Elucidating the context for implementing nonpharmacologic care for neonatal opioid withdrawal syndrome: a qualitative study of perinatal nurses.

BACKGROUND: Up to 95% of neonates exposed to opioids in utero experience neonatal opioid withdrawal syndrome at birth. Nonpharmacologic approaches (e.g., breastfeeding; rooming-in; skin-to-skin care) are evidence-based and should be implemented. These approaches, especially breastfeeding, rely on engagement of the neonates' mothers to help deliver them. However, little is known about the structural and social dynamic context barriers and facilitators to implementing maternal-delivered nonpharmacologic care. METHODS: Using a qualitative descriptive design, perinatal nurses from a Midwest United States hospital family birthing center, neonatal intensive care unit, and inpatient pediatric unit were interviewed. These units were involved in caring for mothers and neonates affected by opioid use. Telephone interviews followed a semi-structured interview guide developed for this study, were audio-recorded, and lasted about 30-60 min. Interviews were transcribed verbatim and independently analyzed by five investigators using the constant comparative method. Themes were discussed until reaching consensus and subsequently mapped to a conceptual model adapted for this study. RESULTS: Twenty-one nurses participated in this study (family birth center, n = 9; neonatal intensive care, n = 6; pediatrics, n = 6). Analysis resulted in four major themes: 1) Lack of education and resources provided to staff and mothers; 2) Importance of interdisciplinary and intradisciplinary care coordination; 3) Flexibility in nurse staffing models for neonatal opioid withdrawal syndrome; and 4) Unit architecture and layout affects maternal involvement. Minor themes supported each of the four major themes. All themes mapped to the conceptual model. CONCLUSIONS: This study provides a more comprehensive understanding of the barriers and facilitators affecting implementation of maternal involvement in nonpharmacologic care of newborns with neonatal opioid withdrawal syndrome. Future efforts implementing nonpharmacologic approaches must consider the context factors affecting implementation, including structural and social factors within the units, hospital, and broader community.

Genome Sequencing as an Alternative to Cytogenetic Analysis in Myeloid Cancers.

BACKGROUND: Genomic analysis is essential for risk stratification in patients with acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS). Whole-genome sequencing is a potential replacement for conventional cytogenetic and sequencing approaches, but its accuracy, feasibility, and clinical utility have not been demonstrated. METHODS: We used a streamlined whole-genome sequencing approach to obtain genomic profiles for 263 patients with myeloid cancers, including 235 patients who had undergone successful cytogenetic analysis. We adapted sample preparation, sequencing, and analysis to detect mutations for risk stratification using existing European Leukemia Network (ELN) guidelines and to minimize turnaround time. We analyzed the performance of whole-genome sequencing by comparing our results with findings from cytogenetic analysis and targeted sequencing. RESULTS: Whole-genome sequencing detected all 40 recurrent translocations and 91 copy-number alterations that had been identified by cytogenetic analysis. In addition, we identified new clinically reportable genomic events in 40 of 235 patients (17.0%). Prospective sequencing of samples obtained from 117 consecutive patients was performed in a median of 5 days and provided new genetic information in 29 patients (24.8%), which changed the risk category for 19 patients (16.2%). Standard AML risk groups, as defined by sequencing results instead of cytogenetic analysis, correlated with clinical outcomes. Whole-genome sequencing was also used to stratify patients who had inconclusive results by cytogenetic analysis into risk groups in which clinical outcomes were measurably different. CONCLUSIONS: In our study, we found that whole-genome sequencing provided rapid and accurate genomic profiling in patients with AML or MDS. Such sequencing also provided a greater diagnostic yield than conventional cytogenetic analysis and more efficient risk stratification on the basis of standard risk categories. (Funded by the Siteman Cancer Research Fund and others.).

Engaging Mothers to Implement Nonpharmacological Care for Infants With Neonatal Abstinence Syndrome: Perceptions of Perinatal and Pediatric Nurses.

BACKGROUND: Little is known about nurse perceptions regarding engagement of mothers in implementation of nonpharmacological care for opioid-exposed infants. PURPOSE: This study was designed to describe perinatal and pediatric nurse perceptions of (1) engaging mothers in the care of opioid-exposed infants and (2) facilitators and barriers to maternal engagement. METHODS: This study used a qualitative descriptive design to interview perinatal and pediatric nurses in one Midwest United States hospital. Interviews were conducted via telephone using a semistructured interview guide and audio recorded. Audio files were transcribed verbatim and thematically analyzed using the constant comparative method. RESULTS: Twenty-one nurses participated in the study, representing a family birth center, neonatal intensive care unit, and pediatric unit. Five major themes resulted from analysis: (1) vulnerability and bias; (2) mother-infant care: tasks versus model of care; (3) maternal factors affecting engagement and implementation; (4) nurse factors affecting engagement and implementation; and (5) recommendations and examples of nursing approaches to barriers. Minor themes supported each of the major themes. IMPLICATIONS FOR PRACTICE: Nurses must engage mothers with substance use histories with empathy and nonjudgment, identify and promote maternal agency to care for their infants, and engage and activate mothers to deliver nonpharmacological care during the hospital stay and following discharge. IMPLICATIONS FOR RESEARCH: Findings suggest interventions are needed to improve (1) nursing education regarding maternal substance use and recovery, (2) empathy for substance-using mothers and mothers in treatment, and (3) identification and support of maternal agency to provide nonpharmacological care to withdrawing infants.

Facilitators and barriers of change toward an elder-friendly surgical environment: perspectives of clinician stakeholder groups.

BACKGROUND: Current acute care surgical practices do not focus on the unique needs of older adults. Adverse outcomes in older patients result from a complex interrelationship between baseline vulnerability and insults experienced during hospitalization. The purpose of this study is to assess the organizational readiness and the barriers and facilitators for the implementation of elder-friendly interventions in the acute care of unplanned abdominal surgery patients. METHODS: This cross-sectional mixed methods study included a convenience sample of clinician stakeholder groups. Eight focus groups were conducted with 33 surgical team members including: 10 health care aides, 6 licensed practical nurses, 6 registered nurses, 4 nurse managers and 7 surgeons, to identify barriers and facilitators to the implementation of an elder-friendly surgical unit. Audio recordings of the focus groups were transcribed verbatim and analysed using interpretive description techniques. Transcripts were coded along with explanatory memos to generate a detailed description of participant experiences. Themes were identified followed by refining the codes. Participants also completed the Organizational Readiness for Implementing Change questionnaire. Differences in organizational readiness scores across clinician stakeholder groups were assessed using Kruskal-Wallice tests. Mann-Whitney tests (Bonferroni's corrections for multiple comparisons) were conducted to assess pair-wise relationships. RESULTS: The focus group data were conceptualized to represent facilitators and barriers to change at two levels of care delivery. Readiness to change at the organizational level was evident in five categories that reflected the barriers and facilitators to implementing an elder-friendly surgical unit. These included education, environment, staffing, policies and other research projects. At the individual level barriers and facilitators were apparent in staff members' acceptance of new roles and duties with other staff, family and patients. Examples of these included communication, teamwork and leadership. The mean change commitment and change efficacy scores on the Organizational Readiness for Implementing Change Questionnaire were 3.7 (0.8) and 3.5 (0.9) respectively. No statistically significant differences were detected between the stakeholder groups. CONCLUSIONS: Staff are interested in contributing to improved care for elderly surgical patients; however, opportunities were identified to enhance facilitators and reduce barriers in advance of implementing the elder-friendly surgical unit intervention.

Identification of potential barriers to nurse-sensitive outcome demonstration.

OBJECTIVE: The objective of this study was to determine differences in chief nursing officer, Magnet(®) program director, nurse leader, and direct care RN perspectives of potential barriers to demonstration of nurse-sensitive outcomes. BACKGROUND: The Magnet Recognition Program(®) and other designations are focusing on patient outcomes. No evidence is available addressing barriers to demonstration of nursing outcomes at multiple levels of practice. METHODS: A Likert scale tool was developed and administered to 526 attendees at the 2012 national Magnet conference. Questions related to available resources, benchmarks, outcome demonstration process understanding, perception of value, and competing priorities. RESULTS: Significant perception differences by role were demonstrated related to available resources, competing priorities, and process understanding supporting demonstration of nurse-sensitive outcomes. No significant differences were identified related to benchmarks or perception of process value to the organization. CONCLUSION: This study provides new information demonstrating potential barriers to demonstration of nurse-sensitive outcomes differing by role. Opportunity exists to develop systems and processes to reduce perceived barriers among the nursing workforce.