The pervasive relevance of COVID-19 within routine paediatric palliative care consultations during the pandemic: A conversation analytic study.

BACKGROUND: The importance of caring for children with complex and serious conditions means that paediatric palliative care must continue during pandemics. The recent pandemic of Coronavirus Disease 2019 (COVID-19) provides a natural experiment to study health communication during pandemic times. However, it is unknown how communication within consultations might change during pandemics. AIM: This study, a sub-study of a larger project, aimed to examine real-world instances of communication in paediatric palliative care consultations prior to and during the COVID-19 pandemic to understand how clinicians and families talk about the pandemic. DESIGN: Paediatric palliative care consultations prior to, during, and immediately following the initial peak of COVID-19 cases in Australia were video recorded and analysed using Conversation Analysis methods. SETTING/PARTICIPANTS: Twenty-five paediatric palliative care consultations (including face-to-face outpatient, telehealth outpatient and inpatient consultations) were video recorded within a public children's hospital in Australia. Participants included 14 health professionals, 15 child patients, 23 adult family members and 5 child siblings. RESULTS: There was a pervasive relevance of both serious and non-serious talk about COVID-19 within the consultations recorded during the pandemic. Topics typical of a standard paediatric palliative care consultation often led to discussion of the pandemic. Clinicians (55%) and parents (45%) initiated talk about the pandemic. CONCLUSIONS: Clinicians should not be surprised by the pervasiveness of COVID-19 or other pandemic talk within standard paediatric palliative care consultations. This awareness will enable clinicians to flexibly address family needs and concerns about pandemic-related matters that may impact health and wellbeing.

Effects of Nonpharmacologic Distraction Methods on Children's Postoperative Pain-A Nonmatched Case-Control Study.

PURPOSE: To investigate whether nonpharmacologic distraction as a supplement to conventional pain management can reduce children's assessment of pain in the postanesthesia care unit (PACU), and if parental assessment is a reliable proxy in assessing children's postoperative pain. DESIGN: A nonmatched case-control study. METHODS: The sample included 241 children aged 2 to 7 years assigned to one of five intervention groups or a control group. Children's and parents' assessments of pain were registered on arrival to PACU and repeated after 15, 30, and 45 minutes using the Wong-Baker FACES Pain Rating Scale. FINDINGS: Positive effects of interventions were found in both children's and parental assessments. Results indicate a positive correlation between children's and parental assessments in children older than 3 years (P < .001). CONCLUSIONS: Nonpharmacologic distraction is recommended as a supplement to conventional postoperative pain management. Parental assessment is a reliable proxy in assessing postoperative pain in children younger than 5 years.

The children's nursing workforce in Kenya, Malawi, Uganda, South Africa and Zambia: generating an initial indication of the extent of the workforce and training activity.

BACKGROUND: This study sought to identify, as far as possible, the extent of the specialist children's nursing workforce in five selected African countries. Strengthening children's nursing training has been recommended as a primary strategy to reduce the under-five mortality rate in African nations. However, information about the extent of the specialist children's nursing workforce in this region is not routinely available. Developing an accurate depiction of the specialist children's nursing workforce is a necessary step towards optimising children's health service delivery. METHODS: This study used a convergent parallel mixed methods design, incorporating quantitative (surveys) and qualitative (questionnaire and interview) components, to generate data addressing three related questions: how many children's nurses are believed to be in practice nationally, how many such nurses are recorded on the national nursing register and how many children's nurses are being produced through training annually. RESULTS: Data provide insights into reported children's nursing workforce capacity, training activity and national training output in the five countries. Findings suggest there are approximately 3728 children's nurses across the five countries in this study, with the majority in South Africa. A total of 16 educational programmes leading to a qualification in paediatric nursing or child health nursing are offered by 10 institutions across the countries in this study, with Kenya, Malawi and Zambia having one institution each and South Africa hosting seven. Data suggest that existing human resources for health information systems do not currently produce adequate information regarding the children's nursing workforce. Analysis of qualitative data elicited two themes: the role of children's nurses and their position within health systems, and the capacity of HRH information systems to accurately reflect the specialist children's nursing workforce. CONCLUSION: The data generated provide an initial indication of the size of the children's nursing workforce in these five countries, as well as an overview of associated training activity. We hope that they can start to inform discussion about what would represent a viable and sustainable regional children's nursing workforce for the future.

Manipulation of oral medication for children by parents and nurses occurs frequently and is often not supported by instructions.

AIM: Due to a lack of age-appropriate formulations, administration of drugs to children remains a challenge. This study aimed to identify the problems experienced in both the outpatient setting and the clinical setting. METHODS: Between June 2017 and January 2018, we performed a cross-sectional, prospective study at the Sophia Children's Hospital, The Netherlands. The study comprised of a structured interview on drug manipulations with parents visiting the outpatient clinic, and an observational study of drug manipulations by nurses at the wards. RESULTS: A total of 201 questionnaires were collected, accounting for 571 drugs and 169 manipulations (30%). Drug substances that were most often mentioned as manipulated were macrogol (n = 23), esomeprazole (n = 15), paracetamol (n = 8), methylphenidate (n = 7) and melatonin (n = 7). Of all manipulated medicines, 93/169 (55%) were manipulated according to the instructions or recommendations of the Summary of Product Characteristics (SmPC) or patient information leaflet. During the observational study, manipulation was performed by 21/35 of observed nurses (60%), of whom 11 deviated from the hospital protocol for manipulation or SmPC (52%). CONCLUSION: Manipulation was a widely used method to administer drugs to children. Validated information regarding manipulation of drugs for both parents and nursing staff is needed.

Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross-sectional study.

AIMS: To examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily. DESIGN: A cross-sectional study. METHODS: From 2016 - 2017, we recruited parents who visited the emergency room of a Japanese paediatric hospital and whose children were discharged without hospitalization. Participants whose children arrived by ambulance were classified as using ambulance services unnecessarily. Participants answered a questionnaire consisting of parents' characteristics, including health literacy scales and the Parents' Uncertainty regarding their Children with Acute Illness Scale. We conducted a receiver operating characteristic analysis to convert the Parents' Uncertainty regarding their Children with Acute Illness Scale results to binary scores. We analysed questionnaire responses using logistic regression analysis. RESULTS: Analysed data were from 171 participants. The cut-off score was 59 for the Parents' Uncertainty regarding their Children with Acute Illness Scale. Results of the logistic regression indicated that parents who did not use resources to obtain information regarding their child's illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances. CONCLUSION: Publicizing available resources regarding child health information, social healthcare activities to raise parents' health literacy and providing explanations in accordance with parents' uncertainty, especially when confronting new symptoms in their child, might reduce unnecessary ambulance use. IMPACT: Of patients transported to hospitals by ambulance, the rate of paediatric parents with mild conditions has been found to be high. The study findings could contribute to the appropriateness of using ambulances and have implications for policymakers and healthcare providers, particularly in the Japanese paediatric emergency system. In particular, parental uncertainty, one of four significant characteristics, could be resolved in clinical settings. Generalization for global health services requires further research.

Cultural sensitivity in paediatric nursing care: a concept analysis using the Hybrid method.

BACKGROUND: Cultural sensitivity is a core concept to establish awareness and knowledge about various ethnicities, cultures, genders and additional diversity characteristics to understand individual's requests and respond appropriately to them. A need for further development of the concept is warranted, especially in the context of paediatric nursing. AIMS: The purpose of this paper was to determine the main elements of cultural sensitivity in the context of paediatric nursing in Iran. METHODS: The Hybrid method was implemented consisting of three phases: theoretical, fieldwork and final analysis. In the theoretical phase, articles from 2007 to 2017 were reviewed for relevance. In the phase of fieldwork, 25 nurses and nine parents were interviewed to explore the aspects of cultural sensitivity in paediatric nursing. The interviews were transcribed, and content analysis was conducted. In the final phase, an overall analysis of the two previous phases was performed. RESULTS: In the theoretical phase, the following attributes were determined: cultural encounter and awareness, acceptance of cultural diversity and designing programmes in accordance with family culture. The fieldwork phase explored three themes of intercultural encounters, intercultural communication and adapting the care plan with family culture. The final synthesis yielded that sensitivity to family requests and beliefs, effective intercultural communication and integration of family culture with the care plan are the main elements of cultural sensitivity in Iranian paediatric nursing. CONCLUSION: With a deeper understanding of the term cultural sensitivity, nurses will have a foundation to improve paediatric nursing care and align the care plan with the patient's culture to provide trust, child/parent participation, secure care, effective communication and satisfaction. Since the concepts are the building blocks that underpin theory, the present concepts identified can help to serve as the foundation for the development of a theoretical model.

The association between nurse staffing levels and paediatric nursing-sensitive outcomes in tertiary hospitals.

AIM: This study aimed to explore the association between paediatric nursing-sensitive outcomes and nurse staffing levels. BACKGROUND: Although previous studies have reported an association between low nursing-sensitive outcomes and high nurse staffing levels in adult populations, there are few studies on paediatric nursing-sensitive outcomes. METHODS: This study used electronic Health insurance review and assessment data for all children under 18 years old admitted at 46 tertiary hospitals in Korea between 2013 and 2014. Multiple logistic regression was used to examine relationships among nurse staffing levels and 11 paediatric nursing-sensitive outcomes. RESULTS: Nurse staffing levels had a clear relationship with the occurrence of lower respiratory tract infection and gastrointestinal infection. Five paediatric nursing-sensitive outcomes (pneumonia, sepsis, arrest / shock / respiratory failure, wound infection and postoperative cardiopulmonary complication) showed weak relationships with nurse staffing levels. Pressure ulcers and failure to rescue had the lowest incidences in hospitals with the lowest nurse staffing levels. CONCLUSIONS: We demonstrated evidence for the relationships of nurse staffing levels with seven paediatric nursing-sensitive outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: For quality paediatric nursing care, nurse staffing improvement is required. The study results could be useful evidence for appropriateness of nursing staffing in paediatric facilities.

An Educational Intervention to Improve Nurses' Understanding of Pain in Children in Western India.

Accurate assessment of pain and its management is a challenging aspect of pediatric care. Nurses, usually the primary caregivers, showed inadequate knowledge and restrictive attitudes toward pain assessment. We evaluated an educational intervention to improve nurses' assessment of pain in a teaching hospital in India. A convenient sample of nurses working in the neonatal intensive care unit, pediatric ward, pediatric intensive care unit, and pediatric cardiac intensive care unit were included in the study. Workshops to improve understanding of pain, its assessment, and management strategies were conducted. A modified and consensually validated Knowledge and Attitudes Survey Regarding Pain questionnaire-2008 consisting of 25 true/false questions, eight multiple choice questions, and two case scenarios was administered before, immediately after, and 3 months after the workshops to evaluate impact of the intervention. Eighty-seven nurses participated. Mean (standard deviation) experience was 4.04 (5.9) years. Thirty-seven percent felt that they could assess pain without pain scales. About half (49.4%) of the nurses had not previously heard of pain scales, while 47.1% reported using a pain scale in their routine practice. Significant improvement was observed between pretest and post-test total scores (15.69 [2.94] vs. 17.51 [3.47], p < .001) as well as the pretest and retention score (15.69 [2.94] vs. 19.40 [4.6], p < .001). Albeit the study site and sampling frame may limit the reliability of the findings, the educational intervention was successful, and better retention test scores suggest a cascading effect. Pain assessment and management education of children should be incorporated in the nursing curriculum and should be reinforced in all pediatric units.

Responding to families with complex needs: a national survey of child and family health nurses.

AIMS: The aim of this study was to explore the extent to which Australian child and family health nurses work with families with complex needs and how their practice responds to the needs of these families. BACKGROUND: Many families with young children face challenges to their parenting capacity, potentially placing their children at risk of poorer developmental outcomes. Nurses increasingly work with families with mental health problems, trauma histories and/or substance dependence. Universal child health services must respond effectively to these challenges, to address health inequalities and to promote the best outcomes for all children and families. DESIGN: The descriptive study used cross-sectional data from the first national survey of child and family health nurses in Australia, conducted during 2011. METHODS: Survey data reported how often, where and how child and family health nurses worked with families with complex needs and their confidence in nursing tasks. FINDINGS: Many, but not all, of the 679 respondents saw families with complex needs in their regular weekly caseload. Child and family health nurses with diverse and complex caseloads reported using varied approaches to support their clients. They often undertook additional professional development and leadership roles compared with nurses who reported less complex caseloads. Most respondents reported high levels of professional confidence. CONCLUSION: For health services providing universal support and early intervention for families at risk, the findings underscore the importance of appropriate education, training and support for child and family health professionals. The findings can inform the organization and delivery of services for families in Australia and internationally.

Mapping the literature of pediatric nursing: update and implications for library services.

OBJECTIVE: The purpose of this study was to identify core journals and other types of literature cited in four major pediatric nursing journals and to characterize coverage of these resources in major bibliographic databases. The study was part of the "Mapping the Literature of Nursing Project" of the Medical Library Association's Nursing and Allied Health Resource Section. It updates a similar analysis published in 2006 and determines whether citation patterns have changed over time. METHODS: Cited references from articles published in 4 pediatric nursing journals between 2011 and 2013 were collected. Cited journal titles were ranked according to number of times cited and analyzed according to Bradford's Law of Scattering and the 80/20 rule to identify the most frequently cited journals. Five databases were surveyed to assess the coverage of the most-often-cited journals. The most frequently cited non-journal sources were also identified. RESULTS: Journals were the most frequently cited sources, followed by books, government documents, Internet resources, and miscellaneous resources. Most cited sources were cited within ten years of their publication, which was particularly true for government documents and Internet resources. Scopus had complete coverage of the most frequently cited journals, whereas PubMed had nearly complete coverage. CONCLUSIONS: Compared with the 2006 study, the list of top-cited journals referenced by pediatric nursing researchers has remained relatively stable, but the number of cited journal titles has increased. Book citations have declined, and Internet and government document references have increased. These findings suggest that librarians should retain subscriptions to frequently cited journal titles, provide efficient document delivery of articles from infrequently used journals, de-emphasize but not eliminate books, and connect patrons with useful open-access Internet resources.

A Quality Improvement Project to Increase Nurse Attendance on Pediatric Family Centered Rounds.

UNLABELLED: Family centered rounds (FCR) occur at the bedside and include the patient and their family when creating a daily medical care plan. Despite recommendations that family centered rounds (FCR) with nursing staff be standard practice, nurses were frequently absent from FCR at our institution. OBJECTIVE: To increase nurse attendance on hospitalist FCR to 80% in three months. Secondary outcomes were to investigate the relationship between nurse-to-patient ratio and nurse attendance, and to assess for change in perception toward FCR. METHODS: This resident driven interrupted time series study included a focus group to identify barriers to nurse attendance on FCR, four plan-do-study-act cycles, and surveys to assess for changes in perceptions toward FCR. Control charts, SHEWHART rules, linear regression and chi squared analysis were used for data analysis. RESULTS: Nurse attendance on FCR improved from 30% to 59%. There was no correlation between nurse-to-patient ratio and nurse attendance on FCR. Surveys indicated increase in the perception that it is helpful to have a nurse present at FCR. CONCLUSIONS: A resident driven quality improvement project can increase nurse presence on FCR.

The influence of organizational context on the use of research by nurses in Canadian pediatric hospitals.

BACKGROUND: Organizational context is recognized as an important influence on the successful implementation of research by healthcare professionals. However, there is relatively little empirical evidence to support this widely held view. METHODS: The objective of this study was to identify dimensions of organizational context and individual (nurse) characteristics that influence pediatric nurses' self-reported use of research. Data on research use, individual, and contextual variables were collected from registered nurses (N = 735) working on 32 medical, surgical and critical care units in eight Canadian pediatric hospitals using an online survey. We used Generalized Estimating Equation modeling to account for the correlated structure of the data and to identify which contextual dimensions and individual characteristics predict two kinds of self-reported research use: instrumental (direct) and conceptual (indirect). RESULTS: Significant predictors of instrumental research use included: at the individual level; belief suspension-implement, research use in the past, and at the hospital unit (context) level; culture, and the proportion on nurses possessing a baccalaureate degree or higher. Significant predictors of conceptual research use included: at the individual nurse level; belief suspension-implement, problem solving ability, use of research in the past, and at the hospital unit (context) level; leadership, culture, evaluation, formal interactions, informal interactions, organizational slack-space, and unit specialty. CONCLUSIONS: Hospitals, by focusing attention on modifiable elements of unit context may positively influence nurses' reported use of research. This influence of context may extend to the adoption of best practices in general and other innovative or quality interventions.

Evaluation of paediatric nursing-sensitive outcomes in an Australian population using linked administrative hospital data.

BACKGROUND: Research into nursing-sensitive outcomes using administrative health data has focussed on hospitalised adults. However, we developed algorithms for the identification of 13 paediatric nursing-sensitive outcomes, which we seek to examine for clinical utility. The aims were to determine the rates of paediatric nursing-sensitive outcomes in a Western Australian hospital and ascertain sociodemographic and clinical characteristics associated with a greater risk of developing nursing-sensitive outcomes in hospitalised children. METHOD: A retrospective cohort study used linked administrative data of all Western Australian children ≤18 years admitted to the only tertiary paediatric hospital in Perth between 1999 and 2009. Rates per 1,000 hospital separations and per 10,000 patient days were calculated for the following nursing-sensitive outcomes: lower respiratory tract infection (LRTI), gastrointestinal (GI) infection, pneumonia, sepsis, arrest/shock/respiratory failure, central nervous system complication, central venous line infection, infectious disease, pressure ulcer, failure to rescue, surgical wound infection, physiologic/metabolic derangement, and postoperative cardiopulmonary complications. Poisson multiple regression models were fitted to estimate rate ratios (RR) and 95% confidence intervals (CI) for suspected risk factors. RESULTS: Linked records of 129,719 hospital separations were analysed. Rates ranged from 0.5/1,000 for pressure ulcer to 14.0/1,000 hospital separations for GI infections. Age was significantly associated with the risk of a nursing-sensitive outcome: compared with adolescents, toddlers had greater risk of GI infection (RR 9.89; 95% CI 6.24, 15.69); infants had 7.74 times greater risk of LRTI (95% CI 5.11, 11.75), while neonates had lower risks for sepsis (RR 0.26; 95% CI 0.08, 0.90) and physiologic/metabolic derangement (RR 0.12; 95% CI 0.04, 0.35). The risk of surgical wound infection was 7.78 times greater (95% CI 5.10, 11.86) for emergency admissions than elective admissions. CONCLUSIONS: Seven of the 13 defined nursing-sensitive outcomes occurred with sufficient frequency (>100 events over the 10 year study period) to be potentially useful for monitoring the quality of nursing care. These nursing-sensitive outcomes are: LRTI, GI infection, pneumonia, surgical wound infection, physiologic/metabolic derangement, sepsis and postoperative cardiopulmonary complications. When used for quality improvement or to benchmark with other agencies, data need to be adjusted for, or stratified by age and admission type, to ensure equitable comparisons.

Identifying paediatric nursing-sensitive outcomes in linked administrative health data.

BACKGROUND: There is increasing interest in the contribution of the quality of nursing care to patient outcomes. Due to different casemix and risk profiles, algorithms for administrative health data that identify nursing-sensitive outcomes in adult hospitalised patients may not be applicable to paediatric patients. The study purpose was to test adult algorithms in a paediatric hospital population and make amendments to increase the accuracy of identification of hospital acquired events. The study also aimed to determine whether the use of linked hospital records improved the likelihood of correctly identifying patient outcomes as nursing sensitive rather than being related to their pre-morbid conditions. METHODS: Using algorithms developed by Needleman et al. (2001), proportions and rates of records that identified nursing-sensitive outcomes for pressure ulcers, pneumonia and surgical wound infections were determined from administrative hospitalisation data for all paediatric patients discharged from a tertiary paediatric hospital in Western Australia between July 1999 and June 2009. The effects of changes to inclusion and exclusion criteria for each algorithm on the calculated proportion or rate in the paediatric population were explored. Linked records were used to identify comorbid conditions that increased nursing-sensitive outcome risk. Rates were calculated using algorithms revised for paediatric patients. RESULTS: Linked records of 129,719 hospital separations for 79,016 children were analysed. Identification of comorbid conditions was enhanced through access to prior and/or subsequent hospitalisation records (43% of children with pressure ulcers had a form of paralysis recorded only on a previous admission). Readmissions with a surgical wound infection were identified for 103 (4.8/1,000) surgical separations using linked data. After amendment of each algorithm for paediatric patients, rates of pressure ulcers and pneumonia reduced by 53% and 15% (from 1.3 to 0.6 and from 9.1 to 7.7 per 10,000 patient days) respectively, and an 84% increase in the proportion of surgical wound infection (from 5.7 to 10.4 per 1,000 separations). CONCLUSIONS: Algorithms for nursing-sensitive outcomes used in adult populations have to be amended before application to paediatric populations. Using unlinked individual hospitalisation records to estimate rates of nursing-sensitive outcomes is likely to result in inaccurate rates.

The Manchester triage system: improvements for paediatric emergency care.

OBJECTIVE: To improve the Manchester Triage System (MTS) in paediatric emergency care. METHODS: The authors performed a prospective observational study at the emergency departments of a university and teaching hospital in The Netherlands and included children attending in 2007 and 2008. The authors developed and implemented specific age-dependent modifications for the MTS, based on patient groups where the system's performance was low. Nurses applied the modified system in 11,481 (84%) patients. The reference standard for urgency defined five levels based on a combination of vital signs at presentation, potentially life-threatening conditions, diagnostic resources, therapeutic interventions and follow-up. The reference standard for urgency was previously defined and available in 11,260/11,481 (96%) patients. RESULTS: Compared with the original MTS specificity improved from 79% (95% CI 79% to 80%) to 87% (95% CI 86% to 87%) while sensitivity remained similar ((63%, 95% CI 59% to 66%) vs (64%, 95% CI 60% to 68%)). The diagnostic OR increased (4.1 vs 11). CONCLUSIONS: Modifications of the MTS for paediatric emergency care resulted in an improved specificity while sensitivity remained unchanged. Further research should focus on the improvement of sensitivity.

Paediatric nurses' knowledge and attitudes related to breastfeeding and the hospitalised infant.

Breastfeeding and breastmilk are essential to hospitalised infants and young children and paediatric nurses are required to have breastfeeding knowledge. However, few studies have investigated paediatric nurses' knowledge and attitudes towards breastfeeding. A descriptive, cross-sectional survey design was used to investigate breastfeeding knowledge, knowledge related to breastfeeding the hospitalised infant, policy and guideline awareness, and attitudes to breastfeeding. Participants demonstrated excellent breastfeeding attitudes and general knowledge but deficits in breastfeeding knowledge related to specific outcomes were identified.