Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents.

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.

Analysis of the reaction and behavior of nurses after training on young child feeding.

OBJECTIVE: to assess the reaction and behavior of nurses after training on the use of educational tool to promote heathy nutrition to children. METHOD: pilot assessment study, of descriptive and quantitative approach, carried out in 2014 with eight nurses from the rural area of Ceará, Brazil, by observing a training workshop on the use of the serial album "Alimentos regionais: promovendo a segurança alimentar na promoção da alimentação infantil saudável" [Regional food: promoting food safety through child healthy feeding]. RESULTS: the analysis of the reaction of nurses to the workshop showed that all of them (100%) were satisfied with the training. In behavior analysis, more than a half of the nurses have achieved the expected performance when implementing the illustrations of the serial album, seven of them (87.5%) being considered able to use the serial album. CONCLUSION: the training was considered effective, as all the participant nurses were satisfied and most of them considered capable of using the educational tool in promoting child healthy feeding.

Analysis of the reaction and behavior of nurses after training on young child feeding / Evaluación de la reacción y comportamiento de las enfermeras después de la formación sobre alimentación infantil / Avaliação de reação e comportamento de enfermeiras após treinamento sobre alimentação infantil

ABSTRACT Objective: to assess the reaction and behavior of nurses after training on the use of educational tool to promote heathy nutrition to children. Method: pilot assessment study, of descriptive and quantitative approach, carried out in 2014 with eight nurses from the rural area of Ceará, Brazil, by observing a training workshop on the use of the serial album "Alimentos regionais: promovendo a segurança alimentar na promoção da alimentação infantil saudável" [Regional food: promoting food safety through child healthy feeding]. Results: the analysis of the reaction of nurses to the workshop showed that all of them (100%) were satisfied with the training. In behavior analysis, more than a half of the nurses have achieved the expected performance when implementing the illustrations of the serial album, seven of them (87.5%) being considered able to use the serial album. Conclusion: the training was considered effective, as all the participant nurses were satisfied and most of them considered capable of using the educational tool in promoting child healthy feeding.

RESUMEN Objetivo: evaluar la reacción y el comportamiento de las enfermeras tras entrenamiento para la utilización de tecnología educativa en la promoción de la alimentación infantil sana. Método: estudio piloto evaluativo, descriptivo y de abordaje cuantitativo, realizado en 2014 con ocho enfermeras en la zona rural de Ceará, Brasil, por medio de taller de entrenamiento y capacitación para utilización del rotafolio «Alimentos regionais promovendo a segurança alimentar¼ en la promoción de la alimentación infantil saludable. Resultados: la evaluación de reacción de las enfermeras al taller señala que todas (100%) quedaron satisfechas con el entrenamiento. En la evaluación de comportamiento, más de la mitad de las enfermeras obtuvieron desempeño dentro de lo esperado en la aplicación de las ilustraciones del rotafolio, siendo siete de ellas (87,5%) consideradas aptas para utilizarlo. Conclusión: el entrenamiento fue considerado eficaz, evidenciado por reacción satisfactoria de las enfermeras y de la capacitación de la mayoría de ellas para usar la tecnología educativa en la promoción de la alimentación infantil sana.

RESUMO Objetivo: avaliar a reação e o comportamento das enfermeiras após treinamento para utilização de tecnologia educativa na promoção da alimentação infantil saudável. Método: estudo piloto avaliativo, descritivo e de abordagem quantitativa, realizado em 2014 com oito enfermeiras na zona rural do Ceará, Brasil, por meio de oficina de treinamento e capacitação para utilização do álbum seriado Alimentos regionais promovendo a segurança alimentar na promoção da alimentação infantil saudável. Resultados: a avaliação de reação das enfermeiras à oficina sinaliza que todas (100%) ficaram satisfeitas com o treinamento. Na avaliação de comportamento, mais da metade das enfermeiras obtiveram desempenho dentro do esperado na aplicação das ilustrações do álbum seriado, sendo sete delas (87,5%) consideradas aptas para utilizar o álbum seriado. Conclusão: o treinamento foi considerado eficaz, evidenciado por reação satisfatória das enfermeiras e capacitação da maioria delas para usar a tecnologia educativa na promoção da alimentação infantil saudável.

Applicability of Orem: training of caregiver of infant with Robin Sequence.

OBJECTIVE: to report the nurses' experience in relation to the training of caregivers of infants with Isolated Robin Sequence (IRS) for maintaining care after hospital discharge from the perspective of Self-Care Theoretical Framework. METHOD: the following categories were considered in this experience report: self-care action, self-care capacity, therapeutic self-care demand, self-care deficit, and nursing system. The nursing system was wholly compensatory and supportive-educative. RESULTS: caregivers' training by nurses results in the acquisition of technical skills and specific knowledge related to the infant's positioning in elevated ventral decubitus, nasopharyngeal intubation, feeding-facilitating techniques and care with the feeding tube. FINAL CONSIDERATIONS: the continuity of home care is guaranteed from caregivers' training for the therapeutic demand.

Effective Communication Strategies for Nurses to Discuss Infant Feeding with New Mothers During Postpartum Hospitalization.

During prenatal care and postpartum hospitalization, nurses have an important role in assisting new mothers to make informed decisions about feeding their newborn infants. There is overwhelming evidence that breastfeeding is beneficial for most new mothers and babies; therefore, perinatal nurses encourage breastfeeding. Newborn infant feeding conversations with women who have chosen to formula feed may be complicated and may cause tension in the nurse-patient relationship. Despite this potential difficulty, these conversations are essential to establish a feeding plan for the newborn infant and to promote healthy outcomes for mothers and babies. Tools are offered for nurses to guide conversations about infant feeding choices and to help to ensure that all mothers receive support and encouragement on their feeding choice.

Applicability of Orem: training of caregiver of infant with Robin Sequence / Aplicabilidad de Orem: capacitación del cuidador del lactante con Secuencia de Robin / Aplicabilidade de Orem: capacitação do cuidador do lactente com Sequência de Robin

ABSTRACT Objective: to report the nurses' experience in relation to the training of caregivers of infants with Isolated Robin Sequence (IRS) for maintaining care after hospital discharge from the perspective of Self-Care Theoretical Framework. Method: the following categories were considered in this experience report: self-care action, self-care capacity, therapeutic self-care demand, self-care deficit, and nursing system. The nursing system was wholly compensatory and supportive-educative. Results: caregivers' training by nurses results in the acquisition of technical skills and specific knowledge related to the infant's positioning in elevated ventral decubitus, nasopharyngeal intubation, feeding-facilitating techniques and care with the feeding tube. Final considerations: the continuity of home care is guaranteed from caregivers' training for the therapeutic demand.

RESUMEN Objetivo: relatar la experiencia de los enfermeros en relación a la capacitación de los cuidadores de lactantes con Secuencia de Robin Aislada (SRA) para mantener los cuidados después del alta hospitalaria en la perspectiva del Referencial Teórico del Autocuidado. Método: las siguientes categorías se consideraron en este relato de experiencia: acción de autocuidado, capacidad de autocuidado, demanda terapéutica de autocuidado, déficit de autocuidado y sistema de enfermería. El sistema de enfermería fue del tipo totalmente compensador y por medio de apoyo-educación. Resultados: la capacitación de los cuidadores por el enfermero resulta en la adquisición de habilidades técnicas y conocimientos específicos relacionados al posicionamiento del lactante en decúbito ventral y elevado, intubación nasofaríngea, técnicas facilitadoras de la alimentación y cuidados con la sonda para alimentación. Consideraciones finales: la continuidad de los cuidados domiciliarios está garantizada a partir de la capacitación del cuidador para la demanda terapéutica.

RESUMO Objetivo: relatar a experiência dos enfermeiros em relação à capacitação dos cuidadores de lactentes com Sequência de Robin isolada (SRI) para manutenção dos cuidados após alta hospitalar na perspectiva do Referencial Teórico do Autocuidado. Método: as seguintes categorias foram consideradas neste relato de experiência: ação de autocuidado, capacidade de autocuidado, demanda terapêutica de autocuidado, déficit de autocuidado e sistema de enfermagem. O sistema de enfermagem foi do tipo totalmente compensatório e por meio de apoio educativo. Resultados: a capacitação do cuidador pelo enfermeiro resulta na aquisição de habilidades técnicas e conhecimentos específicos referentes ao posicionamento do lactente em decúbito ventral e elevado, intubação nasofaríngea, técnicas facilitadoras da alimentação e cuidados com a sonda alimentadora. Considerações finais: a continuidade dos cuidados domiciliares é garantida a partir da capacitação do cuidador para a demanda terapêutica.

Promoting Breast Milk Nutrition in Infants With Cleft Lip and/or Palate.

BACKGROUND: The orofacial defect of cleft lip/palate (CL/P) involves an altered physiological anatomy that affects the infant's feeding ability. Infants have cleft lip (CL), cleft palate (CP), or both (CL/P). Dysfunction in the seal, as with cleft lip, or in the ability to coordinate muscle movement to generate negative pressure, as with cleft palate, leads to feeding issues that may compromise growth and affect bonding. PURPOSE: The purpose of this article is to present (1) scientific evidence that supports clinical feeding practices for the infant with CL/P and (2) teaching strategies for staff and parents. METHODS: Evidence was synthesized using a narrative review of randomized controlled trials, qualitative studies, systematic reviews, professional guidelines, and position statements. Findings were used to present specialized equipment and feeding techniques to support human milk feeding. FINDINGS: Special considerations for feeding infants with CL/P include assessing the infant's sucking ability, demonstrating proper breastfeeding positioning, supporting mothers to establish and maintain their milk supply, considering adaptive feeding equipment (ie, specialized bottles and nipples), and education about the benefits of human milk. IMPLICATIONS FOR PRACTICE AND RESEARCH: Support from healthcare professionals, particularly lactation specialists and nursing staff, is critical. Breastfeeding and the use of human milk should be prioritized and supported. Research is needed to explore environmental, genetic, and nutritional causes (eg, folic acid deficiency) of orofacial defects.

[Not Available]. / Songenent-wohnung 2.0: Was Sonden-dependente Kinder brauchen.

A dramatic increase of home enteral nutrition in pediatric population has been reported over the last decade. Inpatient units discharge more and more children with nasogastric and G- tubes. And for certain percentage the feeding and eating behavior does not improve with time. But longer tube dependency frequently results in general food aversion and refusal. The assessment and treatment, we will line out in this paper, have shown high efficiency for children with feeding tube dependency. To improve the situation of children with feeding tube dependency more treatment facilities are needed. Furthermore early prevention program and feeding tube management should be established to prevent feeding tube dependency.

Perceptions of Pediatric Critical Care Nurses on the Initiation of a Nursing-Led Feeding Protocol.

BACKGROUND: Critically ill children frequently receive inadequate nutritional support. Feeding protocols have been shown to facilitate optimal nutritional care. PURPOSE: We aim to determine the perceptions of critical care nurses with regard to the implementation of a feeding protocol as well as to their preferred teaching methods before introducing this protocol in our pediatric intensive care unit (PICU). We hypothesize that nursing experience and educational level are factors that predict readiness to adopt this protocol. METHODS: All PICU nurses were invited to participate in an online survey to investigate their perceptions on protocol implementation and on preferred teaching methods. Statistical analysis was performed using simple logistic regression and the Fisher exact test. Statistical significance was taken as p < .05. RESULTS: Seventy-four nurses completed the survey. Fifty-four (73%) had nursing degrees. Mean duration of PICU experience was 6.2 years (5th, 95th percentile: 1, 15). Three quarters of participants (74%, n = 55) felt that they did not have sufficient knowledge regarding feeding protocols, and 86% (n = 64) expressed that they were keen to implement a feeding protocol. There was no association between readiness to adopt the feeding protocol with years of ICU experience (OR = 0.99, 95% CI [0.84, 1.18]) and educational level (OR = 1.43, 95% CI [0.31, 6.68]). The preferred teaching methods were bedside teaching (61%), didactic lectures (51%), and the distribution of protocol manuals (50%). PICU nurses felt that the advantages of a feeding protocol included standardization of practice, optimization of patient's nutritional intake, earlier initiation of feeding, increased patient safety, and the extension of nursing roles. Perceived disadvantages included inapplicability of the feeding protocol to all patients, lack of flexibility in feeding management, increased confusion, and doctors placing little value on the feeding protocol. CONCLUSIONS: This study found that nursing experience and level of education do not significantly affect the readiness of nurses to adopt a feeding protocol. Medical and nursing teams should not shy away from introducing a new protocol although their nurses have little experience or prior knowledge of that protocol. Future studies to investigate the impact of tailoring of educational needs before introduction of a new protocol are necessary to study the overall effectiveness of this teaching before introducing a new protocol in the ICU.

Doubts of caregivers of children with cleft lip and palate on postoperative care after cheiloplasty and palatoplasty / Dúvidas de cuidadores de crianças com fissura labiopalatina sobre os cuidados pós-operatórios de queiloplastia e palatoplastia dudas de cuidadores de niños con fisura labiopalatina acerca de los cuidados posoperatorios de queiloplastia y palatoplastia / Dúvidas de cuidadores de crianças com fissura labiopalatina sobre os cuidados pós-operatórios de queiloplastia e palatoplastia

Objective To identify the main doubts of caregivers of children with cleft lip and palate on postoperative care after cheiloplasty and palatoplasty. Method Cross-sectional study carried out in a reference hospital, between September and November 2012. The sample was composed of 50 individuals divided in two groups, of which 25 caregivers of children submitted to cheiloplasty, and 25 of children submitted to palatoplasty. The doubts were identified by an interview applied during the preoperative nursing consultation and were then categorized by similarity. Descriptive statistics was used for analysis of the outcomes. Results Concerning cheiloplasty, the doubts were related to feeding (36%), hygiene and healing (24% each), pain and infection (8% each). With regard to palatoplasty, the doubts were related to feeding (48%), hygiene (24%), pain (16%), bleeding (8%) and infection (4%). Conclusion The study evidenced the concern of caregivers in relation to feeding and care of the postoperative wound. .

Objetivo Identificar as principais dúvidas dos cuidadores de crianças com fissura labiopalatina sobre os cuidados pós-operatórios das cirurgias de queiloplastia e palatoplastia. Método Estudo transversal realizado em um hospital de referência, entre os meses de setembro a novembro de 2012. A amostra constou de 50 indivíduos divididos em dois grupos, sendo 25 cuidadores de crianças submetidas à queiloplastia e 25 crianças submetidas à palatoplastia. As dúvidas foram identificadas por meio de entrevista, realizada durante a consulta de Enfermagem pré-operatória, e, posteriormente, foram categorizadas por similaridade. Utilizou-se a análise estatística descritiva para construção dos resultados. Resultados Observou-se que, em relação à queiloplastia, as dúvidas foram sobre alimentação (36%), higienização e cicatrização (24% cada), e dor e infecção (8% cada). Quanto à palatoplastia, as dúvidas se relacionaram à: alimentação (48%), higienização (24%), dor (16%), sangramento (8%) e infecção (4%). Conclusão Evidenciou-se a preocupação dos cuidadores em relação à alimentação e aos cuidados com a ferida pós-operatória. .

Objetivo Identificar las principales dudas de los cuidadores de niños con fisura labiopalatina acerca de los cuidados posoperatorios de las cirugías de queiloplastia y palatoplastia. Método Estudio transversal llevado a cabo en un hospital de referencia, entre los meses de septiembre a noviembro de 2012. La muestra constó de 50 individuos divididos en dos grupos, siendo 25 cuidadores de niños sometidos a la queiloplastia y 25 niños sometidos a la palatoplastia. Las dudas fueron identificadas por medio de entrevista, realizada durante la consulta de Enfermería preoperatoria y, posteriormente, fueron categorizadas por similaridad. Se utilizó el análisis estadístico descriptivo para la construcción de los resultados. Resultados Se observó que, con respecto a la queiloplastia, las dudas fueron acerca de la alimentación (36%), higienización y cicatrización (24% cada), y dolor e infección (8% cada). En cuanto a la palatoplastia, las dudas estuvieron relacionadas con: la alimentación (48%), higienización (24%), dolor (16%), sangrado (8%) e infección (4%). Conclusión Se evidenció la preocupación de los cuidadores con respecto a la alimentación y los cuidados con la herida posoperatoria. .

[Doubts of caregivers of children with cleft lip and palate on postoperative care after cheiloplasty and palatoplasty]. / Dúvidas de cuidadores de crianças com fissure labiopalatina sobre os cuidados pósoperatórios de queiloplastia e palatoplastia.

OBJECTIVE: To identify the main doubts of caregivers of children with cleft lip and palate on postoperative care after cheiloplasty and palatoplasty. METHOD: Cross-sectional study carried out in a reference hospital, between September and November 2012. The sample was composed of 50 individuals divided in two groups, of which 25 caregivers of children submitted to cheiloplasty, and 25 of children submitted to palatoplasty. The doubts were identified by an interview applied during the preoperative nursing consultation and were then categorized by similarity. Descriptive statistics was used for analysis of the outcomes. RESULTS: Concerning cheiloplasty, the doubts were related to feeding (36%), hygiene and healing (24% each), pain and infection (8% each). With regard to palatoplasty, the doubts were related to feeding (48%), hygiene (24%), pain (16%), bleeding (8%) and infection (4%). CONCLUSION: The study evidenced the concern of caregivers in relation to feeding and care of the postoperative wound.

Alimentación y envejecimiento / Feeding and aging

El envejecimiento se caracteriza por un aumento relativo de la población de 65 años y mayores, pudiendo afirmar que, en nuestro país, constituye un fenómeno demográfico, político, social y sanitario.Diversos estudios han demostrado que el estado nutricional de la población general y de los ancianos, en particular, es un indicador válido para predecir la longevidad y la calidad de vida de este grupo de personas. La Organización Mundial de la Salud (OMS) señaló que la población anciana es un grupo nutricionalmente muy vulnerable como consecuencia de los cambios anatómicos y fisiológicos asociados al envejecimiento. Entre el 35-40% de los ancianos presenta algún tipo de alteración nutricional o malnutrición: desnutrición proteica o proteico-energética, déficit selectivo de vitaminas y minerales, inadecuado aporte hídrico, obesidad, etc.La mejor forma de favorecer la calidad de vida y de prevenir la enfermedad es una adecuada alimentación, denominada también alimentación saludable, adaptada a las circunstancias especiales que pueden presentar las personas mayores, sin olvidar que la gastronomía no está reñida con la salud. En el presente artículo, además, se ofrecen algunos consejos para preparar y cocer los alimentos, así como estrategias culinarias para introducirlos en el menú diario(AU)

Aging is characterized by an increase in relative population of 65 years and older, and can say that, in our country, it is a phenomenon demographic, political, social, and health. Several studies have shown that the nutritional status of the general population and the elderly, in particular, is a valid indicator to predict longevity and quality of life of this group of people. The World Health Organization (who) pointed out that the elderly population is a group nutritionally very vulnerable as a result of anatomical and physiological changes associated with aging. Between 35-40 of the elderly has some kind of altered nutrition or malnutrition: protein or protein-energy malnutrition, selective deficiency of vitamins and minerals, inadequate water intake, obesity, etc. The best way to promote the quality of life and prevent disease is a proper diet, also called healthy eating, adapted to the special circumstances which older persons may present without forgetting gastronomy is not incompatible with health. In this article, some tips are also available for preparing and cooking food, as well as culinary strategies to introduce them in the daily menu(AU)

Favoreciendo la alimentación independiente. Estudio de un caso / Favoring the independent feeding. A case study

Introducción: el desarrollo de las actividades de la vida diaria de la forma más autónoma e independiente posible debería ser prioritario en la valoración y cuidado de las personas dependientes. Objetivo: detección y corrección de los problemas que evitan la alimentación autónoma e independiente en una usuaria de centro residencial. Método: estudio de caso de base cualitativa mediante observación participante. Desarrollo: mayo-junio de 2010. Resultados: se observaron los siguientes problemas que dificultan la correcta alimentación: dificultad en la movilización de brazos y manos para llevar la comida a la boca, nerviosismo y ansiedad durante las comidas y sobreprotección de los cuidadores. Al final del periodo de estudio nuestra usuaria consigue realizar las comidas de forma autónoma e independiente. Discusión: una valoración individualizada puede poner de manifiesto capacidades desconocidas en una persona. Tras la evaluación inicial, se detectaron los problemas que impedían la alimentación de forma independiente de nuestra usuaria y se estableció un plan de acción consensuado con ella. Se apreció un cambio sustancial: no solo era capaz de realizar una comida por sí misma con la mínima ayuda indispensable, sino que aumentó su autoestima (AU)

Introduction: the development of the Daily Life Activities in the most autonomous and independent way ever possible should be a priority in the evaluation and care of the dependent people. Objective: detection and correction of the problems that avoid the autonomous and independent feeding in a user of our residential center. Method: Case Study with qualitative base by means of participant observation. Development: may-june 2010. Results: the problems observed that impede the correct feeding were:difficult movements of arms and hands to take the food to the mouth, nervousness and anxiety during the meals and overprotection of the carers. At the end of the period of study our user managed to fulfil the meals in an autonomous and independent way. Discussion: an individualized evaluation can reveal capacities unknown in a person. After the initial evaluation, there were detected the problems that avoided the feeding in an independent way of our user and it was established a plan agreed with her. It was appreciated a substantial change, not only she was capable of feeding herself with the minimal indispensable help, but it was increased her selfsteem (AU)

Positioning after feedings: what is the evidence to reduce feeding intolerances?

Nursing's goal is to be the least invasive as the patient's condition allows. As a NICU nurse, each feeding for our patients is a priority for them to grow and develop with the idea to speed discharge to home. When infants develop reflux or have increased gastric aspirates, we are concerned that their weight will taper and their length of stay will increase. Positioning provides nurses with a noninvasive option to care for these patients. The that the right-side position is best for infants to enhance digestion stems from theories of anatomy and physics. Research strengthens this supposition for those infants needing help with decreased gastric motility. Other research supports the left lateral and prone positions for those patients with GER. In practice, a patient does not necessarily have one or the other and in fact may have both GER and slowed gastric motility at any given time. The literature supports the right lateral position for enhancing gastric emptying or motility and left lateral position for GER in the uncomplicated patient with one gastrointestinal concern. The knowledge the research provides is encouraging to provide a solution, but it does not clarify the true issues of a complex patient who can have decreased gastric motility needing the right lateral position and also suffer from symptoms of GER requiring the left lateral position (see Table). For those more complicated infants, the solution might best be choosing the prone position. The prone position should not be forgotten as the findings of many studies, although not often the first choice (best results) showed it to be consistently the second best for digestive problems. In any case, the dominant positions appear to be the right or left lateral side with the prone position considered a reasonable compromise. Further research is needed to provide a clear choice for correct positioning in the NICU population. The reality for nurses is that neonatal patients are often fed every 3 hours and their lives depend on each feeding to provide nutrients for growth. It is ideal for these patients to receive every prescribed feeding and be comfortably placed in a variety of positions. Nurses' assumption that the right lateral position is best is considered, in most cases, to be a true statement for those infants with increased gastric aspirates. For those patients with GER, the left lateral position is more highly preferred. It is important for nurses to be aware of the literature but also guide their practice based on the patient assessment and presentation of symptoms. Future knowledge may provide nurses with the data needed to perfect positioning methods for infants with feeding intolerances.

An exemplar for evidence-based nursing practice using the Magnet(®) model as the framework for change: oral feeding practice in the neonatal intensive care unit.

Implementation of research evidence into practice can be challenging in areas such as the neonatal intensive care unit (NICU), where the environment is complex and rapidly changing and caregiving goals have shifted from simply infant survival to supporting positive long-term neurodevelopmental outcomes. Clinical nurse specialists (CNS) are ideally positioned to use research to obtain new knowledge, innovations, and improvements in care as part of an interdisciplinary team. The authors describe the role of the CNS in changing NICU culture around feeding infants, an important and frequent nursing activity, with the Magnet(®) model as the framework for change.