Effectiveness of nurse-home visiting in improving child and maternal outcomes prenatally to age two years: a randomised controlled trial (British Columbia Healthy Connections Project).

BACKGROUND: We investigated the effectiveness of Nurse-Family Partnership (NFP), a prenatal-to-age-two-years home-visiting programme, in British Columbia (BC), Canada. METHODS: For this randomised controlled trial, we recruited participants from 26 public health settings who were: <25 years, nulliparous, <28 weeks gestation and experiencing socioeconomic disadvantage. We randomly allocated participants (one-to-one; computer-generated) to intervention (NFP plus existing services) or comparison (existing services) groups. Prespecified outcomes were prenatal substance exposure (reported previously); child injuries (primary), language, cognition and mental health (problem behaviour) by age two years; and subsequent pregnancies by 24 months postpartum. Research interviewers were masked. We used intention-to-treat analyses. (ClinicalTrials.gov, NCT01672060.) RESULTS: From 2013 to 2016 we enrolled 739 participants (368 NFP, 371 comparison) who had 737 children. Counts for child injury healthcare encounters [rate per 1,000 person-years or RPY] were similar for NFP (223 [RPY 316.17]) and comparison (223 [RPY 305.43]; rate difference 10.74, 95% CI -46.96, 68.44; rate ratio 1.03, 95% CI 0.78, 1.38). Maternal-reported language scores (mean, M [SD]) were statistically significantly higher for NFP (313.46 [195.96]) than comparison (282.77 [188.15]; mean difference [MD] 31.33, 95% CI 0.96, 61.71). Maternal-reported problem-behaviour scores (M [SD]) were statistically significantly lower for NFP (52.18 [9.19]) than comparison (54.42 [9.02]; MD -2.19, 95% CI -3.62, -0.75). Subsequent pregnancy counts were similar (NFP 115 [RPY 230.69] and comparison 117 [RPY 227.29]; rate difference 3.40, 95% CI -55.54, 62.34; hazard ratio 1.01, 95% CI 0.79, 1.29). We observed no unanticipated adverse events. CONCLUSIONS: NFP did not reduce child injuries or subsequent maternal pregnancies but did improve maternal-reported child language and mental health (problem behaviour) at age two years. Follow-up of long-term outcomes is warranted given that further benefits may emerge across childhood and adolescence.

Outcomes for clinical trials involving adults with chronic kidney disease: a multinational Delphi survey involving patients, caregivers and health professionals.

BACKGROUND: Many outcomes of high priority to patients and clinicians are infrequently and inconsistently reported across trials in chronic kidney disease (CKD), which generates research waste and limits evidence-informed decision making. We aimed to generate consensus among patients/caregivers and health professionals on critically important outcomes for trials in CKD prior to kidney failure and the need for kidney replacement therapy, and to describe the reasons for their choices. METHODS: This was an online two-round international Delphi survey. Adult patients with CKD (all stages and diagnoses), caregivers and health professionals who could read English, Spanish or French were eligible. Participants rated the importance of outcomes using a Likert scale (7-9 indicating critical importance) and a Best-Worst Scale. The scores for the two groups were assessed to determine absolute and relative importance. Comments were analysed thematically. RESULTS: In total, 1399 participants from 73 countries completed Round 1 of the Delphi survey, including 628 (45%) patients/caregivers and 771 (55%) health professionals. In Round 2, 790 participants (56% response rate) from 63 countries completed the survey including 383 (48%) patients/caregivers and 407 (52%) health professionals. The overall top five outcomes were: kidney function, need for dialysis/transplant, life participation, cardiovascular disease and death. In the final round, patients/caregivers indicated higher scores for most outcomes (17/22 outcomes), and health professionals gave higher priority to mortality, hospitalization and cardiovascular disease (mean difference >0.3). Consensus was based upon the two groups yielding median scores of ≥7 and mean scores >7, and the proportions of both groups rating the outcome as 'critically important' being >50%. Four themes reflected the reasons for their priorities: imminent threat of a health catastrophe, signifying diminishing capacities, ability to self-manage and cope, and tangible and direct consequences. CONCLUSION: Across trials in CKD, the outcomes of highest priority to patients, caregivers and health professionals were kidney function, need for dialysis/transplant, life participation, cardiovascular disease and death.

The relationship between gender, parenthood and practice intentions among family medicine residents: cross-sectional analysis of national Canadian survey data.

BACKGROUND: Family medicine (FM) residents choose among a range of options as they enter practice, including practice model, clinical domains, settings, and populations. The choices they make have implications for primary care workforce planning and may differ between FM residents who are parents and those who are not, as well as between male and female FM residents. We investigate whether parenthood shapes intentions among FM residents entering practice and whether the effect of parenthood differs between male and female FM residents. METHODS: We conducted cross-sectional analysis of national survey data collected from FM residents in Canadian residency programs by the College of Family Physicians of Canada between 2014 and 2017. The survey captures information on intentions for comprehensive or focused practice, practice model, clinical domains, practice setting, and populations. We used chi-square tests and multivariable logistic regression to investigate the relationships between parenthood, gender, and practice intentions, adjusting for other physician personal characteristics. RESULTS: Almost a quarter of FM residents were parents or became parents during residency. Intentions for the provision comprehensive care were higher among parents, and intentions for clinically focused practice were lower. Differences in intentions for practice models, domains, and settings/population were primarily by gender, though in several cases the effects of parenthood differed between female and male FM residents. Even during residency, the effects of parenthood differ between male and female residents: while three quarters of male parents finish residency in two years, fewer than half of female parents do. CONCLUSIONS: Both parenthood and gender independently shape practice intentions, but the effect of parenthood differs for male and female FM residents. Supporting FM residents who are parents may positively impact the quality and availability of primary care services, especially since parents are more likely to report intentions to provide  comprehensive care soon after entering practice.

British Columbia Healthy Connections Project process evaluation: a mixed methods protocol to describe the implementation and delivery of the Nurse-Family Partnership in Canada.

BACKGROUND: The Nurse-Family Partnership is a home visitation program for first-time, socially and economically disadvantaged mothers. The effectiveness of this public health intervention has been well established in the United States; however, whether the same beneficial outcomes will be obtained within the Canadian context is unknown. As part of the British Columbia Healthy Connections Project, which includes a trial comparing Nurse-Family Partnership's effectiveness with existing services in British Columbia, we are conducting a process evaluation to describe and explain how the intervention is implemented and delivered across five regional Health Authorities. METHODS: A convergent parallel mixed methods research design will be used to address the process evaluation objectives. The principles of interpretive description will guide all sampling, data collection and analytic decisions in the qualitative component of the study. The full population of public health nurses and supervisors (n = 71) will discuss their experiences of implementing and delivering the program in interviews (or focus groups). Managers (n = 5-15) responsible for this portfolio will also be interviewed annually. Fidelity reports with quantitative data on the reach and the dose of the intervention will be collected and analyzed. Summaries of team meetings and supervisory sessions will be analyzed. Data will be used to compare, corroborate and explain results and variances across the five regional Health Authorities. DISCUSSION: The process evaluation results will be of immediate instrumental use to the program implementers to inform intervention delivery. Findings will contribute to the emerging body of evidence surrounding: 1) professional nurse home visitation practice issues; 2) best practices for meeting the needs of families living in rural and remote communities; 3) a deeper understanding of how health and social issues such as mental health problems including substance misuse and exposure to intimate partner violence affect a young mother's capacity to parent; and 4) strategies to support professionals from the primary care, public health and child welfare sectors to work collaboratively to meet the needs of children and families who are at risk or experiencing maltreatment.

Public Health Nurses' Professional Practices to Prevent, Recognize, and Respond to Suspected Child Maltreatment in Home Visiting: An Interpretive Descriptive Study.

The purpose of this analysis was to understand public health nurses' experiences in preventing and addressing suspected child maltreatment within the context of home visiting. The principles of interpretive description guided study decisions and data were generated from interviews with 47 public health nurses. Data were analyzed using reflexive thematic analysis. The findings highlighted that public health nurses have an important role in the primary prevention of child maltreatment. These nurses described a six-step process for managing their duty to report suspected child maltreatment within the context of nurse-client relationships. When indicators of suspected child maltreatment were present, examination of experiential practice revealed that nurses developed reporting processes that maximized child safety, highlighted maternal strengths, and created opportunities to maintain the nurse-client relationship. Even with child protection involvement, public health nurses have a central role in continuing to work with families to develop safe and competent parenting skills.

Modelo educativo para el personal de enfermería: diseño y aplicación / Educational model for nursing staff: design and implementation

Este estudio se realizó con el objetivo de estandarizar la práctica educativa del personal de enfermería del pabellón Fundadores A del Hospital de San José de Bogotá con el paciente, acerca del cuidado en casa con la herida quirúrgica a través del diseño e implementación de un modelo educativo. El diseño metodológico utilizado fue investigación-acción, el cual permite la interrelación de apoyo y asesoría con la población del estudio, así como la generación de nuevos conocimientos al investigador y a los grupos participantes. Este fue un proceso dirigido por etapas. Primero se sensibilizó al personal de enfermería del pabellón Fundadores A,donde conocieron la importancia y la necesidad de implementar el modelo educativo. Con la participación del personal del estudio y del grupo investigador se diseñó el modelo, para seguir con el segundo paso del proceso que abrió el camino a la aplicación y evaluación del mismo. La aplicación del diseño fue considerada por el personal como una herramienta de trabajo que unifica conocimientos y actividades designadas. El resultado evidencia que el grupo no solo recibió los conocimientos del modelo sino que lo convirtieron en parte de su práctica diaria. En conclusión, el modelo educativo mejoró la práctica educativa del personal de enfermería con el paciente de cirugía, sobre los cuidados en casa con la herida quirúrgica. Esto se incluirá en el esquema de calidad que destaca a la institución.