population, scoring, psychometric properties, and clinical utility are described. CONCLUSIONS: Results of this study indicate that a wide range of pain assessment tools are used, including behavioral scales for children unable to self-report. IMPLICATIONS: Foremost, the appropriate assessment method needs to be chosen for each child to manage pain. Knowledge of the criteria for the use of each pain assessment scale will help the clinician select the appropriate scale to use for each child. The practice of "assume pain present," as well as standardization of pain scales, and clinical support tools needs further investigation.

Health care innovations across practice and academia: A theoretical framework.

BACKGROUND: An innovation scholarly interest group used the Jobs to Be Done Theory from the business literature to provide insight into the solution-focused progress that nurses are trying to make in challenging situations. PURPOSE: This article presents a theoretical framework for understanding the progress nurses are trying to make through health care innovations across both practice and academic environments. METHOD: This was a qualitative descriptive study using directed content analysis. We used the Jobs to Be Done Theory to guide the development of the semistructured questionnaire and the interpretation of findings. FINDINGS: A theoretical framework of nursing innovations was derived to summarize and visually display the pathways and linkages of challenges, innovations, and impact domains of nursing innovations. Situations and opportunities arise within the context of interconnectedness and can lead to health care innovations in care delivery, patient care interventions, role transitions, research and translational methods, communication and collaboration, technology and data, teaching methods, and processes to improve care. DISCUSSION: This theoretical framework offers insight into the dynamic interactions of academic-practice partnerships for innovation. Workplace situations are interconnected and can result in needed innovations designed to impact care delivery.

The Distraction in Action Tool©: Feasibility and Usability in Clinical Settings.

PURPOSE: Distraction is a relatively simple, evidence-based intervention to minimize child distress during medical procedures. Timely on-site interventions that instruct parents on distraction coaching are needed. The purpose of this study was to test the feasibility and usability of the Distraction in Action Tool© (DAT©), which 1) predicts child risk for distress with a needle stick and 2) provides individualized instructions for parents on how to be a distraction coach for their child in clinical settings. DESIGN AND METHODS: A mixed-methods descriptive design was used to test feasibility and usability of DAT in the Emergency Department and a Phlebotomy Lab at a large Midwest Academic Medical Center. Twenty parents of children ages 4-10years requiring venipuncture and clinicians performing 13 of those procedures participated. Participants completed an evaluation and participated in a brief interview. RESULTS: The average age of the children was 6.8years, and 80% of parent participants were mothers. Most parents reported the DAT was not difficult to use (84.2%), understandable (100%), and they had a positive experience (89.5%). Clinicians thought DAT was helpful (100%) and did not cause a meaningful delay in workflow (92%). CONCLUSION: DAT can be used by parents and clinicians to assess their children's risk for procedure related distress and learn distraction techniques to help their children during needle stick procedures. PRACTICE IMPLICATIONS: DAT for parents is being disseminated via social media and an open-access website. Further research is needed to disseminate and implement DAT in community healthcare settings.

Iowa Model of Evidence-Based Practice: Revisions and Validation.

BACKGROUND: The Iowa Model is a widely used framework for the implementation of evidence-based practice (EBP). Changes in health care (e.g., emergence of implementation science, emphasis on patient engagement) prompted the re-evaluation, revision, and validation of the model. METHODS: A systematic multi-step process was used capturing information from the literature and user feedback via an electronic survey and live work groups. The Iowa Model Collaborative critically assessed and synthesized information and recommendations before revising the model. RESULTS: Survey participants (n = 431) had requested access to the Model between years 2001 and 2013. Eighty-eight percent (n = 379) of participants reported using the Iowa Model and identified the most problematic steps as: topic priority, critique, pilot, and institute change. Users provided 587 comments with rich contextual rationale and insightful suggestions. The revised model was then evaluated by participants (n = 299) of the 22nd National EBP Conference in 2015. They validated the model as a practical tool for the EBP process across diverse settings. Specific changes in the model are discussed. CONCLUSION: This user driven revision differs from other frameworks in that it links practice changes within the system. Major model changes are expansion of piloting, implementation, patient engagement, and sustaining change. LINKING EVIDENCE TO ACTION: The Iowa Model-Revised remains an application-oriented guide for the EBP process. Intended users are point of care clinicians who ask questions and seek a systematic, EBP approach to promote excellence in health care.

Sacred cow gone to pasture: a systematic evaluation and integration of evidence-based practice.

BACKGROUND: Sacred cows (SC) are old habits in practice, considered routine and above dispute, regardless of evidence to the contrary. PURPOSE: This is the first known report that aims to conduct a systematic evaluation of practices that have been described in the literature as SC and strategies for planned implementation of evidence-based practices (EBP). METHODS: A large, complex, academic medical center department of nursing compared SC to EBP. Nurses systematically reviewed and rated the degree to which current practices adhered to best-evidence versus SC. This initiative, "Sacred Cow: Gone to Pasture," was developed, structured, and implemented according to the Iowa Model of Evidence-Based Practice to Promote Quality Care, as well as Everett Rogers' Diffusions of Innovations Theory. Implementation of EBP followed a phase plan using the Implementation Strategies for Evidence-Based Practice to help to support adoption and integration. RESULTS: Review of organization-specific policies and procedures and reports of actual practices revealed that SC persist, even in a center internationally recognized as a leader in EBP. The SC initiative caught the attention of busy clinicians, and raised awareness of SC and the importance of adherence to EBP. The SC initiative resulted in policy and practice changes and sparked new EBP and research, resulting in numerous improvements, including a significant decline in catheter-associated urinary tract infections and shifting from basins to commercially prepared cloths for patient bathing. LINKING EVIDENCE TO ACTION: A strategic approach is crucial to eliminating SC and integrating EBP. This report calls nurses globally to action, to identify and abandon ineffective healthcare practices. Further research should compare and test the efficacy of implementation strategies, in particular how to sustain EBP in clinical settings.

Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial.

BACKGROUND: Parents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training. OBJECTIVE: The aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress. METHODS: Children undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress. RESULTS: A total of 574 children, ages 4-10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels. DISCUSSION: Some parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.