Exercise as medicine: Providing practitioner guidance on exercise prescription.

The purpose of this study was to examine the effect of a practitioner education program (consisting of education on exercise guidelines and exercise prescription) on practitioner (i) confidence in prescribing exercise and (ii) rate of prescribing exercise. A pre-post study design was utilized. A two-session practitioner education and a toolbox of resources was developed and implemented in January 2020, targeting 12 eligible practitioners at a large primary care and functional medicine office in New York City. A three-question confidence survey was given pre and post. Fifty randomly selected charts were reviewed at baseline (pre), and 25 charts were reviewed monthly for 3 months (February - April 2020) post. There were significant increases and a large effect size in both confidence in prescribing exercise (30% to 89% [p = .020, Phi = 0.596]) and individualizing an exercise prescription between pre- and post-education sessions (20% to 78% [p = .023, Phi = 0.578]). There was also a sustained and significant increase (24% to 63% [p < .001, Phi = 0.379]) in exercise prescription over the three-month period following the education sessions. No statistically significant data was obtained regarding increasing the rate of physical activity among patients. The evidence from this study demonstrates the effectiveness of increasing practitioner confidence and uptake of exercise prescription through education sessions that provide them with the knowledge and tools to properly assess patients' activity level and offer individualized exercise recommendations.

A Continued Professional Development Nursing Partnership in a Remote Bolivian Hospital.

Bolivia's recent enactment of universal health care to increase access and delivery of health services can increase health care demands in underresourced, rural communities. We describe how a global intradisciplinary partnership assessed changing health care needs in a recently expanded hospital in the Bolivian Amazon Basin. The collaboration resulted in designing and implementing an evidence-based triage training program to improve rapid assessment and health outcomes. The interdisciplinary triage training of 19 nurses and physicians showed a significant improvement in their knowledge and implementation capacity, as demonstrated by pre- and posttest scores. As an intradisciplinary team, trainees significantly increased consistency in triage assignments in nine of 10 clinical triage posttraining vignettes. We share insights to overcome unseen challenges and improve future data-driven, evidence-based global implementation projects. [J Contin Educ Nurs. 2021;52(3):142-149.].

Early Peanut Protein Introduction in Clinical Practice.

PURPOSE: New multiple agency recommendations have encouraged the early introduction of peanut protein (PP) in high-risk children to decrease peanut allergies. However, many providers are hesitant to use these recommendations. Our objective was to increase the recommendation of new guidelines by providers during routine infant care and evaluate caregiver acceptance of early PP introduction. DESIGN AND METHODS: This QI project focused on changing providers' knowledge and attitudes as a means to change practice using the "Plan-Do-Study-Act" model. Following provider educational sessions in 4 clinical sites providers and caregivers were questioned about instruction on the introduction of PP. Pre and post educational intervention data were collected from providers using chart audit and caregivers' report through the modified Promoting Healthy Development Survey (PHDS). RESULTS: The educational intervention was effective in increasing provider knowledge (p < .05), providers' dissemination of knowledge to caregivers through provider report (p < .001) and caregiver report (p < .05). CONCLUSIONS: Education increased providers' knowledge about the safety and importance of early introductions of PP, and allayed fears about initiating an allergic reaction. The increased provider recommendation to caregivers was validated by both provider and caregiver report. Caregivers felt comfortable initiating peanut protein. PRACTICE IMPLICATIONS: Provider education led to increased recommendation to caregivers on early introduction of PP and increased caregiver comfort introducing PP.

Helping Babies Breathe (2nd edition) implementation on a shoestring budget in Zanzibar, Tanzania.

BACKGROUND: To assess the efficacy and viability of implementing Helping Babies Breathe, a neonatal resuscitation program for resource-limited environments on a small budget in two of the largest delivery centers in Zanzibar, Tanzania. The quality improvement initiative concentrated on training midwives, who directly care for neonates at birth on Helping Babies Breathe to address high rates of neonatal mortality secondary to birth asphyxia. METHODS: The convenience sample was 59 midwives working in the two delivery centers of interest in Zanzibar, Tanzania. The train-the-trainer implementation strategy with repeated measures design was used to assess knowledge and skills at three time points. Observations were completed through supportive supervision of deliveries in both facilities. A budget was kept throughout the implementation. RESULTS: Knowledge scores and resuscitation skills significantly improved and were sustained over a 6-month period of time, Ps < .001. 130 supportive supervision observations were completed. Eighteen times (14%) a baby did not cry at birth and needed intervention. All were appropriately intervened for and survived the Golden Minute. The budget for this implementation was 9015.50 USD. Considering in-kind donations and financial support by the Zanzibar Ministry of Health the bottom line cost was much lower. CONCLUSION: Results indicate that participants retained knowledge and skills over time and were able to translate these skills into clinical practice. This initiative provides an alternative approach to implementing Helping Babies Breathe, relying on a small budget, local leadership and government support. TRIAL REGISTRATION: Not applicable.

Virtual Orientation of Volunteer Short-Term International Health Teams to Increase Self-Confidence and Cultural and Global Health Competence.

International health team volunteers frequently arrive at service sites with considerable lack of confidence and knowledge gaps because of poor preparation. Preservice orientation has been shown to improve knowledge, confidence, and competence, but current practices fall short of meeting most needs. This health care improvement project was aimed to improve self-confidence and cultural and global health competence using a virtual preservice orientation format. The virtual innovation significantly narrowed the difference in confidence between new and experienced team members. Significant increases were observed in knowledge of global health and health equities for new and experienced team members. Following the orientation, a significant difference in global health skills for the entire team also was observed. Many Americans leave the United States annually attempting to help those in need. This effort is hindered by poor preparation and unreal expectations. Improving health team member confidence and competence is one way to address this concern. [J Contin Educ Nurs. 2019;50(1):35-40.].

Using Motivational Interviewing to Impact Readiness of RNs to Return to the Classroom.

Supporting nurses with associate degrees in nursing (ADNs) to return to school is challenging for nurse executives. Strategies include tuition reimbursement, scholarships, and flexible scheduling. Despite these measures, it is anticipated that we will fall short of a goal of 80% bachelor's degree-prepared nurses by 2020. The aim of this project was to increase ADN-prepared RN readiness to return to school through motivational interviewing.

Helping Babies Breathe implementation in Zanzibar, Tanzania.

AIM: To assess the efficacy and feasibility of implementing Helping Babies Breathe, a neonatal resuscitation programme for resource-limited environments. BACKGROUND: This quality improvement project focused on training midwives on Helping Babies Breathe to address high rates of neonatal mortality secondary to birth asphyxia. METHODS: The convenience sample was 33 midwives in Zanzibar, Tanzania. The train-the-trainer strategy with repeated measures design was used to assess knowledge and skills at 3 time points. Observations were completed during "real-time" deliveries, and a focused interview generated feedback regarding satisfaction and sustainability. RESULTS: Knowledge scores and resuscitation skills significantly improved and were sustained, P < .05. Of the 62 birth observations, 19% needed intervention. All were appropriately resuscitated and survived. CONCLUSION: Results indicate that participants retained knowledge and skills and used them in clinical practice. Observations demonstrated that participants took appropriate actions when presented with a baby who was not breathing.

Implementation of a Sustainable Ventilator-Associated Pneumonia Prevention Protocol in a Pediatric Intensive Care Unit in Managua, Nicaragua.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common nosocomial infection in pediatric intensive care units (ICUs). Ventilator-associated pneumonia protocols decrease the incidence of VAP; however, many components of these protocols are not feasible in all settings. This study was done in a large pediatric hospital in Nicaragua. OBJECTIVE: The aim of this study is to implement a sustainable evidence-based VAP protocol, in a different culture, for the purpose of decreasing VAP rates. METHODS: This quality improvement study used a bidirectional cohort design with the retrospective group as the control and the prospective group as the experimental population. A daily checklist monitored compliance to the implemented protocol in the prospective group. A 2-sided Fisher exact test compared the differences in VAP rates between the 2 populations. RESULTS: During the 90-day implementation period, 123 ventilated patients in 3 separate ICU wings were evaluated, with 99 included in the final analysis. These data for 2014 were compared with the VAP rates recorded for the same time period in 2013. The highest adherence to the protocol was demonstrated by ICU wing 1, with a 90% decrease in VAP rates. No statistical difference in VAP rates was demonstrated by ICU 2, and ICU 3 demonstrated an increase in both patient acuity and VAP rates. DISCUSSION: Implementation of a sustainable VAP protocol in a pediatric ICU in Nicaragua can reduce the incidence of VAP. Multiple barriers and challenges associated with implementation in a resource-constrained environment are discussed.

Coalition Building for Health: A Community Garden Pilot Project with Apartment Dwelling Refugees.

Refugees often experience compromised health from both pre- and post-migration stressors. Coalition theory has helped guide the development of targeted programs to address the health care needs of vulnerable populations. Using the Community Coalition Action Theory as a framework, a coalition was formed to implement a community garden with apartment-dwelling refugees. Outcomes included successful coalition formation, a community garden, reported satisfaction from all gardeners with increased vegetable intake, access to culturally meaningful foods, and evidence of increased community engagement. The opportunity for community health nurses to convene a coalition to affect positive health for refugees is demonstrated.

Animal models for assessment of infection and inflammation: contributions to elucidating the pathophysiology of sudden infant death syndrome.

Sudden infant death syndrome (SIDS) is still not well understood. It is defined as the sudden and unexpected death of an infant without a definitive cause. There are numerous hypotheses about the etiology of SIDS but the exact cause or causes have never been pinpointed. Examination of theoretical pathologies might only be possible in animal models. Development of these models requires consideration of the environmental and/or developmental risk factors often associated with SIDS, as they need to explain how the risk factors could contribute to the cause of death. These models were initially developed in common laboratory animals to test various hypotheses to explain these infant deaths - guinea pig, piglet, mouse, neonatal rabbit, and neonatal rat. Currently, there are growing numbers of researchers using genetically altered animals to examine specific areas of interest. This review describes the different systems and models developed to examine the diverse hypotheses for the cause of SIDS and their potential for defining a causal mechanism or mechanisms.

The Impact of Nurses on Neglected Tropical Disease Management.

Although Neglected Tropical Diseases (NTDs) are largely endemic in the developing nations of Africa, Asia, and South and Central America, they are reemerging with increasing frequency in developed countries. Their diagnosis, treatment, and control are an increasing public health concern that requires a different awareness by health care providers. Neglected tropical diseases (NTDs) are chronic infectious diseases which disproportionately burden poor, rural, and marginalized populations with significant mortality and high morbidity (disability, disfigurement, impaired childhood growth and cognitive development, increased vulnerability to coinfection) that reinforces their poverty. What can we learn from the nurses in developing countries already battling NTD's that could be useful in the developed world? This article provides an overview of distribution, pathophysiology, symptoms, and management of 13 NTDs, with particular attention to the role of nurses in delivering cost-effective integrated interventions. Case studies of schistosomiasis, Chagas disease, and leishmaniasis address recognition and treatment of infected individuals in developed nations where NTD infection is limited primarily to immigrants and travelers.

Implementation of childhood obesity identification and prevention strategies in primary care: A quality improvement project.

The high incidence and prevalence of childhood obesity, coupled with significant morbidity and financial burden, clearly suggest the need for identification and implementation of effective pediatric obesity prevention strategies in primary care. A solution to this problem includes evidence based clinical guidelines that provide concise, culturally appropriate information on the identification and prevention of childhood obesity in primary care settings. The objective of this quality improvement project was to implement childhood obesity identification and prevention guidelines from evidence-based recommendations into practice. Guidelines were implemented during preventative care visits through the use of a tracking form. The development of the tracking form included input from practice staff resulting in increased fidelity. The tracking form included directions for clear and concise guideline implementation and provided opportunities to record patient BMI, nutritional intake, physical activity, familial obesity prevention education and motivational interviewing and facilitated a practice increase in childhood obesity identification and education. Presence of chart indicators, including nutrition and exercise history, were analyzed to determine the fidelity of the practice change in obesity identification and prevention education. Key outcomes included a significant (p < .0001) practice increase in childhood obesity identification as well as a significant increase (p < .05) in documentation of obesity prevention education through motivational interviewing. Practice change incorporating childhood obesity identification and familial prevention guidelines had positive effects in a pediatric population. Implementation of evidence-based guidelines can result in increased identification of children at risk for childhood obesity and enhanced familial obesity prevention education; leading to the long-term goal of creating healthier lifestyles and decreasing risk factors in a vulnerable population.

Increasing HPV vaccination series completion rates via text message reminders.

Human papillomavirus (HPV) is the most frequently diagnosed sexually transmitted infection in the United States. It is associated with the development of cervical, anal-genital, and oral-pharyngeal cancers. The rate of HPV infection among adolescents and young adults in the United States remains high, and completion rates of an HPV vaccine series remain low. At an urban pediatric clinic, adolescent and young adult participants aged 11 to 22 years (n = 37) received text message reminders for their second and third dose of HPV vaccine over an 8-month study period. Of the participants receiving text message reminders, 14% completed the vaccine series at the optimal time, whereas 0% of an interested group (n = 43) and only 3% of a standard care group (n = 232) completed the vaccine series at the optimal time. Findings support the use of text message reminders to improve HPV vaccine series completion rates in a pediatric practice.

Childhood obesity: Can electronic medical records customized with clinical practice guidelines improve screening and diagnosis?

PURPOSE: The purpose of this project was to determine if customization of the electronic medical record (EMR) using evidence-based practice guidelines developed by the National Association of Pediatric Nurse Practitioners and the Expert Panel recommendations for the prevention, screening, and treatment of childhood and adolescent overweight and obesity would improve the rate of screening and diagnosis of obesity in children, 7 to 18 years of age. DATA RESOURCES: A retrospective review of encounters before and after implementation of customized EMR was conducted in a community health center. Data collected were compared for documentation of body mass index (BMI), completion of growth charts, scoring of risk questionnaire, and diagnosis of overweight or obesity. CONCLUSIONS: There was a clear increase in the frequency of recording BMI, completing BMI growth charts, and scoring questionnaires between written and electronic medical records. The number of children diagnosed with overweight or obesity increased with customized EMR but still remains well below the rates of obesity for this community. IMPLICATIONS FOR PRACTICE: Customizing EMR with clinical practice guidelines improved adherence to recommendations for screening and identification of childhood overweight and obesity. Increased recognition and diagnosis will lead to improved interventions and improve outcomes for childhood obesity.

Providers as weight coaches: using practice guides and motivational interview to treat obesity in the pediatric office.

Motivational interview techniques combined with an evidence-based guideline provide valuable tools for the treatment of childhood obesity. The National Association of Pediatric Nurse Practitioners' Healthy Eating and Activity Together guidelines were adopted in a rural pediatric office. After a 6-month pilot, effectiveness of treatment was evaluated with a retrospective chart review. The results suggest that children were motivated for healthy lifestyle changes but had difficulty maintaining motivation and compliance with healthy change choices after 1-2 months; however, with consistent use of motivational interviewing techniques combined with diet and exercise counseling, there was a trend toward lowered body mass index and waist measurements.

Autism spectrum disorder screening in primary care.

OBJECTIVES: One in 110 children in the United States has autism spectrum disorder (ASD). Early identification and early intervention have been shown to improve outcomes for children with ASD. Although recommended, routine ASD screening at 18 and 24 months of age has not been widely adopted in practice. This quality improvement study examined whether a private primary care practice could overcome screening barriers and implement the recommended universal ASD screening practice using the Modified Checklist for Autism in Toddlers™. METHOD: Guided by the Diffusion of Innovations evidence-based conceptual model, a practice change using the Modified Checklist for Autism in Toddlers™ was developed. A retrospective chart review of 99 subjects was done to evaluate screening fidelity and cost. RESULTS: An overall screening fidelity of 91% was achieved over a 7-month period. The cost of screening to the practice averaged $22.78 per month. This was offset by an average of $38.76 of revenue per month. CONCLUSION: These findings suggest that low-cost universal screening can be implemented in primary care when addressed from an organizational perspective.

The long-term effects of prenatal nicotine exposure on neurologic development.

A large body of documented evidence has found that smoking during pregnancy is harmful to both the mother and the fetus. Prenatal exposure to nicotine in various forms alters neurologic development in experimental animals and may increase the risk for neurologic conditions in humans. There is a positive association between maternal smoking and sudden infant death syndrome (SIDS); however, the connection between nicotine addiction, depression, attention disorders, and learning and behavior problems in humans is not straightforward. Nicotine's action on the production and function of neurotransmitters makes it a prime suspect in the pathology of these diseases. Nicotine accentuates neurotransmitter function in adults but desensitizes these functions in prenatally exposed infants and children. This desensitization causes an abnormal response throughout the lifespan. Furthermore, nicotine use by adolescents and adults can alleviate some of the symptoms caused by these neurotransmitter problems while they increase the risk for nicotine addiction. Although nicotine replacement drugs are used by pregnant women, there is no clear indication that they improve outcomes during pregnancy, and they may add to the damage that occurs to the developing neurologic system in the fetus. Understanding the effects of nicotine exposure is important in providing safe care for pregnant women, children, and families and for developing appropriate smoking cessation programs during pregnancy.

The role of infection and inflammation in sudden infant death syndrome.

Sudden Infant Death Syndrome (SIDS) is the most common cause of post-neonatal mortality in the developed world. The exact cause of SIDS is likely to be multifactorial involving a critical developmental period, a vulnerable infant, and one or more triggers. Many SIDS infants have a history of viral illness preceding death. Prone sleep position, one of the leading risk factors, can increase airway temperature, as well as stimulate bacterial colonization and bacterial toxin production. Markers of infection and inflammation are often found on autopsy along with microbial isolates. Although the causal link between infection and SIDS is not conclusive, there is evidence that an infectious insult could be a likely trigger of SIDS in some infants.

Is shock a key element in the pathology of sudden infant death syndrome (SIDS)?

In developed countries, sudden infant death syndrome (SIDS) is the most common cause of death for infants between 1 month and 1 year of age. The etiology of SIDS is likely to be multifactorial, and current paradigms often describe three overlapping elements of risk. Those elements are a critical developmental period, a vulnerable infant, and one or more exogenous stressors. In the triple-risk model, SIDS infants are described as having an underlying vulnerability in cardiorespiratory control in the central nervous system during a critical period when autonomic control is developing. This vulnerability might affect the response to exogenous stressors, including prone sleeping position, hypoxia, and increased carbon dioxide. In the common bacterial hypothesis and fatal triangle, the focus is on the stressors. In the first, a combination of common respiratory infections can cause SIDS in an infant during a developmentally vulnerable period. This theory also includes 3 factors of vulnerability: a genetic predisposition, a vulnerable developmental age, and infectious stressors. In the fatal triangle theory, infection, inflammation, and genetics each play a role in triggering a SIDS fatality. From our work in an animal model, we have found that rat pups die from a combination of infectious insults during a critical time of development. This is exacerbated by perinatal nicotine exposure, a condition shown to alter the autonomic response in exposed offspring. We are proposing that shock and cardiovascular collapse is a key element that links these theories.

A rubric for improving the quality of online courses.

All of the graduate students in the School of Nursing take some of their Master of Science courses online. A group of six School of Nursing faculty members and a graduate student received funding to determine best practices in online courses. The group developed an evaluation rubric to measure quality in the graduate online curriculum. They then applied the rubric to the core courses which are primarily offered online and are required for all graduate nursing students. The project had a positive impact on faculty by offering a tool useful for online course evaluation and development. Additionally it brought to attention the needs of faculty member development in online education.