Development of a Self-Management Theory-Guided Discharge Intervention for Parents of Hospitalized Children.

BACKGROUND: Parents of hospitalized children, especially parents of children with complex and chronic health conditions, report not being adequately prepared for self-management of their child's care at home after discharge. PROBLEM: No theory-based discharge intervention exists to guide pediatric nurses' preparation of parents for discharge. PURPOSE: To develop a theory-based conversation guide to optimize nurses' preparation of parents for discharge and self-management of their child at home following hospitalization. METHODS: Two frameworks and one method influenced the development of the intervention: the Individual and Family Self-Management Theory, Tanner's Model of Clinical Judgment, and the Teach-Back method. A team of nurse scientists, nursing leaders, nurse administrators, and clinical nurses developed and field tested the electronic version of a nine-domain conversation guide for use in acute care pediatric hospitals. CONCLUSIONS: The theory-based intervention operationalized self-management concepts, added components of nursing clinical judgment, and integrated the Teach-Back method. CLINICAL RELEVANCE: Development of a theory-based intervention, the translation of theoretical knowledge to clinical innovation, is an important step toward testing the effectiveness of the theory in guiding clinical practice. Clinical nurses will establish the practice relevance through future use and refinement of the intervention.

Are Nurse Leaders Prepared to Lead Across the Continuum of Care in the New Paradigm?

The movement toward linking reimbursement with outcomes necessitates providing care across a continuum of settings, leading to the need for a new healthcare paradigm. Issues related to shifting to this new paradigm include disagreement about what this paradigm encompasses, the fragmentation of the healthcare system, and overreliance on the medical model as a framework for driving health policy decisions. We advocate for nurse leaders to guide the development of this new paradigm.

Discharge Teaching, Readiness for Discharge, and Post-discharge Outcomes in Parents of Hospitalized Children.

PURPOSE: This study explored the sequential relationships of parent perceptions of the quality of their discharge teaching and nurse and parent perceptions of discharge readiness to post-discharge outcomes (parental post-discharge coping difficulty, readmission and emergency department visits). DESIGN/METHODS: In this secondary analysis of data from a longitudinal pilot study of family self-management discharge preparation, the correlational design used regression modeling with data from a convenience sample of 194 parents from two clinical units at a Midwest pediatric hospital. Data were collected on the day of discharge (Quality of Discharge Teaching Scale; Readiness for Hospital Discharge Scale), at 3weeks post-discharge (Post-Discharge Coping Difficulty Scale), and from electronic records (readmission, ED visits). RESULTS: Parent-reported quality of discharge teaching delivery (the way nurses teach), but not the amount of content, was positively associated with parent perception (B=0.54) and nurse assessment (B=0.16) of discharge readiness. Parent-reported discharge readiness was negatively associated with post-discharge coping difficulty (B=-0.52). Nurse assessment of discharge readiness was negatively associated with readmission; a one point increase in readiness (on a 10 point scale) decreased the likelihood of readmission by 52%. CONCLUSION: There is a sequential effect of quality of discharge teaching delivery on parent discharge readiness, which is associated with parent coping difficulty and child readmission. PRACTICE IMPLICATIONS: Efforts to improve discharge outcomes should include strategies to build nurse teaching skills for high-quality delivery of discharge teaching. In addition, routine nurse assessment of discharge readiness can be used to identify children at risk for readmission and trigger anticipatory interventions.

Barriers to pediatric pain management: a nursing perspective.

This study describes strategies used by the Joint Clinical Practice Council of Children's Hospital of Wisconsin to identify barriers perceived as interfering with nurses' (RNs) ability to provide optimal pain management. A survey was used to ascertain how nurses described optimal pain management and how much nurses perceived potential barriers as interfering with their ability to provide that level of care. The survey, "Barriers to Optimal Pain management" (adapted from Van Hulle Vincent & Denyes, 2004), was distributed to all RNs working in all patient care settings. Two hundred seventy-two surveys were returned. The five most significant barriers identified were insufficient physician (MD) orders, insufficient MD orders before procedures, insufficient time to premedicate patients before procedures, the perception of a low priority given to pain management by medical staff, and parents' reluctance to have patients receive pain medication. Additional barriers were identified through narrative comments. Information regarding the impact of the Acute Pain Service on patient care, RNs' ability to overcome barriers, and RNs' perception of current pain management practices is included, as are several specific interventions aimed at improving or ultimately eliminating identified barriers.

Evidence-based practice: perceptions, skills, and activities of pediatric health care professionals.

The purposes of this descriptive study were to evaluate pediatric professional staffs' perceptions of evidence-based practice (EBP), to identify individual and organizational barriers experienced when applying EBP into practice, and to determine differences in perceptions by those attending and not attending an EBP education series. A total of 486 pediatric health care professionals, 56 of whom attended all of the sessions, completed an anonymous online survey. Professional staff participated in and valued EBP activities but identified barriers to full implementation. Participants in the EBP series were significantly different in several positive ways. Implications for further education and research are delineated based on survey results.

Nurse researchers in children's hospitals.

Little is known about the role of nurse researchers (NRs) and the structure of nursing research programs in children's hospitals in the United States. This descriptive study obtained survey data from 33 NRs. Data suggest that the NR role is emerging and has both commonalities and unique components when compared with the previous studies of NRs in adult hospitals. Most participants have been in their position for less than 4 years. Conducting research, having staff development related to research, and facilitating evidence-based practice or research were common responsibilities. The structure of nursing research programs impacts both the NRs and the program outcomes.

Readiness for discharge in parents of hospitalized children.

Parental preparation for a child's discharge from the hospital sets the stage for successful transitioning to care and recovery at home. In this study of 135 parents of hospitalized children, the quality of discharge teaching, particularly the nurses' skills in "delivery" of parent teaching, was associated with increased parental readiness for discharge, which was associated with less coping difficulty during the first 3 weeks postdischarge. Parental coping difficulty was predictive of greater utilization of posthospitalization health services. These results validate the role of the skilled nurse as a teacher in promoting positive outcomes at discharge and beyond the hospitalization.

Engaging students through collaboration: how Project FUN works.

Students from three disciplines designed, developed, and implemented exercise and nutrition interventions, online modules and videos, to benefit low-income middle school students. The process used to incorporate the scholarship of teaching ito a collaborative college-level application of learning is described.

Reinventing the home visit for undergraduate nursing students.

The Family Outreach Project was designed to teach senior-level undergraduate nursing students how to assess, care for, and develop care plans for children with chronic health conditions and their families. Nursing students (n=24) could attend one focus group conducted at the end of the semester as part of the evaluation of the America's Promise School Project. Responses were audiotaped and transcribed verbatim. Qualitative methods were used to identify themes. Comfort with the visit, professionalism of the students, and usefulness of the home visit to families was assessed. Analysis of focus group responses identified four major themes: learning experience, observations about home environment, concerns about having nothing to offer families, and difficulties with arranging and carrying out the home visits. Family responses (n=10) supported students' perception that families were knowledgeable about their children's chronic health conditions. Families indicated that students were professional and treated families respectfully.

Under pressure: preventing pressure ulcers in critically ill infants.

PURPOSE: To determine whether a pressure ulcer prevention bundle was associated with a significant reduction in pressure ulcer development in infants in the pediatric intensive care unit. DESIGN AND METHODS: Quasi-experimental design involving 399 infants 0 to 3 months of age at a large tertiary care medical center. RESULTS: The implementation of the care bundle was associated with a significant drop in pressure ulcer incidence from 18.8 to 6.8%. PRACTICE IMPLICATIONS: Pressure ulcers can be prevented in the most vulnerable patients with the consistent implementation of evidence-based interventions and system supports to assist nurses with the change in practice.

Changing the tide: an Internet/video exercise and low-fat diet intervention with middle-school students.

The rising tide of obesity erodes the health of youths and many times results in adult obesity. The purpose of this investigation was to examine the effectiveness of an eight-session health promotion/transtheoretical model Internet/video-delivered intervention to increase physical activity and reduce dietary fat among low-income, culturally diverse, seventh-grade students. Those who completed more than half the sessions increased exercise, t (103) = -1.99, p = .05, and decreased the percentage of dietary fat, t (87) = 2.73, p = .008. Responses to the intervention by stage of change, race, and income are examined.

Determinants of physical activity and low-fat diet among low income African American and Hispanic middle school students.

African Americans, Hispanics, and those with low income experience disproportionate health problems that can be prevented by physical activity and a lower fat diet. In this descriptive cross-sectional study, antecedents of diet and exercise within the Health Promotion/Transtheoretical Model were examined among low-income African American and Hispanic seventh-grade students (n = 127). Total support was associated with higher physical activity for girls. African Americans perceived greater social support for activity than Hispanics. Family models and support for physical activity and low-fat diet were greater as family income increased. However, higher family role models and lower dietary fat were found among the lowest income Hispanic students' residing ZIP code with a higher concentration of Hispanics and greater availability of Hispanic foods and culture. A school-based approach may be useful to build peer support for physical activity and lower dietary fat. Parish nurse or clinic settings may be most appropriate for building family role models and support. Living in a neighborhood with traditional Hispanic culture and foods appears to have ameliorated the harmful effects of lower income, although further study with larger samples followed over time is needed.

Diet and exercise in low-income culturally diverse middle school students.

It is important to understand constructs essential to low-fat-diet and physical-activity behaviors of low-income culturally diverse middle-school-age students, because ethnicity and socioeconomic status influence body weight status, and these groups are most at risk for obesity later in life. In this descriptive study, constructs important in low-fat diet and physical activity in low- to middle-income, culturally diverse middle school students were examined. Revised for cultural/developmental appropriateness and reading level, instruments incorporating constructs from the Health Promotion and Transtheoretical Models were tested with 221 youth. Results demonstrated that percentage of fat in diet, total number of strategies used for a low-fat diet, access to low-fat food, and total number of exercise processes varied significantly (p < 0.05) across stages of change for low-fat diet. We concluded that interventions should foster access to low-fat foods and processes for diet and activity change. Despite significantly lower income and higher grade level (both of which are risks for poor health behaviors), students in the private school demonstrated significantly lower fat in diet, higher perception of benefits, and better access to low-fat food. These findings warrant additional study.

Stage-based interventions for low-fat diet with middle school students.

Preventing obesity and cardiovascular disease at early ages is important; however, few effective interventions for early adolescents have been reported. In this study, low-income, culturally diverse students from an urban middle school (n = 60) received four classroom interventions with the use of a combined Health Promotion/Transtheoretical Model to control fat in diet and increase physical activity. A control group (n = 57) received the usual classroom education. Pretest percentage fat in diet was regressed on demographics, access to low-fat foods, perceived self-efficacy, benefits/barriers, and stage of change with results as proposed by the model [F(9,64) = 5.77; p =.000; adjusted R(2) = 0.35]. Posttest percentage fat in food was significantly less for the intervention group as compared with the control group (t = 2.06; df, 115; p =.04).

Addressing health disparities in middle school students' nutrition and exercise.

Those with low income, especially women of African American and Hispanic heritage have the greatest risk of inactivity and obesity. A 4-session (Internet and video) intervention with healthy snack and gym labs was tested in 2 (gym lab in 1) urban low-middle-income middle schools to improve low fat diet and moderate and vigorous physical activity.1 The gym lab was particularly beneficial (p =.002). Fat in diet decreased with each Internet session in which students participated. Percentage of fat in food was reduced significantly p =.018 for Black, White, and Black/Native American girls in the intervention group. Interventions delivered through Internet and video may enable reduction of health disparities in students by encouraging those most at risk to consume 30% or less calories from fat and to engage in moderate and vigorous physical activity.