Nurse Child Care Health Consultants, Professional Development, and Accreditation Improve Medication Safety in Child Care Programs.

Medication administration is a critical safety issue in hospitals and the community. Children are especially at risk because of their dependence on adults to safely administer medications. The purpose of this study was to examine non-compliance with state child care medication administration regulations and factors associated with improved compliance. The data included routine, unannounced inspections of child care programs by state licensing specialists collected in two time periods over 10 years. Factors potentially associated with regulatory compliance were included in this secondary analysis. Most child care center medication administration regulations showed decreased non-compliance between the two time periods. However, regulations pertaining to prescriber orders and parent permission revealed a significant increase in non-compliance (58.4%). Factors positively associated with medication administration regulatory compliance included: compliance with annual professional development (p < 0.0001 in both periods), achievement of accreditation (p = 0.0115 in Time 1), and among centers with children under 3 years of age, compliance with a weekly mandatory visit by a nurse consultant (p = 0.0004 in Time 2). Though family child care homes had a lower frequency of medication administration non-compliance, only 19% were administering medications in Time 1. High quality, safe, and affordable child-care is essential for all children including those with special health care needs. This study highlights the importance of medication safety practices in child care programs, national child care health and safety standards, federal and state policies regarding medication administration regulations, and the critical role of nurse child care health consultants in promoting safe medication administration in child care programs.

Health and Safety in a Family Child Care Network: An Analysis of Violation Data of Routine, Full Unannounced Inspections.

OBJECTIVE: To analyze how engagement with a staffed family child network is associated with compliance on health and safety regulations among family day care (FDC) homes. METHODS: Publically available data on health and safety inspection violations on FDC homes were merged with engagement data from a staffed family child network. Descriptive analysis, logistic regression, and latent class analysis were used. RESULTS: Network FDC homes, compared to non-network FDC homes, were less likely to have health and safety violations in the areas of Child/Family/Staff Documentation (43.1% vs. 53.6%, p = 0.001) and Indoor Safety (36.0% vs. 42.6%, p = .041). Controlling for area median income and for decades since obtaining license, network FDC homes had fewer violations, fewer violation categories, and less variety of violation categories. Additionally, FDC homes which were not engaged with the staffed family child network but were in the city or town in which the network offered services, performed better compared to FDC homes in cities or towns without network resources. CONCLUSIONS FOR PRACTICE: The better compliance among network FDC homes and among FDC homes in cities and towns where the network offers services, suggests that the network is having positive effects on health and safety quality in FDC homes. A staffed child care network may be a means to improve child care quality and may be a means of improving educational and health outcomes for children.

Sleep health in young children living with socioeconomic adversity.

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.

Perspectives on Sleep from Multiethnic Community Parents, Pediatric Providers, and Childcare Providers.

OBJECTIVE: To describe the perceptions of (1) parents, childcare, and health care providers regarding sleep health among multiethnic infants and toddlers living with socioeconomic adversity, (2) factors that contribute to sleep health and its consequences, and (3) best ways to promote sleep health in these children. METHODS: Nested within a larger community-engaged mixed methods study, we used a descriptive qualitative design to describe the experience of multiethnic young parents who were raising 6- to 36-month-old children, pediatric health care providers, and childcare providers living and working in an urban under-resourced community. Semistructured interviews with 25 parents and 16 providers were conducted, transcribed, coded, and analyzed using thematic analysis by a 6-member research team. Interviews continued until themes were saturated. RESULTS: Parent responses and provider responses resulted in overlapping and divergent findings. Common themes among all respondents were the importance of sleep, interest and desire for more sleep health information, and common environmental/social impediments to healthy family sleep. Divergent themes included the importance of bedtime routines and timing, views on the family bed, importance of naps, and healthy sleep aids. Childcare centers were suggested as good sites for sleep health promotion programs. CONCLUSION: Sleep is a topic of interest and importance for young families. There are unique family challenges to be considered in any sleep health promotion program tailored to the needs of the community. The voices of parents and community providers are valuable assets informing the development of novel family-friendly approaches for decreasing sleep disparities and improving the health of young children and families.

Adapting an Evidence-Based Pediatric Acute Asthma Exacerbation Severity Assessment Tool for Pediatric Primary Care.

INTRODUCTION: The purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care. METHOD: The three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool. RESULTS: The criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care. DISCUSSION: The adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.

Negotiating Access to Health Information to Promote Students' Health.

Access to student health information, such as immunizations, screenings, and care plans for chronic conditions, is essential for school nurses to fulfill their role in promoting students' health. School nurses typically encounter barriers to accessing health records and spend many hours attempting to retrieve health information. As a result, nurses' time is poorly utilized and students may suffer adverse outcomes including delayed school entry. In response to this pressing public health issue, a school medical advisor and director of school nurses in a local health department successfully negotiated access for school nurses to three health record systems: a state immunization tracking system, an electronic lead surveillance program, and an electronic health record system. This negotiation process is presented within a framework of the Theory of Diffusion of Innovation and provides a strategy for other school nurses seeking access to student health information.

Health and Safety in Family Day Care Homes: Association Between Regulatory Non-compliance and Lower Median Income.

OBJECTIVES: To determine frequency of non-compliance with child care regulations among family day care homes (FDCH) and identify the role of income in compliance. METHODS: We analyzed non-compliance in 746 routine, unannounced inspection and re-inspection reports of FDCH collected by the Connecticut Department of Public Health licensing specialists in 2007-2008 and linked results to median income of zip code data. We grouped the 83 state regulations into 12 regulation categories, analyzed 11 categories, and used latent class analysis to classify each FDCH as high or low compliance for each category. We used logistic regression analysis to estimate the odds ratios of low compliance. RESULTS: Among the 746 FDCH inspections (594 first inspections and 152 re-inspections), we found high rates of non-compliance in inspection regulations in immunizations (32.9 %), water temperature (35.6 %) and hazards (30.0 %). Among the 11 regulation categories, 4 categories (indoor safety, emergency preparedness, child/family/staff documentation, and qualifications of provider) had regulations with high non-compliance. Median household income of FDCH zip code was lower for re-inspection sites than for inspection sites ($34,715 vs. $57,118, p < 0.0001) and FDCH in the lowest quartile of income had greater odds of low compliance in indoor safety (OR 1.86, 95 % CI 1.04, 3.35, p < 0.05). CONCLUSIONS: The majority of FDCH were in compliance with the majority of regulations, yet there are glaring non-compliance issues in inspections and re-inspections and there are income-based inequities that place children at higher risk who are already at high risk for suboptimal health outcomes.

Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children's body mass index.

BACKGROUND: To address the public health crisis of overweight and obese preschool-age children, the Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) intervention was delivered by nurse child care health consultants with the objective of improving child care provider and parent nutrition and physical activity knowledge, center-level nutrition and physical activity policies and practices, and children's body mass index (BMI). METHODS: A seven-month randomized control trial was conducted in 17 licensed child care centers serving predominantly low income families in California, Connecticut, and North Carolina, including 137 child care providers and 552 families with racially and ethnically diverse children three to five years old. The NAP SACC intervention included educational workshops for child care providers and parents on nutrition and physical activity and consultation visits provided by trained nurse child care health consultants. Demographic characteristics and pre - and post-workshop knowledge surveys were completed by providers and parents. Blinded research assistants reviewed each center's written health and safety policies, observed nutrition and physical activity practices, and measured randomly selected children's nutritional intake, physical activity, and height and weight pre- and post-intervention. RESULTS: Hierarchical linear models and multiple regression models assessed individual- and center-level changes in knowledge, policies, practices and age- and sex-specific standardized body mass index (zBMI), controlling for state, parent education, and poverty level. Results showed significant increases in providers' and parents' knowledge of nutrition and physical activity, center-level improvements in policies, and child-level changes in children's zBMI based on 209 children in the intervention and control centers at both pre- and post-intervention time points. CONCLUSIONS: The NAP SACC intervention, as delivered by trained child health professionals such as child care health consultants, increases provider knowledge, improves center policies, and lowers BMI for children in child care centers. More health professionals specifically trained in a nutrition and physical activity intervention in child care are needed to help reverse the obesity epidemic. TRIAL REGISTRATION: National Clinical Trials Number NCT01921842.

Health and safety of child care centers: an analysis of licensing specialists' reports of routine, unannounced inspections.

OBJECTIVES: We assessed the prevalence of regulatory noncompliance of licensed child care centers and identified factors associated with improved compliance. METHODS: We analyzed 676 routine, unannounced reports of child care centers collected by the Connecticut Department of Public Health licensing specialists over a 2-year time period, included characteristics of centers, and created categories of regulations. RESULTS: The sample included 41% of licensed child care centers. Of the 13 categories of regulations in the analyses, 7 categories (outdoor safety, indoor safety, indoor health, child and staff documentation, emergency preparedness, infant-toddler indoor health, and infant-toddler indoor safety) had regulations with center noncompliance greater than 10%. Playground hazard-free was the regulation with the highest frequency (48.4%) of noncompliance. Compliance with the regulation for 20 hours of continuing education per year for child care providers was the characteristic most frequently associated with regulations compliance. CONCLUSIONS: Efforts to support continuing education of child care providers are essential to improve and sustain healthy and safe early-care and education programs. Analyses of state child care licensing inspection reports provide valuable data and findings for strategic planning efforts.

Family child care providers' self-perceived role in obesity prevention: working with children, parents, and external influences.

OBJECTIVE: To describe the perspective and strategies of family child care providers (FCCPs) to reduce children's suboptimal weight trajectories. DESIGN: In-person, in-depth interviews with FCCPs. SETTING: Family child care homes. PARTICIPANTS: Seventeen FCCPs caring for children 6 weeks to 9 years old; 94% caring for children paying with a state subsidy. PHENOMENON OF INTEREST: Strategies of FCCP to reduce children's suboptimal weight trajectories. ANALYSIS: Constant comparative method of qualitative data analysis. RESULTS: Family child care providers described 3 core strategies: (1) improving children's behavior, (2) engaging and educating parents, and (3) leveraging influences external to their relationship with parents to effect positive change and to avoid parental conflict. These strategies were framed within their knowledge of child development, parental communication, and community services. CONCLUSIONS AND IMPLICATIONS: The findings suggest that FCCPs' role in obesity prevention may be framed within knowledge that may be commonly expected of a child care provider. Partnerships between public health policy makers and FCCP may reduce obesigenic environments by employing training and resources that link obesity prevention and child care provider expertise.

Childcare health and health consultation curriculum: trends and future directions in nursing education.

PURPOSE: The purpose of this study was to identify graduate and undergraduate nursing courses in health and health consultation in childcare and early education, and faculty awareness and interest in federal resources. DESIGN AND METHODS: A questionnaire was sent electronically to 140 faculty in 45 schools of nursing. RESULTS: Fifty-nine faculty from 45 schools (42%) participated, and 80% reported at least one course related to childcare health and safety. Most faculty were not aware of federal initiatives to support childcare health and safety, and the role of nurse childcare health consultants; however, many were interested in receiving instructional materials. PRACTICE IMPLICATIONS: Utilizing federal resources to augment nursing education in childcare health and safety curriculum may strengthen the workforce of nurses providing health consultation to early childhood programs.

The diffusion of innovation in nursing regulatory policy: removing a barrier to medication administration training for child care providers.

Safe medication administration is an essential component of high-quality child care. Its achievement in New Jersey was impeded by a controversy over whether teaching child care providers medication administration involves registered nurses in the process of nursing delegation. Through the theoretical framework of the Diffusion of Innovation, this paper examines how the interpretation of regulatory policy related to nursing practice in New Jersey was adjusted by the Board of Nursing following a similar interpretation of regulatory policy by the Board of Nursing in Connecticut. This adjustment enabled New Jersey nurses to continue medication administration training for child care providers. National data supporting the need for training child care providers in medication administration is presented, the Diffusion of Innovation paradigm is described; the Connecticut case and the New Jersey dilemma are discussed; the diffusion process between the two states is analyzed and an assessment of the need for further change is made.

Promoting child development and behavioral health: family child care providers' perspectives.

INTRODUCTION: Given the significant proportion of children in nonparental child care and the importance of early life experiences on development, interventions to improve a child care provider's ability to enhance a young child's development and behavior are essential. Such interventions require understanding of and responsiveness to the provider's self-perceived roles, responsibilities, and willingness to engage in such interventions, yet prior research is limited. The purpose of the study was to characterize licensed family child care provider perspectives as a first step toward designing effective provider-based interventions to improve children's development and behavior. METHOD: We conducted a qualitative study using in-depth interviews with licensed family child care providers serving economically disadvantaged children. Interviews were audiotaped, transcribed, and synthesized into common themes using the constant comparative method of qualitative data analysis. RESULTS: The family child care providers described five domains related to their role in child development and behavior: (a) promotion, (b) assessment, (c) advising parents, (d) acknowledging barriers, and (e) their own skill development. DISCUSSION: The family child care providers we interviewed describe how the developmental and behavioral health of children is an important aspect of their role and identify innovative and feasible ways to enhance their skills. Understanding the self-perceived role, responsibility, and willingness of child care providers is an important foundation to designing effective interventions to achieve high-quality child care.

Impact of training on child care health consultant knowledge and practice.

PURPOSE: To evaluate a pilot training program for 19 nurse child care health consultants, 14 child care directors, and 9 members of community teams, and to assess the effect of the training on nurses' and directors' perceptions of the health consultant role, nurses' knowledge and practice as health consultants, and child care center policies and practices. METHOD: Data were collected at the conclusion of the program to assess participants' evaluation of the program and the effect of training on directors' and nurses' perceptions of the health consultant's role. Pre- and post-training data were collected regarding nurses' health consultation knowledge in 13 content areas and practice activities, and the effect of training on child care program health and safety policies and practices. FINDINGS: Of the 42 participants, 93.5% rated the program as excellent, and many health consultants and directors reported that the training changed their perception of the health consultant role. Positive significant differences were found in health consultant knowledge and scope of practice, as well as some health and safety policies and practices post-training. CONCLUSION: These findings support the importance of preparation for the health consultant role and increasing evidence of the positive effect of health consultation on the health and safety of child care programs.

Family child care providers' experience in health promotion.

Family child care providers may be well-suited to provide health promotion to young children and their families. The investigators conducted a qualitative study using in-depth interviews with family child care providers serving low-income children. Child care providers perceive that they have an important role in health promotion, including (1) the child's physical health, (2) the child's development, and (3) supporting and educating parents, and are willing to assume this role in the context of collaborative relationships with parents. Providing education and ongoing support to child care providers in developing collaborative partnerships may enhance opportunities for health promotion in this setting.

Collaborative childcare health consultation: a conceptual model.

PURPOSE: This study explored the nature of consultation between childcare providers and nurse childcare health consultants and identified factors that promote a collaborative relationship. DESIGN AND METHODS: A qualitative study using semistructured, individual interviews of five collaborative and five conflicted pairs of nurse childcare health consultants and childcare center directors. Data were analyzed following principles of grounded theory and applying the constant comparative method of analysis. RESULTS: Establishing a collaborative relationship was influenced by previous experiences and four themes in the relationship: open and active communication, commitment, respect, and congruent philosophies. PRACTICE IMPLICATIONS: Preparation in developing collaborative relationships should be incorporated into the education of nurse consultants and childcare directors and providers.

Connecticut's new comprehensive and universal early childhood health assessment form.

Health assessments are required for entrance into child care, Head Start, and preschool programs. However, state and federal screening and documentation mandates vary, and programs create their own forms for keeping required data on file. Inconsistent recording formats present challenges for primary care providers who must document each child's health status and for program administrators who wish to collect data across groups of children. This article describes how the passage of new legislation in Connecticut establishing a statewide prekindergarten program presented the opportunity to develop a comprehensive early childhood health form for all early childhood programs, which promotes children's access to health services and coordination of care among health care professionals, early childhood providers, and families.

State policies regarding nursing delegation and medication administration in child care settings: a case study.

Medication administration is an essential component of quality child care, and nurses play a central role in assuring high-quality training of child care providers. Through key informant interviews and review of public documents, this case study explored the development of state statutes and regulations for medication administration training of child care providers in the state of Connecticut, nursing liability issues related to the definition of this activity, and the role of the Connecticut State Board of Examiners for Nursing. This article also examines the interpretation of the nursing role within this context as delegation versus professional activity and the impact of such designation on nursing practice, child care providers' access to medication administration training by nurses, and children's health status in child care settings. As a result of this case study, the Connecticut State Board of Examiners for Nursing revised its policies, demonstrating an exemplar linkage among research, practice, and policy.

Integrating healthy steps into PNP graduate education.

INTRODUCTION: The purpose of this project was to explore a) the value of an adapted version of the Healthy Steps program for Pediatric Nurse Practitioner (PNP) graduate students and b) the perceptions of PNP program directors regarding practice issues, educational preparation and the Healthy Steps program. METHOD: A four-part workshop was offered to students in their final year of the program. Outcomes were measured through evaluations and a pre-test/post-test design. A survey was also mailed to 24 PNP program directors. RESULTS: More than 90% of the participating students rated this workshop as "good or excellent." All of the students recommended integration of Healthy Steps content into PNP graduate education. PNP program directors voiced concern about the effect of the managed care environment on PNP practice, acknowledged the importance of strengthening health supervision visits, and expressed interest in the Healthy Steps program. DISCUSSION: This project demonstrated that an adapted version of the Healthy Steps program enhanced the education of final year PNP students. PNP program directors expressed concern about practice issues, preparation for practice, and would consider potential adoption of portions of the Healthy Steps curriculum.