Educating the next generation of nurses to be innovators and change agents.

With over 4 million nurses in the United States and an ever changing health care environment, undergraduate nursing faculty must consider proactively educating students on essential principles of innovation within the core curriculum. New nurses must be prepared to identify and facilitate innovations to enhance patient and populations outcomes. The purpose of this paper is to describe an approach to prepare the next generation of registered nurses to be innovators and change agents through a Health Care Innovation Program within an undergraduate nursing program. The paper describes the importance of innovations within nursing and provides details on the curriculum and approach used to incorporate health care innovations content and application. Examples of health care innovation student projects are provided. An evaluation of the program after three years of implementation assessed graduates' use of taught innovation principles and their own innovative behaviors. The majority of graduates described using innovation principles taught in the Program and scored high on innovation self-efficacy. Graduates with higher average innovation scores were more likely to engage in innovative behavior. A national conversation is encouraged to ensure our educational programs are effectively preparing the future generation of nurses to be innovators and change agents.

Increase in Oxytocin From Skin-to-Skin Contact Enhances Development of Parent-Infant Relationship.

OBJECTIVE: To examine changes that occur in infant and parent salivary oxytocin (OT) and salivary cortisol (SC) levels during skin-to-skin contact (SSC) and whether SSC alleviates parental stress and anxiety while also supporting mother-father-infant relationships. METHODS: This randomized crossover study was conducted in the neonatal intensive care unit (NICU) with a sample of 28 stable preterm infants and their parents. Saliva samples were collected from infants, mothers, and fathers on Days 1 and 2 (1/parent) for OT and cortisol measurement pre-SSC, during a 60-min SSC session, and a 45-min post-SSC. Parental anxiety was measured at the same time points. Parent-infant interaction was examined prior to discharge on Day 3 via video for synchrony and responsiveness using Dyadic Mutuality Coding. RESULTS: Salivary OT levels increased significantly during SSC for mothers ( p < .001), fathers ( p < .002), and infants ( p < .002). Infant SC levels decreased significantly ( p < .001) during SSC as compared to before and after SSC. Parent anxiety scores were significantly related to parent OT and SC levels. Parents with higher OT levels exhibited more synchrony and responsiveness ( p < .001) in their infant interactions. CONCLUSION: This study addresses a gap in understanding the mechanisms linking parent-infant contact to biobehavioral responses. SSC activated OT release and decreased infant SC levels. Facilitation of SSC may be an effective intervention to reduce parent and infant stress in the NICU. Findings advance the exploration of OT as a potential moderator for improving responsiveness and synchrony in parent-infant interactions.

Secondary Traumatic Stress in NICU Nurses: A Mixed-Methods Study.

BACKGROUND: Secondary traumatic stress is an occupational hazard for healthcare providers who care for patients who have been traumatized. This type of stress has been reported in various specialties of nursing, but no study to date had specifically focused on neonatal intensive care unit (NICU) nurses. PURPOSE: (1) To determine the prevalence and severity of secondary traumatic stress in NICU nurses and (2) to explore those quantitative findings in more depth through nurses' qualitative descriptions of their traumatic experiences caring for critically ill infants in the NICU. METHODS: Members of NANN were sent e-mails with a link to the electronic survey. In this mixed-methods study, a convergent parallel design was used. Neonatal nurses completed the Secondary Traumatic Stress Scale (STSS) and then described their traumatic experiences caring for critically ill infants in the NICU. SPSS version 24 and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS: In this sample of 175 NICU nurses, 49% of the nurses' scores on the STSS indicated moderate to severe secondary traumatic stress. Analysis of the qualitative data revealed 5 themes that described NICU nurses' traumatic experiences caring for critically ill infants. IMPLICATIONS FOR PRACTICE: NICU nurses need to know the signs of secondary traumatic stress that they may experience caring for their critically ill infants. Avenues for dealing with the stress should be provided. IMPLICATIONS FOR RESEARCH: Future research with a higher response rate to increase the external validity of the findings to the population of neonatal nurses is needed.

Utilization of Mental Health Services in School-Based Health Centers.

BACKGROUND: We summarize utilization patterns for mental health services in school-based health centers. METHODS: Administrative data on school-based health center visits in New Haven, Connecticut were examined for the 2007-2009 school years. Relative frequencies of mental health visits by age were calculated as a percentage of all visits and were stratified by sex, ethnicity/race, and insurance status. RESULTS: Mental health visits accounted for the highest proportion of visits (31.8%). The proportion of mental health visits was highest at 8 years (42.8%) and at 13 years (39.0%). The proportion of mental health visits among boys (38.4%) was higher than among girls (26.7%). Hispanic students had a lower proportion of mental health visits than black students (23.5% vs 35.8%) in all but 2 age groups. Students in the white/other ethnicity category had higher proportions of mental health visits than Hispanic and black students between ages 12 and 15. Students with no health insurance (22.5%) had lower proportions of mental health visits than students covered by Medicaid (34.3%) or private insurance (33.9%). The percentage of mental health visits by students with private insurance was highest (37.2%-49%) in the 13-15 age range. CONCLUSIONS: Usage patterns for mental health issues show pronounced, nonrandom variation relative to age and other demographic characteristics especially with 8-year-old boys.

Exclusive breast-feeding promotion among HIV-infected women in South Africa: an Information-Motivation-Behavioural Skills model-based pilot intervention.

OBJECTIVE: Exclusive breast-feeding (EBF) provides optimal nutrition for infants and mothers. The practice of EBF while adhering to antiretroviral medication decreases the risk of mother-to-child transmission of HIV from approximately 25 % to less than 5 %. Thus the WHO recommends EBF for the first 6 months among HIV-infected women living in resource-limited settings; however, EBF rates remain low. In the present study our aim was to design and implement a pilot intervention promoting EBF among HIV-infected women. DESIGN: The Information-Motivation-Behavioural Skills (IMB) model was applied in a brief motivational interviewing counselling session that was tested in a small randomized controlled trial. SETTING: Pietermaritzburg, South Africa, at two comparable rural public health service clinics. SUBJECTS: Sixty-eight HIV-infected women in their third trimester were enrolled and completed baseline interviews between June and August 2014. Those randomized to the intervention arm received the IMB-based pilot intervention directly following baseline interviews. Follow-up interviews occurred at 6 weeks postpartum. RESULTS: While not significantly different between trial arms, high rates of intention and practice of EBF at 6-week follow-up were reported. Findings showed high levels of self-efficacy being significantly predictive of breast-feeding initiation and duration regardless of intervention arm. CONCLUSIONS: Future research must account for breast-feeding self-efficacy on sustaining breast-feeding behaviour and leverage strategies to enhance self-efficacy in supportive interventions. Supporting breast-feeding behaviour through programmes that include both individual-level and multi-systems components targeting the role of health-care providers, family and community may create environments that value and support EBF behaviour.

Direct-breastfeeding in the neonatal intensive care unit and breastfeeding duration for premature infants.

AIM: To explore the relationship between direct-breastfeeding in the neonatal intensive care unit (NICU) and breastfeeding duration after discharge. BACKGROUND: Initiating and maintaining breastmilk feeding is an important goal that begins in the NICU. Little is known about direct-breastfeeding in the NICU and its relation to breastfeeding duration. METHODS: Chart review of 46 infants (<32weeks gestational age or <1500 grams) whose mothers provided breastmilk. RESULTS: One month after discharge, mothers still providing breastmilk were more likely to have provided ≥1 direct-breastfeed per day in the NICU (21.16, CI: 3.13-143.25, p<0.01) and had prior breastfeeding experience (OR: 9.16, CI: 1.02-82.34, p<0.05). At 4months, mothers still providing breastmilk were more likely to have provided ≥1 direct-breastfeed per day in the NICU (OR: 12.80, CI: 1.39-118.32, p<0.05). CONCLUSIONS: Direct-breastfeeding in the NICU may play an essential role in preparing mothers for breastfeeding after discharge, thus potentially impacting breastfeeding duration.

Breastfeeding Self-efficacy: A Critical Review of Available Instruments.

Increasing breastfeeding rates in the United States is a national priority. Yet, initiation and duration of breastfeeding remains below national targets. Breastfeeding self-efficacy has been shown to be a strong predictor of both breastfeeding initiation and duration and is therefore an important characteristic to be able to measure. However, there is currently a myriad of instruments for measuring breastfeeding self-efficacy, which makes selection of an appropriate instrument difficult. Thus, our aim was to identify, compare, and critically review available breastfeeding self-efficacy instruments. In a systematic review, 6 breastfeeding self-efficacy instruments were identified. The instruments' purposes, theoretical framework, final scale development, and application in 5 most recent settings were analyzed. The 6 breastfeeding self-efficacy instruments apply a number of theoretical and conceptual frameworks in their development, with Bandura's social cognitive theory being most common. Content, construct, and predictive validity were strong for most scales. Some, but not all, have been successfully adapted to novel settings. In sum, there are several measurements of breastfeeding self-efficacy that can and should be employed to better understand reasons for suboptimal breastfeeding rates and the effects of interventions on breastfeeding self-efficacy. Instrument selection should be based on domains of primary interest, time available, peripartum timing, and assessment of previous adaptations. Failure to apply appropriate measures in research may garner results that are inconclusive, inaccurate, or nonrepresentative of true study effects.

Parental oxytocin responses during skin-to-skin contact in pre-term infants.

OBJECTIVE: Maternal skin-to-skin contact (M-SSC) has been found to reduce adverse consequences of prematurity, however, its neurobiological mechanisms have been unknown. The purpose of the study was to examine oxytocin mechanism in modulating parental stress and anxiety during M-SSC and P-SSC (paternal SSC) with their pre-term infants. METHODS: Twenty-eight stable pre-term infants and their parents (triads) were recruited in a 2-day cross-over study and 26 mothers and 19 fathers completed the study protocol. Each triad was randomly assigned to one of the two sequences: M-SSC was conducted on day-1 and P-SSC on day-2; and P-SSC on day-1 and M-SSC on day-2. Parents' saliva samples for oxytocin and cortisol assays and visual analog anxiety levels were collected pre-SSC, 30-min during-SSC, and 30-min post-SSC. RESULTS: Both maternal and paternal oxytocin levels were significantly increased during-SSC from baseline. Maternal oxytocin dropped post-M-SSC, but paternal oxytocin continued to be maintained at a higher level during post-P-SSC. Both maternal and paternal cortisol levels significantly decreased during-SSC from baseline. Maternal cortisol continuously dropped post-M-SSC, but paternal cortisol increased post-P-SSC. Both mothers' and fathers' anxiety levels decreased during-SSC from baseline, and then increased post-SSC. Mother-father dyads also showed correlated or synchronized stress and anxiety responses in the NICU. CONCLUSION: M-SSC and P-SSC activated the oxytocin release and reduced stress and anxiety responses in mothers and fathers of pre-term infants. PRACTICE IMPLICATIONS: SSC plays a positive role in early post-partum period and patterns of maternal and paternal bio-behavioral responses to SSC with pre-term infants might be different.

Direct-Breastfeeding Premature Infants in the Neonatal Intensive Care Unit.

BACKGROUND: The neonatal intensive care unit (NICU) presents challenges for breastfeeding, especially with feeding directly at the breast (direct-breastfeeding). OBJECTIVES: The objectives of this study were to describe the characteristics of direct-breastfeeding and identify factors that are associated with direct-breastfeeding in the NICU. METHODS: A retrospective chart review of 88 infants born < 34 weeks gestational age whose mothers provided human milk was conducted. Analyses included chi-square and logistic regression models. RESULTS: Of infants who received human milk at the time of their first oral feeding, 59% received their first oral feeding at breast and 33% of mothers had a specific breastfeeding goal. Mothers who breastfed ≥ 1 direct-breastfeed per day were more likely to have a breastfeeding goal (odds ratio [OR] = 11.13; 95% confidence interval [CI], 1.43-86.88) and be older (OR = 1.33; 95% CI, 1.03-1.72). Their infants had more days between the first breastfeed and introduction of a bottle (OR = 1.56; 95% CI, 1.11-2.17) and had shorter lengths of stay (OR = 0.9; 95% CI, 0.9-0.97). Mothers were more likely to provide direct-breastfeeding at discharge if they were non-Hispanic (OR = 0.05; 95% CI, < 0.01-0.60), were primiparous (OR = 0.06; 95% CI, 0.01-0.45), had a specific breastfeeding goal (OR = 13.79; 95% CI, 1.99-95.80), and their infant had a shorter length of stay (OR = 0.94; 95% CI, 0.90-0.98). CONCLUSION: Mothers should be supported to breastfeed before using bottles in the NICU. In addition, goal setting is important for prenatal care providers to discuss with all mothers early in pregnancy, especially those at high risk for premature delivery.

Cross-cultural adaptation of instruments assessing breastfeeding determinants: a multi-step approach.

BACKGROUND: Cross-cultural adaptation is a necessary process to effectively use existing instruments in other cultural and language settings. The process of cross-culturally adapting, including translation, of existing instruments is considered a critical set to establishing a meaningful instrument for use in another setting. Using a multi-step approach is considered best practice in achieving cultural and semantic equivalence of the adapted version. We aimed to ensure the content validity of our instruments in the cultural context of KwaZulu-Natal, South Africa. METHODS: The Iowa Infant Feeding Attitudes Scale, Breastfeeding Self-Efficacy Scale-Short Form and additional items comprise our consolidated instrument, which was cross-culturally adapted utilizing a multi-step approach during August 2012. Cross-cultural adaptation was achieved through steps to maintain content validity and attain semantic equivalence in the target version. Specifically, Lynn's recommendation to apply an item-level content validity index score was followed. The revised instrument was translated and back-translated. To ensure semantic equivalence, Brislin's back-translation approach was utilized followed by the committee review to address any discrepancies that emerged from translation. RESULTS: Our consolidated instrument was adapted to be culturally relevant and translated to yield more reliable and valid results for use in our larger research study to measure infant feeding determinants effectively in our target cultural context. CONCLUSIONS: Undertaking rigorous steps to effectively ensure cross-cultural adaptation increases our confidence that the conclusions we make based on our self-report instrument(s) will be stronger. In this way, our aim to achieve strong cross-cultural adaptation of our consolidated instruments was achieved while also providing a clear framework for other researchers choosing to utilize existing instruments for work in other cultural, geographic and population settings.

An integrative review of factors that influence breastfeeding duration for premature infants after NICU hospitalization.

OBJECTIVE: To determine what factors affect breastfeeding duration after discharge home from the neonatal intensive care unit (NICU) for high-risk mothers and their premature infants. DATA SOURCES: The electronic databases of CINAHL and PubMed were used to identify studies published in English. Date of publication did not limit inclusion in the review. STUDY SELECTION: Using exclusion and inclusion criteria, 292 articles were initially assessed for relevance to the research question through abstract review. Further screening resulted in full review of 52 articles. Reference list searching added an additional six articles. Finally, in-depth review of these 58 articles resulted in 24 studies that fully met inclusion and exclusion criteria. DATA EXTRACTION: Studies were reviewed for information related to factors associated with breastfeeding duration for high-risk mothers and preterm infants after NICU discharge home. DATA SYNTHESIS: Studies were categorized into five themes, including NICU factors, feeding and soothing methods, maternal characteristics, maternal experiences, and support programs. Most significant factors affecting duration included exposure to kangaroo mother care, prenatal education, and quantity of maternal breast milk supply during the first week after discharge. Breastfeeding also was affected by maternal breastfeeding knowledge and perception of providing appropriate volumes. CONCLUSIONS: Mothers face many challenges breastfeeding their premature infants after NICU discharge. Ideally, all mothers need to receive support after NICU discharge, and the transition to home can be challenging even if breastfeeding is well established. However, NICU professionals are in a perfect position to provide guidance to families so they are able to anticipate and effectively solve lactation challenges at home.

State of the science: a contemporary review of feeding readiness in the preterm infant.

Oral feeding readiness has been described by researchers in the neonatal intensive care unit, and research has continued on this topic for many years. The purpose of this narrative review is to identify research and practice guidelines related to oral feeding readiness in preterm infants that have occurred during the last decade. The introduction and mastery of oral feeding is a major developmental task for the preterm infant that is often a prerequisite for discharge from the neonatal intensive care unit. Having a better understanding of the evidence supporting the development of this skill will help the practicing nurse choose appropriate interventions and the researcher to develop trajectories of research that continue to increase our knowledge in this important practice area.

Maternal influenza vaccination: evaluation of a patient-centered pamphlet designed to increase uptake in pregnancy.

We developed and tested a theoretically-based pamphlet entitled 'Influenza in Pregnancy,' specifically designed to increase pregnant women's knowledge, reduce barriers to maternal vaccination, and subsequently improve vaccine uptake. A randomized control trial was conducted on pregnant women (n = 135) at three locations in Connecticut during the 2011-2012 season to evaluate the impact of the patient-centered pamphlet. The women were randomized to one of three groups: the pamphlet; pamphlet/benefit statement (vaccinating the pregnant woman also benefits the young infant); or control. A Chi square analysis compared the intervention with control using the primary outcome of vaccination. A secondary outcome of the perceptions of health beliefs of maternal vaccination were measured through General Linear Model/ANOVA model for repeated measures. Overall 66.9% (89/133) were vaccinated. Both the pamphlet group 72.9% (35/48) (χ² = 6.81, df = 1 p = .009), and the pamphlet/benefit statement group 86.1% (31/36) (χ² = 13.74, df = 1, p < .001), had significantly higher vaccine uptake than the control group 46.9% (23/49). The potential barrier, perception of vaccine safety (F = 4.973, df = 2, p < .01), and benefit of vaccination to mother and infant (F = 6.690, df = 2, p < .01) significantly improved for the intervention groups compared to control group. The pamphlet significantly increased the pregnant women's perceptions of the safety and benefit of the vaccine, and the overall uptake.

Pain assessment and measurement in neonates: an updated review.

Pain assessment and measurement are the cornerstones of pain management. Pain assessment connotes a comprehensive multidimensional description. Conversely, pain measurement provides a numeric quantitative description of each factor illustrating pain qualities. Pain scales provide a composite score used to guide practice and research. The type of infant pain instrument chosen is a significant factor in guiding pain management practice. The purpose of this review was to summarize current infant pain measures by introducing a conceptual framework for pain measurement. Although more than 40 infant pain instruments exist, many were devised solely for research purposes; several of the newly developed instruments largely overlap with existing instruments. Integration of pain management into daily practice remains problematic. Understanding how each instrument measures infant pain allows clinicians to make better decisions about what instrument to use with which infant and in what circumstances. In addition, novel new measurement techniques need further testing.

The doctor of nursing practice graduate as faculty member.

This article focuses on the emerging role of the Doctor of Nursing Practice (DNP) graduate as faculty member. Discussion includes historical composition of faculties. Re-evaluation of Boyer's model of scholarship in relation to faculty roles is examined. Discussion includes barriers facing current DNP faculty as well as the potential advantages that DNP graduates may make toward school of nursing faculties. Discussion concludes with considerations for the future of the discipline as demographics and traditional values shift over time.

Kangaroo care and behavioral and physiologic pain responses in very-low-birth-weight twins: a case study.

The purpose of this case study was to describe pain responses in three study conditions: longer (30 minutes) kangaroo care (KC) before and throughout heel stick (KC30), shorter (15 minutes) KC before and throughout heel stick (KC15), and incubator care throughout heel stick (IC) in 28-week gestational age twins. Pain responses were measured by crying time, Preterm Infant Pain Profile (PIPP), and heart rate variability indexes, including low-frequency power (LF, representing sympathetic activity), high-frequency power (HF, parasympathetic activity), and LF/HF ratio (sympathetic-parasympathetic balance). Both twins cried more and had higher PIPP pain scores and tachycardia during heel stick in the IC condition. Infant B had an incident of apnea and tachycardia by the end of the heel stick and a bradycardia episode during recovery in the IC condition. The twins had lower LF/HF ratios (better autonomic nervous system balance) during recovery in both longer and shorter KC conditions compared with the IC condition. Infant B had difficulty returning to LF/HF ratio baseline level after the painful procedure in the IC condition. These data suggest that both longer and shorter KC before and throughout painful procedures can be helpful in reducing behavioral and physiologic pain responses in preterm infants.

Effects of skin-to-skin contact on autonomic pain responses in preterm infants.

UNLABELLED: The purpose of this randomized crossover trial was to determine the effects on autonomic responses in preterm infants of longer Kangaroo Care (30 minutes, KC30) and shorter KC (15 minutes, KC15) before and throughout heel stick compared with incubator care (IC). Beat-to-beat heart rate (HR) and spectral power analysis of heart rate variability, low frequency power (LF), high frequency power (HF), and LF/HF ratio were measured in 26 infants. HR changes from Baseline to Heel Stick were significantly less in KC30 and KC15 than in IC, and more infants had HR decrease in IC than in 2 KC conditions. In IC, LF and HF significantly increased from Baseline to Heel Stick and dropped from Heel Stick to Recovery; in 2 KC conditions, no changes across study phases were found. During Heel Stick, LF and HF were significantly higher in IC than in KC30. In all 3 conditions, LF/HF ratio decreased from Baseline to Heel Stick and increased to Recovery; no differences were found between IC and two KC conditions. Both longer and shorter KC before and throughout heel stick can stabilize HR response in preterm infants, and longer KC significantly affected infants' sympathetic and parasympathetic responses during heel stick compared with incubator care. PERSPECTIVE: This study showed that KC has a significant effect on reducing autonomic pain responses in preterm infants. The findings support that KC is a safe and effective pain intervention in the neonatal intensive care unit.

Heparinized saline vs normal saline for maintenance of intravenous access in neonates: an evidence-based practice change.

PURPOSE: To design, implement, and to evaluate the outcomes of an evidence-based practice change regarding the use of heparin in intravenous (IV) locks to improve patient safety. Phase I of the project examined dwell time, hours of patency, gestational age at birth and at time of IV lock insertion, birthweight and weight at time of insertion, and reason for discontinuation for IV access devices prior to and following the practice change from heparinized saline (HS) to normal saline (NS) flush. Phase II of the project was to determine the effect of the educational program on staff knowledge of the use of heparinized saline vs normal saline flushes. SUBJECTS: The setting was an 18 bed level III NICU located in the northeastern United States. A sample of 70 infants with IV locks were included in the study; HS (n = 34) and NS (n = 36) respectively. Infants with IV's that were converted to IV locks were excluded. Only professional NICU staff (n = 40) were recruited for the educational offering. DESIGN: A comparative descriptive design with two components was utilized. METHODS: A retrospective and prospective chart review was used to compare the outcomes of neonates with IV locks flushed with heparin and normal saline flush and evaluated the outcomes. A pretest/posttest design was used to analyze the change of the NICU staff's knowledge concerning heparin flush before and after an educational offering. MAIN OUTCOME MEASURES: IV lock patency after practice change to NS flush and the change of the NICU staff's knowledge concerning heparin flush after an educational offering. PRINCIPAL RESULTS: There was a statistically significant difference in IV catheter patency with NS flushed catheters averaging 13 hours longer than HS flushed catheters (p = 0.02). Also a statistically significant increase in mean scores was noted for the NICU staff posttest after the educational offering (p = .0001). There was a 20% increase in knowledge scores. CONCLUSIONS: Findings from this project support the current literature base suggesting that the use of heparin is unnecessary for the maintenance of IV access devices. Unnecessary exposure of neonates to heparin increases risk to patient safety and should therefore be avoided. Future research should examine the use of heparin in central lines in neonates. Findings additionally support educating staff prior to practice changes.

Neonatal nurse practitioner role transition: the process of reattaining expert status.

Neonatal nurse practitioners (NNPs) have managed care for high-risk hospitalized infants in the United States for over 30 years. The journey from being expert nurse to being novice NNP and then finally to being expert NNP is fraught with many challenges. This study used a qualitative descriptive design to describe advanced practice role transition among 70 NNPs. The data consisted of participants' written responses to open-ended questions. Four themes emerged that depicted a linear progression of the transition process from school preparation to beginning feelings in the new role and then development into a more confident practice. Theme 1: First impressions emphasized the ambivalence novice NNPs experienced regarding their preparedness for the role during a stressful and exciting adjustment period. Theme 2: The transition demonstrated the overwhelmingly similar feelings of anxiety, insecurity, exhaustion, and lack of confidence that plagued decision making. Theme 3: Making it as a real NNP indicated that the 1-year mark was a consistent, significant timeframe for feeling like a real NNP. Theme 4: The helpers and hinderers revealed the vulnerability of the novice NNPs to harsh criticism as well as the importance of support, especially from nurse colleagues. NNPs are a valuable resource; thus, enhancing transition is a worthy goal.