Integrative nursing in Europe - A competency profile for nursing students validated in a Delphi-study.

BACKGROUND: Integrative nursing is a framework for providing holistic care and includes complementary therapies and non-pharmacological interventions. There is no common European approach on how to educate healthcare professionals on complementary therapies and non-pharmacological interventions for symptom management. Nurses report a lack of formal education as the main barrier to applying integrative nursing. OBJECTIVES: The aim of this study is to develop and validate integrative nursing learning outcomes in a competency profile for bachelor nursing students. METHODS: A two-round Delphi study was conducted with experts on integrative nursing and/or nurse education from eight European countries. The expert panelists rated their level of agreement with learning outcomes in relation to "Knowledge, Skills, Responsibility and Autonomy" on a nine-point Likert scale (1 = strongly disagree/9 = strongly agree) and were invited to add comments in an open text field. The Rand manual's description of levels of appropriateness was used, and experts' suggestions were analyzed thematically and used for reformulating or adding learning outcomes. RESULTS: In the first round, 19 out of 23 experts participated, versus 18 in the second round. In all, thirty-five learning outcomes within the three areas Knowledge, Skills and Responsibility/Autonomy were rated. After two Delphi rounds, twenty-four included learning outcomes were classified as appropriate, with median levels of appropriateness between 7 and 9; none had been classified as inappropriate. The learning outcomes include general knowledge about selected complementary therapies and non-pharmacological interventions, safety, national rules and regulations, communication and ethical skills and competencies for self-care actions and for applying simple evidence-based complementary therapies and non-pharmacological interventions in nursing practice. CONCLUSIONS: The competency profile consist of validated competencies; the high degree of consensus from the expert panelists makes the learning outcomes relevant for structuring a teaching module for nursing students about integrative nursing.

Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study.

AIMS AND OBJECTIVES: To identify the prevalence and determinants of medication administration errors (MAEs). BACKGROUND: Insight into determinants of MAEs is necessary to identify interventions to prevent MAEs. DESIGN: A prospective observational study in two Dutch hospitals, a university and teaching hospital. METHODS: Data were collected by observation. The primary outcome was the proportion of administrations with one or more MAEs. Secondary outcomes were the type, severity and determinants of MAEs. Multivariable mixed-effects logistic regression analyses were used for determinant analysis. Reporting adheres to the STROBE guideline. RESULTS: MAEs occurred in 352 of 2576 medication administrations (13.7%). Of all MAEs (n = 380), the most prevalent types were omission (n = 87) and wrong medication handling (n = 75). Forty-five MAEs (11.8%) were potentially harmful. The pharmaceutical forms oral liquid (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.25), infusion (OR 1.73, CI 1.02-2.94), injection (OR 3.52, CI 2.00-6.21), ointment (OR 10.78, CI 2.10-55.26), suppository/enema (OR 6.39, CI 1.13-36.03) and miscellaneous (OR 6.17, CI 1.90-20.04) were more prone to MAEs compared to oral solid. MAEs were more likely to occur when medication was administered between 10 a.m.-2 p.m. (OR 1.91, CI 1.06-3.46) and 6 p.m.-7 a.m. (OR 1.88, CI 1.00-3.52) compared to 7 a.m.-10 a.m. and when administered by staff with higher professional education compared to staff with secondary vocational education (OR 1.68, CI 1.03-2.74). MAEs were less likely to occur in the teaching hospital (OR 0.17, CI 0.08-0.33). Day of the week, patient-to-nurse ratio, interruptions and other nurse characteristics (degree, experience, employment type) were not associated with MAEs. CONCLUSIONS: This study identified a high MAE prevalence. Identified determinants suggest that focusing interventions on complex pharmaceutical forms and error-prone administration times may contribute to MAE reduction. RELEVANCE TO CLINICAL PRACTICE: The findings of this study can be used to develop targeted interventions to improve patient safety.

Aromatherapy massage seems effective in critically ill children: an observational before-after study.

Children treated in a pediatric intensive care unit (PICU) are at risk of distress and pain. This study investigated if aromatherapy massage can reduce children's distress and improve comfort. This observational before-after study was performed in a 22-bed PICU in Cape Town, South Africa. The aromatherapy massage consisted of soft massaging using the "M-technique" and a 1% blend of essential oils of Lavender (Lavandula angustifolia), German Chamomile (Matricatia recutita) and Neroli (Citrus aurantium) mixed with a grapeseed carrier oil. All present children were eligible, except those who had recently returned, were asleep or deemed unstable. The primary outcome was distress measured with the COMFORT-Behavior scale (COMFORT-B). Secondary outcomes were heart rate, oxygen saturation (SatO2), the Numeric Rating Scale (NRS)-Anxiety and pain assessed by the NRS-Pain scale. Outcomes variables were evaluated with Wilcoxon signed-rank test and multiple regression analysis. The intervention was applied to 111 children, fifty-one of whom (45.9%) were younger than three years old. The group median COMFORT-B score before intervention was 15 (IQR 12-19), versus 10 (IQR 6-14) after intervention. Heart rate and NRS-Anxiety were significantly lower after the intervention (P < 0.001). Multiple regression analysis showed that interrupted massages were less effective than the uninterrupted massages. Parental presence did not influence the outcome variables. We did not find a significant change on the NRS-Pain scale or for SatO2. Aromatherapy massage appears beneficial in reducing distress, as measured by the COMFORT-B scale, heart rate and the NRS-Anxiety scale, in critically ill children. Thus, the potential of aromatherapy in clinical practice deserves further consideration.

Nurse-led self-management support after organ transplantation-protocol of a multicentre, stepped-wedge randomized controlled trial.

BACKGROUND: Recipients of an organ transplantation face a number of challenges and often need to change their health behaviour. Good self-management skills are essential for optimal clinical outcomes. However, few interventions are available to support post-transplant self-management. To fill this gap, we developed a self-management support intervention offered by nurse practitioners. The primary aim of the study is to implement and test the effectiveness of the ZENN intervention in promoting self-management skills among heart, kidney liver and lung transplant recipients in comparison to standard care. The secondary aim is to assess the self-management support skills of nurse practitioners who will deliver the intervention. METHODS: This multi-centre stepped-wedge randomized controlled trial will take place from September 2020 until May 2023. All departments will commence with inclusion of patients in the control period. Each department will be randomly assigned to a start date (step in the wedge) to commence the experimental period. Patients in the control period will receive standard care and will be asked to complete questionnaires at baseline (T0), 6 months (T1) and 12 months (T2), to assess self-management, self-regulation, quality of life and adherence. During the experimental period, patients will receive standard care plus the ZENN intervention and receive the same set of questionnaires as participants in the control period. Nurse practitioners will complete a baseline and follow-up questionnaire to assess differences in self-management support skills. Video recordings of outpatient clinic consultations during the control and experimental periods will determine the differences in nurses' needs-thwarting and needs-supporting skills between the control and experimental period. DISCUSSION: The ZENN intervention could be a useful approach to support patients' self-management skills after organ transplantation and thus promote clinical outcomes as well as avoid adverse events. TRIAL REGISTRATION: Dutch Trial Register NL8469 . Registered on March 19, 2020.

Music Interventions in Pediatric Surgery (The Music Under Surgery In Children Study): A Randomized Clinical Trial.

BACKGROUND: Perioperative music interventions have been shown to reduce anxiety and pain in adults. This inexpensive, easily applicable intervention could be of benefit to children as well. Our objective was to determine the effects of music interventions on distress, anxiety, and postoperative pain in infants undergoing surgery. METHODS: The Music Under Surgery In Children study was designed as a parallel, single-blind, randomized controlled trial with an a priori formulated hypothesis. Data were collected between August 2015 and October 2016 in a single tertiary care children's hospital. There was a 24-hour follow-up with blind primary outcome assessment. A random sample of 432 eligible 0-3 years of age infants admitted for orchidopexy, hypospadias, or inguinal hernia repair receiving general anesthesia and caudal block were asked for participation. Subjects were assigned to a preoperative music intervention, pre- and intraoperative music intervention, or no music intervention (control) via random allocation using a computer-generated list with the use of opaque envelopes. The main outcome measure was the postoperative level of distress assessed with the COMFORT-Behavior scale, which is an observational scale; furthermore, preoperative level of distress, preoperative anxiety, and physiological measurements such as heart rate (HR) and blood pressure were measured. The trial was registered at the Dutch Trial Register, number NTR5402 (www.trialregister.nl). RESULTS: One hundred ninety-five infants with median age 6.9 months (interquartile range, 3.3-11.1) were randomized, 178 of whom were included in the primary analysis. A nonsignificant difference in COMFORT-Behavior scale scores between the pre- and intraoperative music intervention group and control group at 4 hours after surgery was found (mean difference, -1.22; 95% CI, 2.60-0.17; P = .085). Additional analysis showed weak nonsignificant evidence for an interaction effect between music exposure and COMFORT-Behavior score at baseline (P = .027 with a Bonferroni-adjusted significance level of .025). General linear modeling showed a statistically significantly reduced HR after the preoperative music intervention in the holding area in the combined preoperative music intervention and intraoperative music intervention group compared to the control group (P = .003). The differences in HR among the 3 study arms at all time points were not statistically significant (P = .069). CONCLUSIONS: Music interventions do not seem to benefit all young infants undergoing surgery. The potential benefits of music interventions in the preoperative period and in more distressed children warrant further exploration.

The fragile spirituality of parents whose children died in the pediatric intensive care unit.

Spiritual care is recognized as a relevant dimension of health care. In the context of pediatric palliative end-of-life care, spirituality entails more than adhering to a spiritual worldview or religion. Interviews with parents whose critically ill child died in the pediatric intensive care unit revealed features of a spirituality that is fragmentary and full of contradictions. This type of spirituality, which we refer to as fragile, speaks of parents' connectedness with the deceased child and the hope of some kind of reuniting after one's own death. Acknowledging that fragments of spirituality can be part of parents' experiences in their child's end-of-life stage can be a meaningful contribution to compassionate care.

Children Listening to Music or Watching Cartoons During ER Procedures: A RCT.

OBJECTIVE: This study aims to determine if listening to music and watching cartoons are effective to distract children from pain and distress during procedures in the emergency room (ER). METHODS: This study is a single-center, 3-armed, superiority randomized controlled trial comparing listening to music, watching cartoons, and standard care during ER procedures in children aged 3-13 years. The primary outcome was pain measured from video footage with the Alder Hey Triage Pain Score (AHTPS). Children older than 4 years self-reported pain with the Faces Pain Scale-Revised (FPS-R). The secondary outcome was distress measured with the Observational Scale of Behavioral Distress-revised (OSBD-r). Another indicator of distress was heart rate. RESULTS: Data of 191 participants were analyzed for the 3 groups: music (n = 75), cartoon (n = 62), and control (n = 54). The median age was 7.3 years (4.9-9.7). In multivariable analysis, pain assessed with the AHTPS was significantly lower (B = -1.173, 95% confidence interval -1.953, -0.394, p = .003) in the music group than in the control groups. Across the 3 groups, 108 children self-reported pain with the FPS-R after the procedure. The scores were lowest in the music group, but the differences between groups were not significant (p = .077). OSBD-r distress scores assigned during the procedures were not significantly different between the 3 groups (p = .55). Heart rate directly after the procedure was not statistically significantly different between the 3 groups (p = .83). CONCLUSIONS: Listening to recorded music is a beneficial distraction for children experiencing pain during ER procedures, whereas watching cartoons did not seem to reduce pain or distress.

Can live music therapy reduce distress and pain in children with burns after wound care procedures? A randomized controlled trial.

OBJECTIVE: Burn wound care procedures are very painful and lead to distress. Live music therapy has shown beneficial effects on distress and pain in specific pediatric patient populations. In this study we measured whether live music therapy has beneficial effects in terms of less distress and pain in children with burns after wound care procedures. METHODS: This randomized assessor-blinded controlled trial (RCT) took place at the burns unit of the Red Cross War Memorial Children's Hospital, Cape Town, South Africa. It included newly admitted inpatients between the ages of 0 and 13 years undergoing their first or second wound care procedures. Excluded were children with a hearing impairment or low level of consciousness. The intervention group received one live music therapy session directly after wound care in addition to standard care. The control group received standard care only. The primary outcome was distress measured with the Observational Scale of Behavioral Distress-revised (OSBD-r). The secondary outcome was pain measured with the COMFORT-behavioral scale (COMFORT-B). In addition, in children older than 5 years self-reported distress with the validated Wong-Baker scale (FACES) and pain with the Faces Pain Scale-Revised (FPS-R) were measured. Patients in both groups were videotaped for three minutes before wound care; during the music therapy or the control condition; and for two minutes thereafter. Two researchers, blinded to the study condition, independently scored the OSBD-r and the COMFORT-B from the video footage before and after music therapy. RESULTS: We included 135 patients, median age 22.6 months (IQR 15.4-40.7 months). Change scores did not significantly differ between the intervention and the control groups for either distress (p=0.53; d=0.11; 95% CI -0.23 to 0.45) or pain (p=0.99; d=0.04; 95% CI -0.30 to 0.38). Self-reported distress in a small group of children (n=18) older than 5 years indicated a significant reduction in distress after live music therapy (p=0.05). CONCLUSIONS: Live music therapy was not found effective in reducing distress and pain in young children after burn wound care. Older children might be more responsive to this intervention.

Massage has no observable effect on distress in children with burns: A randomized, observer-blinded trial.

IMPORTANCE: In a previous observational study we found that massage therapy reduced anxiety and stress in pediatric burn patients. We aimed to test this effect in a randomized controlled trial. OBJECTIVE: To determine whether (1) aromatherapy massage can provide relaxation to hospitalized children with burns; (2) massage with aromatherapy oil is more effective than without; and (3) massage sessions are more effective when repeated. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled clinical trial with 3 arms conducted in a burns unit from April 2013 to December 2014 in Cape Town, South Africa. INTERVENTIONS: Massage with carrier oil, massage with aromatherapy oil, and standard nursing care only. MAIN OUTCOMES AND MEASURES: Scores on the Muscle Tension Inventory (MTI) and Behavioral Relaxation Scale (BRS) to assess level of relaxation. Scores on the COMFORT behaviour scale and Numeric Rating Scale Distress to assess level of distress. Secondary outcomes were heart rate and oxygen saturation levels. Linear mixed models were used to determine the effect of condition and session number (1 to a maximum of 5 sessions per child) correcting for baseline outcomes of COMFORT behaviour scores and heart rates after sessions. Secondary analyses included the addition of sex, age, and total body surface area (TBSA) burned as covariates. RESULTS: We included 284 children aged 5 weeks to 13 years with TBSA burned between 10 and 45%. Two-thirds (65.5%) were under the age of 3 years. Mixed model analyses revealed no significant difference in reduction of COMFORT behavior scores (p=0.18), or heart rates (p=0.18) between the three study arms. These outcomes were also not associated with the session number (p=0.92 and p=0.13, respectively). Level of relaxation could not be reliably assessed with the MTI and BRS because 119 patients (41.9%) had bandages covering the larger part of the face, and in 40.1% of cases the child was not in the required position. CONCLUSION AND RELEVANCE: Massage therapy with or without essential oil was not effective in reducing distress behavior or heart rate in hospitalized children with burns. Evaluating the effectiveness of massage in terms of relaxation proved difficult in young children. TRIAL REGISTRATION: The Netherlands National Trial Registry: NRT3929.

Do Hospitalized Premature Infants Benefit from Music Interventions? A Systematic Review of Randomized Controlled Trials.

OBJECTIVE: Neonatal intensive care units (NICU) around the world increasingly use music interventions. The most recent systematic review of randomized controlled trials (RCT) dates from 2009. Since then, 15 new RCTs have been published. We provide an updated systematic review on the possible benefits of music interventions on premature infants' well-being. METHODS: We searched 13 electronic databases and 12 journals from their first available date until August 2016. Included were all RCTs published in English with at least 10 participants per group, including infants born prematurely and admitted to the NICU. Interventions were either recorded music interventions or live music therapy interventions. All control conditions were accepted as long as the effects of the music intervention could be analysed separately. A meta-analysis was not possible due to incompleteness and heterogeneity of the data. RESULTS: After removal of duplicates the searches retrieved 4893 citations, 20 of which fulfilled the inclusion/exclusion criteria. The 20 included studies encompassed 1128 participants receiving recorded or live music interventions in the NICU between 24 and 40 weeks gestational age. Twenty-six different outcomes were reported which we classified into three categories: physiological parameters; growth and feeding; behavioural state, relaxation outcomes and pain. Live music interventions were shown to improve sleep in three out of the four studies and heart rate in two out of the four studies. Recorded music improved heart rate in two out of six studies. Better feeding and sucking outcomes were reported in one study using live music and in two studies using recorded music. CONCLUSIONS: Although music interventions show promising results in some studies, the variation in quality of the studies, age groups, outcome measures and timing of the interventions across the studies makes it difficult to draw strong conclusions on the effects of music in premature infants.

The Effects of Perioperative Music Interventions in Pediatric Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Music interventions are widely used, but have not yet gained a place in guidelines for pediatric surgery or pediatric anesthesia. In this systematic review and meta-analysis we examined the effects of music interventions on pain, anxiety and distress in children undergoing invasive surgery. DATA SOURCES: We searched 25 electronic databases from their first available date until October 2014. STUDY SELECTION: Included were all randomized controlled trials with a parallel group, crossover or cluster design that included pediatric patients from 1 month to 18 years old undergoing minimally invasive or invasive surgical procedures, and receiving either live music therapy or recorded music. DATA EXTRACTION AND SYNTHESIS: 4846 records were retrieved from the searches, 26 full text reports were evaluated and data was extracted by two independent investigators. MAIN OUTCOME MEASURES: Pain was measured with the Visual Analogue Scale, the Coloured Analogue Scale and the Facial Pain Scale. Anxiety and distress were measured with an emotional index scale (not validated), the Spielberger short State Trait Anxiety Inventory and a Facial Affective Scale. RESULTS: Three RCTs were eligible for inclusion encompassing 196 orthopedic, cardiac and day surgery patients (age of 1 day to 18 years) receiving either live music therapy or recorded music. Overall a statistically significant positive effect was demonstrated on postoperative pain (SMD -1.07; 95%CI-2.08; -0.07) and on anxiety and distress (SMD -0.34 95% CI -0.66; -0.01 and SMD -0.50; 95% CI -0.84; - 0.16. CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis indicates that music interventions may have a statistically significant effect in reducing post-operative pain, anxiety and distress in children undergoing a surgical procedure. Evidence from this review and other reviews suggests music therapy may be considered for clinical use.

Limited effects of intravenous paracetamol on patent ductus arteriosus in very low birth weight infants with contraindications for ibuprofen or after ibuprofen failure.

UNLABELLED: Finding the optimal pharmacological treatment of a patent ductus arteriosus (PDA) in preterm neonates remains challenging. There is a growing interest in paracetamol as a new drug for PDA closure. In this prospective observational cohort study, we evaluated the effectiveness of intravenous paracetamol in closing a PDA in very low birth weight infants with a hemodynamically significant PDA who either did not respond to ibuprofen or had a contraindication for ibuprofen. They received high-dose paracetamol therapy (15 mg/kg/6 h intravenous) for 3-7 days. Cardiac ultrasounds were performed before and 3 and 7 days after treatment. Thirty-three patients were included with a median gestational age of 25(1/7) weeks (IQR 1.66), a median birth weight of 750 g (IQR 327), and a median postnatal age of 14 days (IQR 12). Paracetamol was ineffective in 27/33 patients (82 %). Even more, after previous exposure to ibuprofen, this was even 100 %. CONCLUSION: In this study, paracetamol after ibuprofen treatment failure was not effective for PDA closure in VLBW infants. From the findings of this study, paracetamol treatment for PDA closure cannot be recommended for infants with a postnatal age >2 weeks. Earlier treatment with paracetamol for PDA might be more effective.

Aromatherapy massage seems to enhance relaxation in children with burns: an observational pilot study.

OBJECTIVE: This observational pilot study investigated effects of aromatherapy massage in paediatric burn patients. METHODS: The setting was a 17 beds level I burn unit in Cape Town, South Africa. Between January and October 2009 heart rates and respiratory rates of patients who underwent aromatherapy massage sessions were read before and after the sessions. Primary outcomes were decline in heart rates and respiratory rates, a sign of relaxation. Behavioural responses (sleep/awake state, facial expression, body posture) were documented as secondary outcomes. RESULTS: A convenience sample of 71 paediatric burn patients (median age 3 years) underwent a total of 126 massage sessions. Mean heart rate decreased significantly from 118 (SD 20) to 109 (SD 21), t=9.8, p<0.001. Mean respiratory rate decreased significantly from 34 (SD 8) to 30 (SD 8), t=10.2, p<0.001. Most massage sessions (92.8%) elicited positive behaviour to the massage, e.g. the child fell asleep, calmed or asked to continue. Nine patients (7.2%) with a median age of 15 months who underwent a single massage session did not show positive behaviour but cried, wriggled or were distressed. CONCLUSIONS: Aromatherapy massage seems to be a helpful nonpharmacological approach to reduce hospitalized paediatric burn patients' distress. Future studies with better research designs and validated outcome measures should confirm our findings.

Does postoperative 'M' technique massage with or without mandarin oil reduce infants' distress after major craniofacial surgery?

AIM: This article is a report of a randomized controlled trial of the effects of 'M' technique massage with or without mandarin oil compared to standard postoperative care on infants' levels of pain and distress, heart rate and mean arterial pressure after major craniofacial surgery. BACKGROUND: There is a growing interest in non-pharmacological interventions such as aromatherapy massage in hospitalized children to relieve pain and distress but well performed studies are lacking. METHODS: This randomized controlled trial allocated 60 children aged 3-36 months after craniofacial surgery from January 2008 to August 2009 to one of three conditions; 'M' technique massage with carrier oil, 'M' technique massage with mandarin oil or standard postoperative care. Primary outcome measures were changes in COMFORT behaviour scores, Numeric Rating Scale pain and Numeric Rating Scale distress scores assessed from videotape by an observer blinded for the condition. RESULTS: In all three groups, the mean postintervention COMFORT behaviour scores were higher than the baseline scores, but differences were not statistically significant. Heart rate and mean arterial pressure showed a statistically significant change across the three assessment periods in all three groups. These changes were not related with the intervention. CONCLUSIONS: Results do not support a benefit of 'M' technique massage with or without mandarin oil in these young postoperative patients. Several reasons may account for this: massage given too soon after general anaesthesia, young patients' fear of strangers touching them, patients not used to massage.

An evaluation of nutritional practice in a paediatric burns unit.

INTRODUCTION: Burn injuries evoke a systemic metabolic response with profound effects on organ function, susceptibility to infection, wound healing, growth and development, and mortality. Children are especially vulnerable to nutritional deficiencies owing to their limited energy reserves. METHODS: We evaluated the feeding practice in a paediatric burns unit. All children admitted to the unit were studied for a minimum of 3 consecutive days. Patients were divided into two groups: those with burns less than 20% (group 1) and burns >or=20% of total body surface area (TBSA) (group 2). Dietary prescriptions, intake, compliance with feeding practices, and the use of supplementary nutrition were assessed. Under-feeding and over-feeding were defined when there was a discrepancy between prescribed and actual food intake. RESULTS: Forty children (mean age 5.8 years) were studied. They sustained between 2% and 55% TBSA burns. Inadequate caloric intake was seen in 19 of 29 patients and in 9 of 11 patients in groups 1 and 2, respectively. In contrast, excess protein supplementation was seen in 24 of 29 group 1 patients and 6 of 11 group 2 patients. The dietician's food prescription was followed for 170 of 211 days; prescription compliance was correct in only 39 of 211 days. CONCLUSION: Adequate nutrition is essential for burns patients, but several factors can lead to either under- or over-feeding. A daily dietary consumption chart and evaluation of compliance are essential for each patient. There should be greater acceptability of tube enteral feeding.