Prevention of postpartum traumatic stress in mothers with preterm infants: manual development and evaluation.

Premature birth has been associated with multiple adverse maternal psychological outcomes that include depression, anxiety, and trauma as well as adverse effects on maternal coping ability and parenting style. Infants who are premature are more likely to have poorer cognitive and developmental functioning and, thus, may be harder to parent, both as infants and as they get older. In response to these findings, a number of educational and behavioral interventions have been developed that target maternal psychological functioning, parenting, and aspects of the parent-infant relationship. The current study aimed to both develop and evaluate a treatment that integrates, for the first time, effective interventions for reducing symptoms of posttraumatic stress disorder (PTSD) and enhancing maternal-infant interactions. Conclusions from the study indicate that the intervention is feasible, able to be implemented with a high level of fidelity, and is rated as highly satisfactory by participants. Though encouraging, these findings are preliminary, and future studies should strive to reproduce these findings with a larger sample size and a comparison group.

Reducing hospital expenditures with the COPE (Creating Opportunities for Parent Empowerment) program for parents and premature infants: an analysis of direct healthcare neonatal intensive care unit costs and savings.

More than 500,000 premature infants are born in the United States every year. Preterm birth results in a multitude of negative adverse outcomes for children, including extended stays in the neonatal intensive care unit (NICU), developmental delays, physical and mental health/behavioral problems, increased medical utilization, and poor academic performance. In addition, parents of preterms experience a higher incidence of depression and anxiety disorders along with altered parent-infant interactions and overprotective parenting, which negatively impact their children. The costs associated with preterm birth are exorbitant. In 2005, it is estimated that preterm birth cost the United States $26.2 billion. The purpose of this study was to perform a cost analysis of the Creating Opportunities for Parent Empowerment (COPE) program for parents of premature infants, a manualized educational-behavioral intervention program comprising audiotaped information and an activity workbook that is administered to parents in 4 phases, the first phase commencing 2 to 4 days after admission to the NICU. Findings indicated that the COPE program resulted in cost savings of at least $4864 per infant. In addition to improving parent and child outcomes, routine implementation of COPE in NICUs across the United States could save the healthcare system more than $2 billion per year.

Maternal anxiety and depression after a premature infant's discharge from the neonatal intensive care unit: explanatory effects of the creating opportunities for parent empowerment program.

BACKGROUND: Understanding the processes through which interventions work for mothers of premature infants is necessary for the advancement of science and the translation of efficacious interventions into clinical practice settings. OBJECTIVE: To test a theoretical model examining the processes through which an educational-behavioral intervention program (Creating Opportunities for Parent Empowerment [COPE]) influences mothers' anxiety and depression 2 months after discharge of their premature infants from the neonatal intensive care unit (NICU). METHODS: A secondary analysis was conducted using data from a randomized controlled trial with 246 mothers of low-birth-weight preterm infants who were assigned randomly to COPE or placebo control conditions. Measures included mothers' stress in the NICU, mothers' anxiety and depression, and mothers' beliefs about their infants and their role. Observers blind to study group condition also rated the quality of mother-infant interaction in the NICU. RESULTS: Structural equation modeling suggested that the model tested provided a reasonable fit to the data, chi2(64) = 97.67, p = .004, root mean square error of approximation = .046, comparative fit index = .97. Participation in COPE was both directly and indirectly, via associations with increased maternal beliefs and less maternal depression and anxiety in the NICU, related to mothers' decreased posthospital depression and anxiety. Participation in the COPE program also was associated with higher mother-infant interaction scores. CONCLUSION: Implementation of COPE could lessen postdischarge maternal anxiety and depression, which may improve outcomes for both mothers and preterm infants.

Mental health worries, communication, and needs in the year of the U.S. terrorist attack: national KySS survey findings.

INTRODUCTION: To reduce the escalating rate of mental health/psychosocial morbidities in children and adolescents, NAPNAP initiated a new national campaign entitled Keep your children/yourself Safe and Secure (KySS). The objective of the first phase of this campaign was to conduct a national survey to assess the mental health knowledge, attitudes, worries, communication, and needs for intervention of children/teens, parents, and pediatric health care providers. This first report from the KySS survey describes the child/teen and parental findings. METHODS: A cross-section of 621 children/teens and 603 of their parents from 24 states completed the KySS survey during visits to their primary health care providers. RESULTS: The five greatest worries of both children/teens and their parents included knowing how to cope with stressful things in their lives, anxiety, depression, parent-child relationships, and problems with self-esteem. The majority of children/teens and their parents reported that they do not talk to their primary care providers about these issues. Participants expressed a multitude of needs and suggestions regarding how to better recognize, prevent, and deal with mental health problems. CONCLUSION: Opportunities must be created for children/teens and their parents to communicate their mental health worries and needs to each other and to their pediatric primary care providers to facilitate earlier diagnosis and treatment of mental health problems. Interventions are urgently needed to assist children and teens in coping with the multitude of stressors related to growing up in today's society.

Factors affecting hospital-based nurses' willingness to respond to a radiation emergency.

BACKGROUND: Despite increased government and public awareness of the threat of a radiological emergency resulting from a terrorist attack or industrial accident, limited emphasis has been placed on preparing the US health care workforce for such an event. The purpose of this study was to develop and apply a rapid survey to evaluate hospital-based nurses' baseline knowledge, self-assessed clinical competence, perception of personal safety, and willingness to respond in the event of a radiological emergency. METHODS: The study was conducted in 2 phases, the first targeting nursing units likely to respond in the event of a radiological emergency and the second focusing more generally on members of the New York State Emergency Nurses Association currently employed as hospital-based nurses. RESULTS: Among the 668 nurses surveyed, baseline knowledge was found to be inadequate. Although baseline knowledge, clinical competence, and perception of personal safety were all positively associated with willingness to respond, perception of safety appeared to be the primary determinant. Furthermore, baseline knowledge did not appear to be strongly associated with perception of personal safety. CONCLUSIONS: Based on these results, the investigators recommend further clinical training to enhance preparedness and a more detailed exploration of the determinants of perceived personal safety.

Nurse practitioner educators' perceived knowledge, beliefs, and teaching strategies regarding evidence-based practice: implications for accelerating the integration of evidence-based practice into graduate programs.

UNLABELLED: The paradigm shift to evidence-based practice (EBP) in the United States has been slow. Evidence has supported that one barrier to accelerating this paradigm shift is that many nurses have negative attitudes toward research, in large part due to the manner in which they were taught research in their educational programs. The primary aims of this study were to (a) describe nurse educators' knowledge, beliefs, and teaching practices regarding EBP; (b) determine whether relationships exist among these variables; and (c) describe major barriers and facilitators to the teaching of EBP in nurse practitioner curriculums. A descriptive survey was conducted with a sample of 79 nurse practitioner educators who are members of the Association of Faculties of Pediatric Nurse Practitioners (AFPNP) and the National Organization of Nurse Practitioner Faculties (NONPF). The 25 AFPNP participants completed the survey while attending a national conference in Orlando, FL. The remaining 54 NONPF randomly selected participants responded to an e-mail version of the survey. Participants' self-reported knowledge and beliefs about the benefits of EBP and the need to integrate it into academic curricula were strong, although their responses indicated a knowledge gap in EBP teaching strategies. Few academic programs offered a foundational course in EBP. Significant relationships were found among educators' knowledge of EBP and (a) their beliefs that EBP improves clinical care, (b) beliefs that teaching EBP will advance the profession, (c) how comfortable they feel in teaching EBP, and (d) whether EBP clinical competencies are incorporated into clinical specialty courses. CONCLUSION AND IMPLICATIONS: Graduate programs need to offer a foundational course in EBP and integrate EBP throughout clinical specialty courses in order for advanced practice nurses to implement this type of care upon entry into practice. There is a need to educate faculty to become proficient in EBP as knowledge of EBP is highly related to its teaching and incorporation into graduate education. Further research is needed to describe the knowledge and state of teaching EBP in graduate faculty who are not active in clinical practice.

Testing the theoretical framework of the COPE program for mothers of critically ill children: an integrative model of young children's post-hospital adjustment behaviors.

OBJECTIVE: To test a theoretical model examining processes through which a parent-focused educational-behavioral intervention [Creating Opportunities for Parent Empowerment (COPE)] relates to children's post-hospital adjustment problems. METHODS: Mothers (n = 143) and their 2-7-year-old children, unexpectedly hospitalized in two pediatric intensive care units, were randomized to COPE or control conditions. Maternal measures included parental beliefs, anxiety, negative mood, and child adjustment 3 months post discharge. Observers rated maternal support of their children during hospitalization. RESULTS: Structural equation modeling suggested that the model tested provided a reasonable fit to the data [chi2 (97 df) = 129.43; p = .016; root mean square error of approximation = .048; comparative fit index = .95]. COPE effects on children's post-hospital externalizing behaviors were indirect, via associations with parental beliefs and maternal negative mood state. Furthermore, COPE participation was associated with more maternal support of their children, which was also associated with less internalizing and externalizing behaviors 3 months post discharge. CONCLUSION: Implementing COPE may help avert future mental health problems in this high risk population. Understanding the processes by which an already empirically validated program relates to child outcomes is likely to aid clinicians and administrators in the widespread uptake of the COPE program.

Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial.

OBJECTIVE: Although low birth weight premature infants and parents are at high risk for adverse health outcomes, there is a paucity of studies that test early NICU interventions with parents to prevent the development of negative parent-infant interaction trajectories and to reduce hospital length of stay. Our objective was to evaluate the efficacy of an educational-behavioral intervention program (ie, Creating Opportunities for Parent Empowerment) that was designed to enhance parent-infant interactions and parent mental health outcomes for the ultimate purpose of improving child developmental and behavior outcomes. DESIGN, SETTING, AND PARTICIPANTS: A randomized, controlled trial was conducted with 260 families with preterm infants from 2001 to 2004 in 2 NICUs in the northeast United States. Parents completed self-administered instruments during hospitalization, within 7 days after infant discharge, and at 2 months' corrected age. Blinded observers rated parent-infant interactions in the NICU. INTERVENTION: All participants received 4 intervention sessions of audiotaped and written materials. Parents in the Creating Opportunities for Parent Empowerment program received information and behavioral activities about the appearance and behavioral characteristics of preterm infants and how best to parent them. The comparison intervention contained information regarding hospital services and policies. MAIN OUTCOME MEASURES: Parental stress, depression, anxiety, and beliefs; parent-infant interaction during the NICU stay; NICU length of stay; and total hospitalization were measured. RESULTS: Mothers in the Creating Opportunities for Parent Empowerment program reported significantly less stress in the NICU and less depression and anxiety at 2 months' corrected infant age than did comparison mothers. Blinded observers rated mothers and fathers in the Creating Opportunities for Parent Empowerment program as more positive in interactions with their infants. Mothers and fathers also reported stronger beliefs about their parental role and what behaviors and characteristics to expect of their infants during hospitalization. Infants in the Creating Opportunities for Parent Empowerment program had a 3.8-day shorter NICU length of stay (mean: 31.86 vs 35.63 days) and 3.9-day shorter total hospital length of stay (mean: 35.29 vs 39.19 days) than did comparison infants. CONCLUSIONS: A reproducible educational-behavioral intervention program for parents that commences early in the NICU can improve parent mental health outcomes, enhance parent-infant interaction, and reduce hospital length of stay.

Nurses' perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift.

BACKGROUND: The paradigm shift to evidence-based nursing practice in the United States has been slow. Although multiple barriers to evidence-based practice (EBP) have been identified through prior studies, there is a gap in the literature specifically identifying key variables (e.g., belief that EBP produces quality outcomes) that are correlated with the extent to which nurses engage in EBP. AIM: The primary aims of this study were to (1) describe nurses' knowledge, beliefs, skills, and needs regarding EBP; (2) determine whether relationships exist among these variables; and (3) describe major barriers and facilitators to EBP. METHODS: A descriptive survey was conducted with a convenience sample of 160 nurses who were attending EBP conferences or workshops in four states located within the Eastern Region of the United States. RESULTS: Although participant beliefs about the benefit of EBP were high, knowledge of EBP was relatively low. Significant relationships were found between the extent to which the nurses' practice is evidence-based and (1) nurses' knowledge of EBP, (2) nurses' beliefs about the benefits of EBP, (3) having an EBP mentor, and (4) using the Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. CONCLUSION AND IMPLICATIONS: Health care systems need to implement interventions that not only increase nurses' EBP knowledge and skills, but also strengthen their beliefs about the benefit of evidence-based care. EBP mentors may be key in accelerating a more rapid shift toward evidence-based nursing practice. Theoretically driven randomized controlled trials are urgently needed to test the effectiveness of interventions on advancing evidence-based care.

Creating opportunities for parent empowerment: program effects on the mental health/coping outcomes of critically ill young children and their mothers.

OBJECTIVE: Increasing numbers of children in the United States (ie, approximately 200 children per 100,000 population) require intensive care annually, because of advances in pediatric therapeutic techniques and a changing spectrum of pediatric disease. These children are especially vulnerable to a multitude of short- and long-term negative emotional, behavioral, and academic outcomes, including a higher risk of posttraumatic stress disorder (PTSD) and a greater need for psychiatric treatment, compared with matched hospitalized children who do not require intensive care. In addition, the parents of these children are at risk for the development of PTSD, as well as other negative emotional outcomes (eg, depression and anxiety disorders). There has been little research conducted to systematically determine the effects of interventions aimed at improving psychosocial outcomes for critically ill children and their parents, despite recognition of the adverse effects of critical care hospitalization on the nonphysiologic well-being of patients and their families. The purpose of this study was to evaluate the effects of a preventive educational-behavioral intervention program, the Creating Opportunities for Parent Empowerment (COPE) program, initiated early in the intensive care unit hospitalization on the mental health/psychosocial outcomes of critically ill young children and their mothers. DESIGN: A randomized, controlled trial with follow-up assessments 1, 3, 6, and 12 months after hospitalization was conducted with 174 mothers and their 2- to 7-year-old children who were unexpectedly hospitalized in the pediatric intensive care units (PICUs) of 2 children's hospitals. The final sample of 163 mothers ranged in age from 18 to 52 years, with a mean of 31.2 years. Among the mothers reporting race/ethnicity, the sample included 116 white (71.2%), 33 African American (20.3%), 3 Hispanic (1.8%), and 2 Indian (1.2%) mothers. The mean age of the hospitalized children was 50.3 months. Ninety-nine children (60.7%) were male and 64 (39.3%) were female. The major reasons for hospitalization were respiratory problems, accidental trauma, neurologic problems, and infections. Fifty-seven percent (n = 93) of the children had never been hospitalized overnight, and none had experienced a previous PICU hospitalization. INTERVENTIONS: Mothers in the experimental (COPE) group received a 3-phase educational-behavioral intervention program 1) 6 to 16 hours after PICU admission, 2) 2 to 16 hours after transfer to the general pediatric unit, and 3) 2 to 3 days after their children were discharged from the hospital. Control mothers received a structurally equivalent control program. The COPE intervention was based on self-regulation theory, control theory, and the emotional contagion hypothesis. The COPE program, which was delivered with audiotapes and matching written information, as well as a parent-child activity workbook that facilitated implementing the audiotaped information, focused on increasing 1) parents' knowledge and understanding of the range of behaviors and emotions that young children typically display during and after hospitalization and 2) direct parent participation in their children's emotional and physical care. The COPE workbook, which was provided to parents and children after transfer from the PICU to the general pediatric unit, contained 3 activities to be completed before discharge from the hospital, ie, 1) puppet play to encourage expression of emotions in a nonthreatening manner, 2) therapeutic medical play to assist children in obtaining some sense of mastery and control over the hospital experience, and 3) reading and discussing Jenny's Wish, a story about a young child who successfully copes with a stressful hospitalization. OUTCOME MEASURES: Primary outcomes included maternal anxiety, negative mood state, depression, maternal beliefs, parental stress, and parent participation in their children's care, as well as child adjustment, which was assessed with the Behavioral Assessment System for Children (parent form). RESn (parent form). RESULTS: COPE mothers reported significantly less parental stress and participated more in their children's physical and emotional care on the pediatric unit, compared with control mothers, as rated by nurses who were blinded with respect to study group. In comparison with control mothers, COPE mothers reported less negative mood state, less depression, and fewer PTSD symptoms at certain follow-up assessments after hospitalization. In addition, COPE mothers reported stronger beliefs regarding their children's likely responses to hospitalization and how they could enhance their children's adjustment, compared with control mothers. COPE children, in comparison with control children, exhibited significantly fewer withdrawal symptoms 6 months after discharge, as well as fewer negative behavioral symptoms and externalizing behaviors at 12 months. COPE mothers also reported less hyperactivity and greater adaptability among their children at 12 months, compared with control mothers. One year after discharge, a significantly higher percentage of control group children (25.9%) exhibited clinically significant behavioral symptoms, compared with COPE children (2.3%). In addition, 6 and 12 months after discharge, significantly higher percentages of control group children exhibited clinically significant externalizing symptoms (6 months, 14.3%; 12 months, 22.2%), compared with COPE children (6 months, 1.8%; 12 months, 4.5%). CONCLUSIONS: The findings of this study indicated that mothers who received the COPE program experienced improved maternal functional and emotional coping outcomes, which resulted in significantly fewer child adjustment problems, in comparison with the control group. With the increasing prevalence of attention-deficit/hyperactivity disorder and externalizing problems among children and the documented lack of mental health screening and early intervention services for children in this country, the COPE intervention could help protect this high-risk population of children from developing these troublesome problems. As a result, the mental health status of children after critical care hospitalization could be improved. With routine provision of the COPE program in PICUs throughout the country, family burdens and costs associated with the mental health treatment of these problems might be substantially reduced.