Evaluation of Nursing Coursework for Biased Content.

ABSTRACT: Bias-free content in nursing education prepares students to provide equitable care. The process of assessing content promotes the dismantling of systemic bias in health care, advancing social justice, diversity, equity, and inclusion. Unfortunately, there are no published studies to guide the evaluation of nursing curricula for the presence of bias. This innovative project aimed to identify bias in a course and develop a structure to guide the wider evaluation of the curriculum to identify and remove biased content. A modified version of the Upstate Bias Checklist was applied to a 15-week, three-semester hour, prelicensure, graduate-level nursing course.

Informing Use of the Patient Health Questionnaire-2 to Detect Moderate or Greater Depression Symptoms in Adolescents and Young Adults in Outpatient Primary Care.

OBJECTIVE: We compared the Patient Health Questionnaire (PHQ)-2 to the PHQ-9 and examined the implications of using various cutoff scores on the PHQ-2 to detect moderate or greater depressive symptoms on the PHQ-9. We hypothesized that a cutoff score of ≥2 would be optimal for detecting scores of ≥10 on the PHQ-9. METHODS: Demographic and depression screening data from 3,256 routine preventive visits for patients aged 12-25 years at the adolescent and young adult clinic at Children's Hospital Colorado between March 2017 and July 2019 were collected retrospectively. Patients completed routine depression screening at 2,183 visits which were included for analysis. PHQ-2 scores and PHQ-9 scores were calculated for each included patient visit. Associations between different PHQ-2 cutoff scores and moderate or greater depressive symptoms on the PHQ-9 (≥10) were evaluated. RESULTS: A PHQ-2 score ≥2 had a sensitivity of 89% and specificity of 83% for detecting patients with moderate or greater depressive symptoms on the PHQ-9. On a receiver operating characteristic curve, a PHQ-2 cutoff of ≥2 optimized sensitivity and specificity. Analysis of gender and ethnic/racial subgroups demonstrated the same optimal cutoff score for each group studied. For patients aged 21 years and older a PHQ-2 cutoff of ≥3 was most accurate. DISCUSSION: Lowering the positive PHQ-2 cutoff to ≥2 has several clinical advantages, including increased detection of moderate or greater depressive symptoms and depressive disorders. Providers may increase identification of depression by making this change particularly if they follow a positive PHQ-2 with a full PHQ-9.

The effect of inpatient addiction screening and intervention on readmissions.

AIM: The number of individuals in the United States (US) needing treatment for substance use disorder (SUD) but not receiving treatment at a specialty facility was reported to be almost 18 million in 2019. This study measured the difference in subsequent hospital visits between groups, one receiving screening, brief intervention, and referral to treatment (SBIRT) and one receiving usual care. BACKGROUND: There are studies that discuss SBIRT in terms of process evaluation, staff training, reduced readmission rates, and self-reported reductions in substance use. However, the interrelationship between components of SBIRT implementation, such as feasibility, cost, and sustainability need additional investigation. This study compared readmissions between groups receiving SBIRT counseling (n = 101) and those receiving usual care (n = 99). RESULTS: The overall total number of subsequent visits for SUD for the group receiving SBIRT (53) was significantly lower than for the group receiving usual care (128). The overall total number of non-SUD subsequent visits was not significantly different between groups. The study also identified differences between sexes that require further investigation. CONCLUSIONS: The findings of this study demonstrate a measure of difference based on SBIRT intervention. The SBIRT program can be incorporated into daily practice in the acute care setting through nursing education and utilization of the electronic health platform.

Immunization-Associated Pain: Taking Research to the Bedside.

BACKGROUND: Immunization-associated pain is the number one cause of pain in pediatric settings. Untreated pain has many short- and long-term detrimental effects. The purpose of this project was to implement a nonpharmaceutical immunization-associated-pain prevention program. METHOD: This project was implemented at a pediatric primary care clinic. Staff were educated about immunization-associated pain and techniques for decreasing/preventing pain. Families were educated about pain control, and the practitioner and parent/child picked interventions to decrease pain. Preimplementation and postimplementation data were collected using previously validated pain and satisfaction scales. RESULTS: Pain prevention interventions decreased pain for children between 2 months and 7 years of age by 4.7 points on a Faces, Legs, Activity, Cry, Consolability (i.e., FLACC) scale. For children 7 years and older, pain during immunization decreased on average by 1.76 points on the visual analog scale. CONCLUSION: Non-pharmaceutical interventions are effective in decreasing immunization-associated pain.

Regulation of Controlled Substance Prescribing: An Overview for Certified Nurse-Midwives and Certified Midwives.

In addition to the regulation of prescriptive authority and prescribing practices conducted by individual states, the prescription of controlled substances is also regulated at the federal level by the US Drug Enforcement Administration (DEA). While there are variations in state laws relative to controlled substance prescribing, federal law is uniform across states as established by the Controlled Substances Act (21 United States Code § 801-890) and the DEA Regulations (Title 21, Code of Federal Regulations). The only controlled substance for which states have authorized use that is outside the regulations set forth in the Controlled Substances Act is marijuana for the treatment of certain medical conditions. A review of statutes and administrative rules for all 50 states and the District of Columbia revealed that certified midwives (CMs) are authorized to prescribe controlled substances only in the state of New York, and there are variations across states in the regulation of controlled substance prescribing by certified nurse-midwives (CNMs). The purpose of this article is to examine the federal regulation of controlled substance prescribing by the US DEA and common variations in state regulations relative to controlled substance prescribing.

Achieving High Adolescent HPV Vaccination Coverage.

BACKGROUND AND OBJECTIVE: Despite national recommendations for adolescent human papillomavirus (HPV) vaccination, rates have lagged behind those of other adolescent vaccines. We implemented interventions and examined rates of vaccination coverage in a large, urban, safety net health care system to understand whether our tactics for achieving high rates of adolescent vaccination were successful. METHODS: Denver Health is an integrated urban safety net health system serving >17 000 adolescents annually. The process for achieving high vaccination rates in our health system includes "bundling" of vaccines, offering vaccines at every visit, and standard orders. Data from vaccine registry and utilization statistics were used to determine vaccination rates in adolescents aged 13 to 17 years from 2004 to 2014, and these findings were compared with state and national rates for 2013. Regression analysis was used to identify characteristics associated with vaccination. RESULTS: In 2013 (N = 11 463), HPV coverage of ≥1 dose was 89.8% (female subjects) and 89.3% (male subjects), compared with national rates of 57.3% and 34.6%. Rates of HPV coverage (≥3 doses) were 66.0% for female subjects and 52.5% for male subjects, versus 37.6% and 13.9% nationally. For both sexes, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed, vaccine coverage was 95.9% (86.0% nationally), and meningococcal conjugate vaccine coverage was 93.5% (77.8% nationally). Female subjects, Hispanic subjects, non-English speakers, and teenagers <200% below the federal poverty level were more likely to have received 3 doses of HPV. CONCLUSIONS: Through low-cost, system-wide standard procedures, Denver Health achieved adolescent vaccination rates well above national coverage rates. Avoiding missed opportunities for vaccination and normalizing the HPV vaccine were key procedures that contributed to high coverage rates.

Regulation of Prescriptive Authority for Certified Nurse-Midwives and Certified Midwives: 2015 National Overview.

Statutory restrictions regarding the regulation of prescriptive authority for midwives continue to create barriers to practice in many states.

Labor down or bear down: a strategy to translate second-stage labor evidence to perinatal practice.

Scientific evidence supports spontaneous physiologic approaches to second-stage labor care; however, most women in US hospitals continue to receive direction from nurses and birth attendants to use prolonged Valsalva bearing-down efforts as soon as the cervix is completely dilated. Delaying maternal bearing-down efforts during second-stage labor until a woman feels an urge to push (laboring down) results in optimal use of maternal energy, has no detrimental maternal effects, and results in improved fetal oxygenation. Although most commonly used with women who are undergoing epidural anesthesia, laboring down is just one component of physiologic second-stage labor care that can be used to achieve optimal maternal and neonatal outcomes for women with or without an epidural. Prior efforts to translate evidence regarding second-stage labor care to practice have not been successful. In this article, the scientific evidence for second-stage labor care and previous efforts at clinical translation are reviewed. The Ottawa Hospital Second Stage Protocol is presented as a model with potential to allow translation of evidence to practice. Recommendations to enhance widespread adoption of evidence-based practice are provided, including improved collaboration between nurses and birth attendants.

Use of glycosylated hemoglobin increases diabetes screening for at-risk adolescents in primary care settings.

OBJECTIVE: To examine rates of diabetes screening in obese adolescents in an ethnically diverse primary care health care system before and after an internal recommendation to use HbA1c-based screening. RESEARCH DESIGN AND METHODS: Adolescents 12-18-years old with BMI > 95% were identified through electronic medical record review during two 18-month periods in 8 community health clinics and 13 school-based health centers: period 1 (P1, 19 April 2008 to 19 October 2009) and period 2 (P2, 3 May 2010 to 3 November 2011). Testing for diabetes in the 2 yr preceding the most recently elevated BMI was reviewed. RESULTS: A total of 2870 obese adolescents were identified in P1 and 3940 in P2. Ethnicity was primarily Hispanic, with smaller populations of Black and White youth. The percent of obese teens screened for diabetes increased from 40% in P1 to 47% in P2. Use of HbA1c increased 493% during P2. Older teens (>15 yr), those seen during P2, and those with BMI ≥ 30 kg/m2 were more likely to be screened. Record review confirmed equal rates of type 2 diabetes in the two periods: 8 incident (0.7%) cases in P1 and 13 (0.7%) in P2. CONCLUSIONS: The use of HbA1c, a non-fasting and logistically simpler test, was associated with increased diabetes screening in primary care. The percentage of screened patients with confirmed type 2 diabetes remained unchanged. Thus, despite potential pitfalls, the use of HbA1c for screening appears to be as successful as previous approaches in identifying adolescents with diabetes.

Directive versus supportive approaches used by midwives when providing care during the second stage of labor.

INTRODUCTION: Although the risks associated with using sustained and forceful maternal bearing-down efforts during the second stage of labor have been well documented, most women who give birth in the United States bear down in response to direction from care providers about when and how to push rather than in response to their own physiologic urges. The purpose of this study was to describe the practices used by certified nurse-midwives/certified midwives (CNMs/CMs) in response to maternal bearing-down efforts when caring for women in second-stage labor and to identify factors associated with the use of supportive approaches to second-stage labor care. METHODS: A national survey of 705 CNMs/CMs was conducted using mailed questionnaires. The instrument was an 84-item, fixed-choice questionnaire using Likert type scales that had been validated. A 72.6% response rate was achieved, and 375 of the respondents cared for women during the second stage of labor. RESULTS: Most CNMs/CMs (82.4%) often or almost always supported women without epidural anesthesia to initiate bearing-down efforts only when the woman felt an urge to do so. When caring for women without an epidural, most of the respondents (67%) reported that they often or almost always supported a woman's spontaneous bearing-down efforts without providing direction. Most participants reported using more directive practices when caring for women with epidural anesthesia. Whether caring for women with or without an epidural, most respondents (77.1% and 79.6%, respectively) often or almost always provided more direction as the fetal head emerged and the final stretching of the perineum was taking place. A change in fetal heart tones that led the midwife to believe the birth needed to occur quickly was the circumstance that had the greatest degree of influence on the participant's (90.6%) decision to provide more direction during bearing-down efforts. Many participants indicated that they also were influenced to provide more direction when women in labor asked for more direction (73.3%) or appeared to be fatigued (74.6%). DISCUSSION: The majority of CNMs/CMs use supportive approaches to bearing-down efforts during second-stage labor care and most used directive approaches as an intervention aimed at avoiding potential problems.

Regulation of prescriptive authority for certified nurse-midwives and certified midwives: a national overview.

INTRODUCTION: Certified nurse-midwives (CNMs) and certified midwives (CMs) provide primary care to women across the lifespan. Yet these primary care providers face barriers to practice that include restrictive state laws and regulations regarding prescriptive authority. The purpose of this review is to critically examine and report the regulatory requirements relative to prescriptive authority for CNMs/CMs in the United States. METHODS: State statutes and rules relative to midwifery practice were reviewed for all 50 United States and the District of Columbia. RESULTS: CNMs have been granted the authority to write prescriptions in all 50 United States and the District of Columbia, while CMs have been granted prescriptive authority only in the state of New York. Prescriptive authority for CNMs and CMs is regulated by individual state agencies and regulatory boards. Regulations regarding prescriptive authority for CNMs and CMs vary widely from state to state and are described, with a summary for each state presented. DISCUSSION: While CNMs are granted fully independent prescriptive authority in some states, the regulatory requirements relative to prescriptive authority for CNMs/CMs limit patients' access to necessary services in most states.

The development of the Community-based Nurse-midwifery Education Program: An innovation in distance learning.

Since the inception of nurse-midwifery education 80 years ago, educators have looked for ways in which to educate enough nurse-midwives. The application of distance learning to nurse-midwifery education expanded opportunities for a greater number of students to have access to an education in nurse midwifery. The story of the Community-based Nurse-midwifery Education Program is presented as an exemplar.

Domestic violence during pregnancy: implications for practice.

Domestic violence affects many women and their families. Although estimates of the prevalence of domestic violence during pregnancy vary, it is likely that most providers of women's health care will encounter pregnant women who experience domestic violence. The purpose of this article is to review research that has investigated associations between domestic violence during pregnancy and other demographic and lifestyle variables, as well as the literature regarding clinical assessment and intervention strategies.