Family Management Skills Reported by Parents of Preterm Infants in the NICU Using the Self- and Family Management Framework (SFMF).

BACKGROUND: Across the globe, family-integrated care (FICare) has become an evidence-based standard in which parents deliver the majority of infant care in the neonatal intensive care unit (NICU). Because of extensive barriers to parent presence, adaptations to FICare may be required for successful implementation. Family management theory may provide structure to the Parent Education of FICare and help nurses guide parents' skill development as equal care members. PURPOSE: To identify family management skills employed by NICU parents using the Self- and Family Management Framework (SFMF). METHODS: We conducted secondary analyses of qualitative interview data from NICU parents (n = 17) who shared their experiences of using family management skills to care for their infant. We categorized skills according to 3 main self- and family management processes: Focusing on Infant Illness Needs; Activating Resources; and Living With Infant Illness. RESULTS: Parents reported several family management skills currently identified in the SFMF, as well as new skills such as conflict management, power brokerage, and addressing resources related to social determinants of health. Parent activation of resources was critical to sustaining parent focus on the infant's illness needs. IMPLICATIONS FOR PRACTICE AND RESEARCH: By teaching skills that parents reported as helping them manage infant care, neonatal nurses may better facilitate parent integration into the care team. Future researchers can incorporate the skills identified in this study into the design of family management interventions that facilitate FICare implementation in the United States.

Individual and Work-Related Characteristics Associated with COVID-19 Vaccination Status among Ohio Nurses.

Uptake of the COVID-19 vaccine by nurses lags behind that of other health care professionals with minimal empirical evidence to understand this phenomenon. In this secondary analysis, we examined nurses' individual and work-related characteristics and their association with COVID-19 vaccination status. Alumni of three Ohio nursing colleges and members of a professional organization were invited to complete questionnaires from June through August 2021. Logistic regression models were used to evaluate associations between nurse characteristics and vaccination status. Among 844 respondents, 754 (80.30%) had received at least one dose of the vaccine. Older age, having a bachelor's degree or higher, and working in critical care were associated with vaccination. Providing direct care for COVID-19 patients in the last 7 days and a higher perception of one's work being affected by COVID-19 were significantly associated with being vaccinated, whereas prior COVID-19 infection was inversely associated with vaccination status. Our findings suggest that COVID-19 vaccine uptake among nurses is influenced by a host of factors related to virus knowledge, beliefs, and risk perceptions. Awareness of these factors can aid the development of interventions to increase nurses' acceptance of vaccines.

Neonatal Nurses' Report of Family-Centered Care Resources and Practices.

BACKGROUND: A paucity of studies describes the prevalence of family-centered care (FCC) practices and resources in US neonatal units. PURPOSE: To identify US prevalence of FCC practices and resources and to identify the largest gaps in resource provision. METHODS: Neonatal nurses completed an online survey through national conferences (eg, NANN educational conference), neonatal organization Web sites (eg, NANN research survey), and social media (eg, NANN and NPA Facebook). Nurses provided demographics and the National Perinatal Association Self-Assessment on Comprehensive Family Support, a 61-item checklist of FCC practices and resources from 6 categories: family-centered developmental care, staff education/support, peer support, palliative care, discharge education, and mental health support. RESULTS: Nurses (n = 103) reported lowest resources for Peer Support and Mental Health Support. About a third had a neonatal intensive care unit parent advisory committee (n = 39; 37.9%). Only 43.7% (n = 45) had necessary amenities for families to stay with their infants. Less than a third felt that mental health professionals were adequately staffed to provide counseling to parents (n = 28; 27.5%). Very few nurses had adequate training on providing parents psychological support (n = 16; 15.8%). More than half (n = 58; 56.3%) stated that all staff receive training in family-centered developmental care. Finally, less than half (n = 42; 40.8%) stated that staff see parents as equal members of the care team. IMPLICATIONS FOR PRACTICE: We demonstrate a consistent and widespread lack of training provided to neonatal staff in nearly every aspect of comprehensive FCC support. IMPLICATIONS FOR RESEARCH: Researchers need to identify unit/organizational interventions that increase adoption and implementation of FCC practices and resources.

A clinical-academic partnership to develop a family management intervention for parents of preterm infants.

AIMS: To examine the critical role that an academic clinical partnership played in the development and refinement of a family management intervention in the Neonatal Intensive Care Unit (NICU). BACKGROUND: Clinical-academic partnerships enable earlier infusion of implementation science principles into development of evidence-based interventions, yet partners often report difficulty leveraging resources, personnel and expertise to create beneficial outcomes for all. DESIGN: Longitudinal qualitative descriptive design. METHODS: To develop and refine the intervention, designated time was taken during meetings of the NICU's Parent Partnership Council (PPC), a committee comprised of nursing, physician and allied health leadership and former NICU parents. Partnership was also achieved by having bedside clinical nurses, in addition to medical and nursing students, participate as research team members. Qualitative data were collected via email, research team and Council meetings, and informal individual chats with key stakeholders (N = 25) and NICU mothers (N = 22). Qualitative data were analysed deductively using thematic analysis based on MacPhee's partnership logic model and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) model. The consolidated criteria for reporting qualitative research checklist guided our work. RESULTS: During Council meetings, the clinical-academic nurse, Director of Family-Integrated Care and Council members identified the need for a family management intervention, and worked together to develop and refine PREEMIE PROGRESS. Mothers found the intervention had numerous strengths and perceived a benefit knowing they helped future parents. CONCLUSIONS: This work was only possible by leveraging both the university's technology/research resources and the clinical expertise of the NICU staff and PPC. Co-authored presentations, publications and grant funding continued this NICU's legacy in family-centred care and helped shape the clinical-academic nurse's career. RELEVANCE TO CLINICAL PRACTICE: Clinical-academic partnerships can promote excellence in nursing practice, research and education through swifter knowledge translation and earlier infusion of implementation science principles into the development of evidence-based nursing interventions.

Expect the unexpected: Adolescent and pre-teens' experience of diabetes technology self-management.

OBJECTIVE: Only 17% of adolescents with type 1 diabetes (T1D) are currently meeting their glycemic targets despite advances in diabetes technologies. Self-management behaviors and challenges specific to use of diabetes technologies are insufficiently studied in adolescents. We aimed to describe the experience of diabetes technology self-management, including facilitators and barriers, among preteens/adolescents with low and high A1C. RESEARCH DESIGN AND METHODS: Youth (10-18 years of age) with T1D who use insulin pump therapy were recruited from the larger quantitative cohort of a mixed methods study for participation in semi-structured qualitative interviews. Maximum variability sampling was used to recruit youth with A1C <7.5% (n = 5) and A1C >9% (n = 5). Participants' personal insulin pump and continuous glucose monitoring data were downloaded and served as a visual reference. Interviews were analyzed using a qualitative descriptive approach. RESULTS: Participants were 50% female with a median age of 14.9 years and 80% used CGM. The sample was predominantly white (90.0%). Analysis produced four major themes, Bad Day, Expect the Unexpected, Nighttime Dependence, and Unpredictability, It's Really a Team and interconnecting subthemes. Youth characterized ''Bad Days'' as those requiring increased diabetes focus and self-management effort. The unpredictability (''Expect the Unexpected'') of glucose outcomes despite attention to self-management behaviors was considerable frustration. CONCLUSIONS: Diabetes devices such as insulin pumps are complex machines that rely heavily on individual proficiency, surveillance, and self-management behaviors to achieve clinical benefit. Our findings highlight the dynamic nature of self-management and the multitude of factors that feed youths' self-management behaviors.

Top priorities for the next decade of nursing health services research.

BACKGROUND: The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE: To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD: A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS: Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION: The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.

Self-management among pre-teen and adolescent diabetes device users.

OBJECTIVE: Despite increased diabetes device use, few adolescents with type 1 diabetes (T1D) meet glycemic targets. We examine associations between utilization of insulin pumps and continuous glucose monitoring (CGM) and glycemic control. RESEARCH DESIGN AND METHODS: This prospective cohort study included 80 youths (10-18 years of age) with T1D. Multiple linear regression and linear mixed models (LMM) were used to estimate the effects of device self-management on HbA1c and daily time in range (70-180 mg/dL), respectively. RESULTS: Every blood glucose (BG) input/day was associated with a 0.2% decrease in HbA1c (95% CI: -0.297, -0.013), each bolus/day was associated with a 0.2% decrease (-0.327, -0.057), and use of CGM was associated with a 0.5% decrease (-1.00, -0.075). Among CGM users (n = 45) every 10% increase in CGM use was associated with a 0.3% decrease in HbA1c (-0.390, -0.180). In LMM accounting for within subject and between subject variability, there was a negative association between BG input/day frequency (coefficient = -1.880, [-2.640, -1.117]) and time in range. Residual random effects for CGM users were large showing time in range varied between youth with a SD of 15.0% (3 hours and 36 minutes) (SE 2.029, [11.484, 19.530]). Time in range varied significantly from day-to-day with SD of 18.6% (4 hours and 40 minutes) (SE0.455, [17.690, 19.473]). CONCLUSIONS: Device self-management behaviors among youth are significantly associated with both HbA1c and time in range. Our findings showing an association between reduced time in range and increased self-management behaviors is novel and deserves further investigation.

Evaluating Feasibility of Personal Diabetes Device Data Collection for Research.

BACKGROUND: Diabetes devices, like insulin pumps and continuous glucose monitors (CGMs), capture and store patient adherence and utilization data that can be retrieved or downloaded providing objective information on self-management behaviors; yet, diabetes device data remain underutilized in research. OBJECTIVE: The aim of the study was to examine the usability and feasibility of personal diabetes device data collected using a clinical download platform retooled for research purposes. METHODS: Investigators evaluated the feasibility of raw diabetes device data collection. One hundred eight preteens and adolescents with Type 1 diabetes and their parents provided consent/assent. RESULTS: Data were successfully collected from the diabetes devices (insulin pumps and CGM) of 97 youth using a clinical download software adapted for research, including data from all three commercially available CGM systems and insulin pumps brands, which contained all current and previous models of each insulin pump brand. The time required to download, mode of connection, and process varied significantly between brands. Despite the use of an agnostic download software, some outdated device brands and cloud-based CGM data were unsupported during data collection. Within the download software, dummy clinical accounts were created for each study participant, which were then linked back to a master study account for data retrieval. Raw device data were extracted into seven to eight Excel files per participant, which were then used to develop aggregate daily measures. DISCUSSION: Our analysis is the first of its kind to examine the feasibility of raw diabetes device data using a clinical download software. The investigators highlight issues encountered throughout the research process, along with mitigating strategies to inform future inquiry. CONCLUSION: This study demonstrates the feasibility of raw data collection, from a wide variety of insulin pump and CGM brands, through the retooling of a clinical download software. Data from these personal devices provide a unique opportunity to study self-management behavior and the glycemic response of individuals in their everyday environments.

Paediatric clinical and social concerns identified by home visit nurses in the immediate postdischarge period.

AIM: To describe paediatric postdischarge concerns manifesting in the first 96 hr after hospital discharge. DESIGN: Analysis of nursing documentation generated as part of a randomized controlled trial evaluating the effect of a nurse home visit on healthcare re-use. METHODS: We analysed home visit records of 651 children (age <18) hospitalized at a large Midwestern children's hospital in 2015 and 2016 who were enrolled in the trial. Registered nurses documented concerns in structured fields and free-text notes in visit records. Descriptive statistics were used to summarize visit documentation. Free-text visit notes were reviewed and exemplars illustrative of quantitative findings were selected. RESULTS: Overall, nurses documented at least one concern in 56% (N = 367) of visits. Most commonly, they documented concerns about medication safety (15% or 91 visits). Specifically, in 11% (N = 58) of visits nurses were concerned that caregivers lacked a full understanding of medications and in 8% (N = 49) of visits families did not have prescribed discharge medications. Pain was documented as present in 9% of all visits (N = 56). Nurses completed referrals to other providers/services in 12% of visits (N = 78), most frequently to primary care providers. In 13% of visits (N = 85) nurses documented concerns considered beyond the immediate scope of the visit related to social needs such as housing and transportation. CONCLUSION: Inpatient and community nurses and physicians should be prepared to reconcile and manage discharge medications, assess families' medication administration practices and anticipate social needs after paediatric discharge. IMPACT: Little empirical data are available describing concerns manifesting immediately after paediatric hospital discharge. Concerns about medication safety were most frequent followed by concerns related to housing and general safety. The results are important for clinicians preparing children and families for discharge and for community clinicians caring for discharged children.

The future of pediatric nursing science.

The provision of safe and effective nursing care to children is dependent upon pediatric nurse scientists creating knowledge that guides and directs day-to-day nursing practice. Current trends demonstrating steady decreases of pediatric nurses and inadequate numbers of PhD-prepared pediatric nurse scientists put the health of our children at risk. The purposes of this paper are to (1) summarize current health care demands in pediatrics, (2) present our concern that the number of pediatric nurse scientists is inadequate to generate foundational knowledge to guide pediatric nursing practice, (3) present our perspectives on factors influencing the number of pediatric nurse scientists, and (4) recommend specific actions for nursing leaders, nursing faculty, and professional nursing organizations to increase the depth and breadth of pediatric nursing science to meet current and future pediatric care needs.

Operational Failures Detected by Frontline Acute Care Nurses.

Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses' direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses' detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability. © 2017 Wiley Periodicals, Inc.

Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units.

Missed nursing care is an emerging measure of front-line nursing care effectiveness in neonatal intensive care units (NICUs). Given Magnet® hospitals' reputations for nursing care quality, missed care comparisons with non-Magnet® hospitals may yield insights about how Magnet® designation influences patient outcomes. The purpose of this secondary analysis was to evaluate the relationship between hospital Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals. A random sample of certified neonatal intensive care unit nurses was invited to participate in a cross-sectional survey in 2012; data were analyzed from nurses who provided direct patient care (n=230). Logistic regression was used to model relationships between Magnet® designation and reports of the occurrence of and reasons for missed care while controlling for nurse and shift characteristics. There was no relationship between Magnet® designation and missed care occurrence for 34 of 35 types of care. Nurses in Magnet® hospitals were significantly less likely to report tensions and communication breakdowns with other staff, lack of familiarity with policies/procedures, and lack of back-up support from team members as reasons for missed care. Missed nursing care in NICUs occurs regardless of hospital Magnet® recognition. However, nurses' reasons for missed care systematically differ in Magnet® and non-Magnet® hospitals and these differences merit further exploration.

A Nurse Transitional Home Visit Following Pediatric Hospitalizations.

By incorporating focused feedback from families and other stakeholders a multidisciplinary team redesigned a single nurse home visit to improve transitions to home for pediatric patients following short-stay, acute care hospitalizations. Refinements to the nurse-led transitional home visit included standardization of teaching focused on condition- and medication-specific concerns, the use of red flags or warning signs to prompt caregiver action, and the provision of reassurance.

Testing a post-discharge nurse-led transitional home visit in acute care pediatrics: the Hospital-To-Home Outcomes (H2O) study protocol.

AIMS: The aims of this study were: (1) to explore the family perspective on pediatric hospital-to-home transitions; (2) to modify an existing nurse-delivered transitional home visit to better meet family needs; (3) to study the effectiveness of the modified visit for reducing healthcare re-use and improving patient- and family-centered outcomes in a randomized controlled trial. BACKGROUND: The transition from impatient hospitalization to outpatient care is a vulnerable time for children and their families; children are at risk for poor outcomes that may be mitigated by interventions to address transition difficulties. It is unknown if an effective adult transition intervention, a nurse home visit, improves postdischarge outcomes for children hospitalized with common conditions. DESIGN: (1) Descriptive qualitative; (2) Quality improvement; (3) Randomized controlled trial. METHODS: Aim 1 will use qualitative methods, through focus groups, to understand the family perspective of hospital-to-home transitions. Aim 2 will use quality improvement methods to modify the content and processes associated with nurse home visits. Modifications to visits will be made based on parent and stakeholder input obtained during Aims 1 & 2. The effectiveness of the modified visit will be evaluated in Aim 3 through a randomized controlled trial. DISCUSSION: We are undertaking the study to modify and evaluate a nurse home visit as an effective acute care pediatric transition intervention. We expect the results will be of interest to administrators, policy makers and clinicians interested in improving pediatric care transitions and associated postdischarge outcomes, in the light of impending bundled payment initiatives in pediatric care.

The water footprint of California's energy system, 1990-2012.

California's energy and water systems are interconnected and have evolved in recent decades in response to changing conditions and policy goals. For this analysis, we use a water footprint methodology to examine water requirements of energy products consumed in California between 1990 and 2012. We combine energy production, trade, and consumption data with estimates of the blue and green water footprints of energy products. We find that while California's total annual energy consumption increased by just 2.6% during the analysis period, the amount of water required to produce that energy grew by 260%. Nearly all of the increase in California's energy-related water footprint was associated with water use in locations outside of California, where energy products that the state consumes were, and continue to be, produced. We discuss these trends and the implications for California's future energy system as it relates to climate change and expected water management challenges inside and outside the state. Our analysis shows that while California's energy policies have supported climate mitigation efforts, they have increased vulnerability to climate impacts, especially greater hydrologic uncertainty. More integrated analysis and planning are needed to ensure that climate adaptation and mitigation strategies do not work at cross purposes.

Missed oral feeding opportunities and preterm infants' time to achieve full oral feedings and neonatal intensive care unit discharge.

OBJECTIVE: To examine the association of missed oral feeding opportunities among preterm infants with achievement of full oral feedings and length of hospitalization. STUDY DESIGN: A secondary analysis of clinical trial data was conducted. Study infants included in the analysis (N = 89) were randomized to one of four standardized feeding progression approaches; detailed records on all feedings were maintained. The proportion of oral feeding opportunities reported as missed due to factors unrelated to the infant's clinical condition was calculated for each infant. RESULTS: The proportion of missed oral feeding opportunities per infant ranged from 0 to 0.12; 30 infants experienced one or more missed oral feeding opportunity. Each 1% increase in the proportion of missed oral feeding opportunities extended the time to achieve full oral feeding by 1.45 days (p = 0.007) and time to discharge by 1.36 days (p = 0.047). CONCLUSION: Preterm infants' missed oral feeding opportunities may adversely affect feeding outcomes and extend hospitalization.

A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study.

AIM: We describe an innovative research protocol to test the role of missed nursing care as a mediator of the association between nurse workload and patient outcomes in the neonatal intensive care unit. BACKGROUND: Increases in nurses' workloads are associated with adverse patient outcomes in neonatal intensive care settings. Missed nursing care is a frequently hypothesized explanation for the association between workload and outcomes. Few studies to date have tested missed care as a variable that mediates the workload-outcomes relationship. DESIGN: We use a longitudinal, observational study design. METHODS: We will recruit approximately 125 nurses (80% of target population) providing direct patient care in one neonatal intensive care unit. Four, 6-week data collection cycles occur over 1 year. At the end of every shift, nurses report on their workloads and the frequency with which specific patient care activities were missed for each infant cared for during the shift. Infant-specific nurse reports of missed care are linked to shift-level infant outcomes data extracted from the electronic health record. Funding for the study began in July 2012; Research Ethics Committee approval was granted in December 2012. DISCUSSION: Missed care may explain the effects of nurse workload on patient outcomes. This research will generate preliminary evidence regarding the causal relationships among nurses' workloads, missed care and infant outcomes that we will confirm in a future multi-site study.

A descriptive study of nurse-reported missed care in neonatal intensive care units.

AIMS: The aims of this study are to describe: (1) the frequency of nurse-reported missed care in neonatal intensive care units; and (2) nurses' reports of factors contributing to missed care on their last shift worked. BACKGROUND: Missed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown. DESIGN: A descriptive analysis of neonatal nurses' self-reports of missed care using data collected through a cross-sectional web-based survey. METHODS: A random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach. RESULTS: Nurses reported missing a range of patient care activities on their last shift worked. Nurses most frequently missed rounds, oral care for ventilated infants, educating and involving parents in care and oral feedings. Hand hygiene, safety and physical assessment and medication administration were missed least often. The most common reasons for missed care included frequent interruptions, urgent patient situations and an unexpected rise in patient volume and/or acuity on the unit. CONCLUSION: We find that basic nursing care in the neonatal intensive care unit is missed and that system factors may contribute to missed care in this setting.