Student-led Doctor of Nursing Practice projects in the clinical environment: Viewpoint from hospital-based nurse scientists and leaders.

BACKGROUND: Exponential increases in Doctor of Nursing Practice (DNP) program enrollment have come with a rapid rise in the number of capstone projects conducted in clinical environments. However, misaligned priorities between students, faculty, and clinician leaders have created significant challenges. PURPOSE: Identify opportunities to strengthen collaboration between academic and clinical stakeholders to better support DNP projects and education. METHODS: Experienced hospital-based nurse leaders engaged in scholarly discourse supplemented by policy and research in DNP education. FINDINGS: Facilitating a DNP project requires significant investment of time, resources, and funds from the healthcare institution. Discord has arisen due to unclear responsibilities or decision-making ability for clinical stakeholders, ethical dilemmas for students who are also employees of the clinical site, and mismatched priorities between clinical need and student/academic project desires. Clinical leaders have raised significant concerns about DNP project proposals that are research-focused, diverge from healthcare institution goals, and lack a sustainability plan. DISCUSSION: Fortification of academic-practice partnerships and clarification of roles in the DNP student project are necessary to ensure that the project is of educational value to the student, a demonstration of learning for faculty, and of sustained clinical value to the healthcare system.

Pediatric Death and Family Organ Donation: Bereavement Support Services in One Pediatric Health System.

Health care providers need to support families and provide resources when facing their child's death and potential organ donation. Aims of this retrospective chart review in a tertiary health care system were: (1) describe characteristics of pediatric organ donors compared to those who were not; (2) determine differences between services utilized by families who selected organ donation versus those who did not. From 2017 to 2023 of 288 pediatric deaths, 76 were organ donors and 212 did not donate. Organ donors' mean age at admission was 6.3 ± 5.8 years. Thirty-four (44.7%) participated in Honor Walks. Significant differences existed between organ donors and non-organ donors in patients who were diagnosed with SIDS (3.9% vs 13.2%; P = .025). This study provides additional data to help further our understanding of bereavement support services for families making difficult decisions regarding organ donation.

A Quality Improvement Project to Revise and Reduce Nursing Data Entry in a Pediatric Trauma Unit.

ABSTRACT: Meaningful direct nurse-patient interactions have been found to positively influence patient experiences and outcomes while increasing nurse satisfaction. Through redesigning a database, this process improvement project reduced nurse data entry time, allowing more opportunities for direct patient interactions. This project demonstrated that database redesign is a strategic action to decrease nurse data entry workload that can be used in hospital settings.

Perceived Barriers to Administration of Aromatherapy in Nurses Caring for Pediatric Patients With Postoperative Nausea and Vomiting: An Evidence-based Practice Project.

INTRODUCTION: Postoperative nausea and vomiting (PONV) is prevalent among surgical patients, causing hospitalizations, extended stays, and patient dissatisfaction. Children are twice as likely to experience PONV than adult patients. Complementary therapy holds promise for PONV treatment but meets clinical use barriers. We explored perioperative nurses' perceived barriers to the use of complementary aromatherapy. METHOD: Presurvey and postsurveys assessed nurses' (n = 27) knowledge and barriers to aromatherapy use before and after an educational in-service. RESULTS: Primary PONV treatment involved antiemetics. Barriers to aromatherapy included product availability, caregiver refusal, and patient-specific factors. Post-in-service, the nurses felt more familiar with aromatherapy and inclined to use it. DISCUSSION: Increased education and guidelines on aromatherapy promote its incorporation into clinical practice. Institutional policies addressing the selection, administration, documentation, and monitoring of aromatherapy should be established to ensure the consistency and standardization of its use.

Effects of Gabapentin on Emergence Delirium in Pediatric Tonsillectomy/Adenoidectomy Patients: A Post-Hoc Analysis.

Emergence delirium (ED) is a significant source of both short- and long-term negative effects in the postoperative pediatric population, most notably following otolaryngology surgeries with an occurrence rate of 17.9%. Gabapentin, a gamma aminobutyric acid agonist, has been used for enhanced recovery in adult patients and for the purpose of decreasing ED in some pediatric patients undergoing strabismus surgery. This secondary analysis examined the effects of preoperative administration of gabapentin on the reduction of postoperative ED in pediatric patients between the ages of 3-18 undergoing elective tonsillectomy and adenoidectomy. The parent study randomized subjects to receive preoperative gabapentin vs placebo. Our chart review encompassed both objective and subjective measures to identify the incidence of ED. While we found no statistical significance between the treatment and control groups, there was a clinically significant reduction of ED behaviors in the gabapentin group. The limitations included nonstandardized intraoperative medication administration, small sample size, and the lack of a validated tool for documenting behaviors associated with ED in the immediate postoperative period. Based on the results of this analysis, further investigation is warranted into the potential benefit of gabapentin to reduce the incidence of postoperative ED in the pediatric patient.

Hospitalization patterns for adolescents with eating disorders during COVID-19.

PURPOSE: The purpose of this study was to examine differences in clinical characteristics and hospital length of stay (LOS) for adolescents with eating disorders (EDs) requiring medical stabilization during the pre-COVID-19 and COVID-19 time periods. METHODS: Medical record data were abstracted for patients with EDs hospitalized for medical stabilization between 1/1/2019-2/29/2020 (pre-COVID-19) and 3/1/2020-12/31/2021 (during COVID-19). Patient demographics, clinical characteristics and LOS were compared between COVID-19 eras. Patients were categorized as boarding if they remained hospitalized ≥ 1 day after medical stabilization. Multivariate negative binomial linear regression models were performed to determine incidence rate ratios (IRR) and 95% confidence intervals (95% CI) for factors related to increased LOS. RESULTS: Of the 467 admissions during this study, 120 were pre-COVID-19 and 347 were during COVID-19. Monthly admissions for EDs were higher during COVID-19 versus pre-COVID-19 (15.8 vs. 8.6, p = 0.001). On multivariate analysis, factors associated with increased LOS included admission during COVID-19 (IRR 1.27, 95% CI 1.15-1.40), p = 0.001), boarding (IRR 1.77, 95% CI 1.63-1.93, p = 0.001), public insurance (IRR 1.12, 95% CI 1.01-1.23, p = 0.032), nasogastric tube usage (IRR 1.62, 95% CI 1.48-1.76, p = 0.001), heart rate < 40 beats per minute (IRR 1.21, 95% CI 1.11-1.33, p = 0.001) and abnormal electrocardiogram (IRR 1.25, 95% CI 1.14-1.37, p = 0.001). CONCLUSION: In addition to clinical factors, we found that admission during COVID-19, boarding, and public insurance were associated with increased LOS among patients with EDs. There is a need for greater availability of ED treatment centers to care for patients with EDs after medical stabilization.

The COVID-19 pandemic has had a profound effect on the mental health of young people worldwide. This public health crisis has led to a significant increase in individuals seeking care for an eating disorder. In the United States, hospital admissions for adolescents with eating disorders requiring medical stabilization increased significantly during the COVID-19 pandemic. This study examines differences in the demographic and clinical characteristics of patients with an eating disorder hospitalized pre-COVID-19 and during the COVID-19 pandemic in one pediatric hospital in the United States. We found a significant increase in hospital admissions during the pandemic as well as longer hospital stays. Factors associated with prolonged hospitalizations include those patients with public insurance (Medicaid), nasogastric tube for delivery of nutrition, and low heart rate. We found no difference in demographic factors such as age, gender, and insurance as well as degree of malnutrition and medical severity between the two time periods. The shortage of appropriate eating disorder treatment options upon hospital discharge were especially challenging during the COVID-19 pandemic.

Transferring critical pediatric patients from emergency department to intensive care: A quality improvement initiative.

BACKGROUND: Transfer of care, moving hospitalized patients between care areas, is a critical point of vulnerability for healthcare organizations. Patient information handoff is an essential activity occurring frequently in hospital environments. Poor communication has been linked with adverse events and poor patient outcomes. This evidence-based quality project aimed to enhance the handoff process between the Emergency Department (ED) and Pediatric Intensive Care Unit (PICU) by standardizing transfer of care steps. This was accomplished through customizing a reporting tool to contain all the information the receiving department deemed necessary for safe patient care. METHODS: A customized situation, background, assessment, recommendation (SBAR) form handoff tool was developed for ED to PICU transfers. This SBAR tool included information that PICU nurses identified as critical to transfer of care. Nurse perceptions were surveyed pre- and post-implementation. Patient safety event reports were tracked to evaluate events related to transfer of care before and after the practice change. FINDINGS: An increased number of PICU nurses agreed the customized handoff tool was complete and organized. Additionally, more nurses agreed that handoff gave all information needed to safely care for critically ill patients transferred from the ED. Lastly, bedside patient checks increased, and patient safety events related to transfer of care decreased. DISCUSSION: This project demonstrated that implementation of a standardized transfer of care process coupled with a customized handoff tool increased PICU nurse perceptions that handoff was organized, and all information needed to safely care for critically ill patients was conveyed. APPLICATION TO PRACTICE: Transfer of care processes between the ED and PICU should be standardized. The use of customized tools may improve information exchange between nurses and ensure that all vital patient information is communicated.

Developmental Care Rounds: An Initiative to Improve Nursing Confidence and Contributions at the Bedside.

Purpose: To describe the use of developmental care (DC) rounds as an initiative to ensure the implementation of bedside DC. To measure the confidence of NICU nurses with participation in DC rounds. Design: Evidence-based practice/quality improvement initiative aimed to answer the following questions: What are the implementation rates of bedside DC nursing interventions used or discussed during DC rounds? Do NICU nurses report agreement with education about DC rounds prior to DC rounds starting? Do nurses in the NICU feel confident participating in DC rounds Do nurses with more years of NICU nursing experience feel more confident than nurses with fewer years of nursing experience? Sample: 513 DC rounds and 101 nursing surveys. Main Outcome Variable: Nursing survey Likert score response and implementation rate of DC nursing interventions. Results: Implementation of bedside DC nursing interventions was strong in the NICU. Areas of opportunity include developmental bath, oral care with breast milk, use of scent clothes, kangaroo care, breastfeeding, use of head plan when appropriate, assignment of a primary baby buddy when appropriate, and use of schedule when needed. Nurses reported their confidence in participation in DC during the implementation of this project.

Variability in qualifications for principal investigator status in research studies by nurses: A call for clarification.

PURPOSE: To describe existing guidance for qualifications of principal investigator s (PI s) of human subjects research and explore how they are operationalized for pediatric nurse scientists and clinical nurses in children's hospitals. DESIGN AND METHODS: After reviewing federal regulations, accreditation guidelines, and the literature, a convenience sample of members of the National Pediatric Nurse Scientist Collaborative (NPNSC). Participants completed a 33-item survey that included questions about Institutional Review Board (IRB), guidelines, and policies for PI status at their affiliated children's hospitals. RESULTS: The survey was electronically disseminated to 179 members of NPNSC through the Collaborative's listserv. Of the 39 members who responded, 90% hold a PhD and 80% practice in a free-standing children's hospital, nearly all of which (93%) are recognized as Magnet® hospitals. While the majority of respondents indicated that nurse scientists and other nurses were allowed to be PIs of research studies, educational requirements for PI status varied, with 3% requiring a PhD, 15% a baccalaureate degree, and 10% a graduate degree. 54% of respondents reported there was no degree requirement for PI status; however15% reported that even doctorally prepared nurse scientists cannot serve as PIs of research studies at their affiliated children''s hospitals. CONCLUSIONS: The survey identified substantial variability in requirements for PI status and potential barriers to pediatric nurses conducting independent research as PIs at children's hospitals. PRACTICE IMPLICATIONS: Operationalizing existing guidance will expand inclusion of nurse scientist expertise in human subjects research.

Gabapentin Premedication to Reduce Postoperative Pain for Pediatric Tonsillectomy/Adenoidectomy: A Pilot Study.

PURPOSE: To examine the effects of preoperative gabapentin administration on postoperative pain in pediatric patients undergoing tonsillectomy/adenoidectomy (T/A) in a single ambulatory surgery location within a pediatric healthcare organization. DESIGN: This randomized, controlled pilot study enrolled patients age 3-18 years with American Society of Anesthesiologists (ASA) scores of I-II undergoing T/A. METHODS: Both gabapentin and placebo groups were given study medication preoperatively and received standard opiate regimens intraoperatively and postoperative pain instructions. Outcome measurements included: time to first analgesic medication in the postanesthesia care unit (PACU), mean acetaminophen, ibuprofen, and opiate doses in mg/kg. Additionally, we examined pain scores, medication use, and side effects reported by daily pain diaries completed by patients/families for 3 days postoperatively. FINDINGS: Forty-nine patients were included in final analysis (gabapentin n = 26, placebo n = 23). Demographic and clinical characteristics of both groups were similar; the majority (46 of 49) were under the age of 13. Both groups received opiates in PACU. Some patients in both groups received hydrocodone/acetaminophen postoperatively. There were no reported differences in side effects between groups. Gabapentin group reported less use of opiates, acetaminophen, and ibuprofen post-discharge. We identified small effect sizes for opiates and acetaminophen, and medium effect size for ibuprofen (80.1% gabapentin versus 100% placebo, RR 0.81 [95% CI 0.67-0.97]). Median pain scores were 4 on a scale of 10 for both groups for all 3 days of follow-up. Overall median satisfaction score was 9, with a mean difference of 0.35 (95% CI -0.78 - 1.37). Analysis of variance revealed no difference in pain scores or satisfaction per pain diaries between the groups in general and no difference in score trajectory. CONCLUSIONS: We were able to establish a rigorous process and feasibility to launch a larger, multi-center trial to examine this important issue. There remain few evidence-based options for acute pain relief in pediatric surgical populations besides opiates. Identifying opiate alternatives that are effective, cost efficient and safe are needed for pediatric tonsillectomy patients.

Facilitating Communication in a Pediatric Surgery Center: Implementation of an Interactive Communication Board.

BACKGROUND: Increasing linguistic diversity has important implications for providers serving limited English proficiency (LEP) populations. LEP patients have decreased understanding, increased risk for adverse events, and lower healthcare satisfaction. Limited interpreting methods affect nurses' ability to provide efficient, culturally competent care. OBJECTIVE: An interactive communication board was implemented to evaluate the perceived effectiveness of LEP patient communication and increase nurse satisfaction with communication in a pediatric ambulatory surgery center. METHODS: A pre-post survey design evaluated the implementation of an interactive communication board. After a 3-month implementation period, post-surveys assessed nurse satisfaction, perception of time required to interpret nursing tasks, and feasibility of the tool. RESULTS: Nurses reported a 64% increase (2.27 ± 0.88 pre; 3.57 ± 0.76 post; p = 0.0007) in satisfaction with the interpretation process and a 43% increase (2.07 ± 0.70 pre; 3.50 ± 0.76 post; p = 0.0001) in their self-perceived ability to communicate with LEP populations post-intervention. CONCLUSION: Communication boards and similar tools can improve nurse satisfaction and streamline the interpretation process in peri-operative periods. IMPLICATIONS FOR NURSING: Similar tools could be implemented in other healthcare settings to increase communication efficiency between nurses and LEP populations. Further projects must be conducted to evaluate the experience and efficacy of this tool from the patient/caregiver perspective.

Impact of caloric prescriptions and degree of malnutrition on incidence of refeeding syndrome and clinical outcomes in patients with eating disorders: A retrospective review.

BACKGROUND: For individuals with eating disorders (EDs), medical stabilization is paramount for restoration of body weight. Careful nutritional rehabilitation minimizes risk of refeeding syndrome. Study's purpose: describe clinical outcomes of pediatric/adolescent patients with EDs treated with lower calorie (<1300 kcals/day, n = 137), higher calorie (≥1400 kcals/day, n = 154) diets. METHODS: Retrospective chart reviews conducted for patients with known/suspected EDs. INCLUSION: patients ages 12-21 years with anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS), atypical anorexia nervosa (AtAN). EXCLUSION: patients with other EDs, co-morbid medical conditions. Demographic information, length of stay, anthropometrics, prior weight loss were recorded. Malnutrition classifications based on: %mBMI, BMI z-score, prior weight loss percentage. Laboratory data, electrolyte supplementations were collected. Initial calorie intake/calorie intake day 7 were recorded. RESULTS: No significant differences in age, admit weight, BMI, BMI z-score, %mBMI at admission, weight gain between the two groups. Six (4.4%) patients in lower calorie group, 4 (2.6%) in higher calorie group met criteria for severe refeeding syndrome based on ASPEN consensus recommendations (P = .52). Higher calorie group length of stay was significantly shorter than lower calorie group (P = .006). Shorter length of stay associated with increased calorie intake (P < .001), greater %mBMI (P < .001). Higher calorie prescriptions were not associated with different rates of hypomagnesia (P = 1) and hypokalemia (P = .34). There was significant increase in rate of hypophosphatemia in the lower calorie group versus the higher calorie group. CONCLUSION: Higher calorie diets were associated with decreased length of stay without impacting risk of refeeding syndrome.

Family Support Practices to Impact Stress Scores in Parents of Critically Ill Children.

BACKGROUND: When a child becomes critically ill and hospitalized in intensive care, this can be emotionally and physically traumatic for parents. OBJECTIVE: The purpose of the initiative was to utilize a stress screening tool to quantify parental stress and examine the use of family support services as a way to impact stress scores. METHODS: The Family Stress Thermometer (FST) was introduced and parents were asked to circle their stress level at up to three time points. Along with recorded stress scores, resources accessed were documented, how often it was utilized, and parental suggestions that might ease stressors recorded. RESULTS: The results indicate the FST accurately recorded elevated stress levels in parents with critically ill children, analysis showed a statistically significant decrease in the stress levels of parents over time. CONCLUSIONS: This project appears to validate parental distress levels as a modifiable risk factor. IMPLICATIONS FOR NURSING: The FST was cost-effective and easy to administer. As part of comprehensive plans of care for families, interprofessional teams can work to design support services that meet individualized needs of parents with critically ill children. Partnering with parents to quantify their stress and responding to their needs will insure the likelihood of this happening.

Effect of Live Versus Recorded Music on Children Receiving Mechanical Ventilation and Sedation.

BACKGROUND: Music is often used as a nonpharmacological pain management strategy, but little evidence is available about its role in pediatric critical care patients. OBJECTIVE: To determine the effect of a live music intervention versus a recorded music intervention on heart rate, blood pressure, and respiratory rate in pediatric critical care patients receiving mechanical ventilation and sedation. METHODS: An exploratory randomized controlled trial was performed in a pediatric intensive care unit. Participants were randomly allocated to receive a live music intervention with standard care or a recorded music intervention with standard care. Each intervention was delivered by a board-certified music therapist for 15 minutes. Heart rate, respiratory rate, and blood pressure were measured at baseline and at 15-minute intervals for 60 minutes after the intervention. RESULTS: A total of 33 patients aged 0 to 2 years completed the study: 17 were assigned to the live music group and 16 to the recorded music group. In the live music group, a significant reduction in heart rate was observed immediately after the intervention and was sustained at 60 minutes after the intervention. Although the live music group also exhibited a downward trend in blood pressure, those differences were not significant. CONCLUSIONS: The results of this study indicate that live music interventions may be more effective than recorded music interventions in reducing pain and anxiety in pediatric critical care patients. The advantage of live music may be due to the adaptability of the music delivery by a trained music therapist.

Decreased Wait Time and Increased Satisfaction With Bedside Pancreatic Enzyme Dosing for the Inpatient Adolescent With Cystic Fibrosis: A Quality Improvement Project Comparing Enzyme Self-Administration to Nurse Administration.

For children with cystic fibrosis (CF), enzymes are essential with meals to absorb nutrients and ensure adequate growth. When hospitalized, CF patients typically rely on nurse-administered medications. Recently, a pediatric hospital unit began allowing adolescents with CF enzymes at the bedside. Postimplementation, a satisfaction questionnaire was administered to participating patients and nurses measuring patient and nurse satisfaction with access to bedside enzymes versus nurse administration and overall time for enzyme delivery. The survey utilized a 5-point Likert scale. The wait time for pancreatic enzymes decreased for self-administered enzymes when compared to those that were nurse administered. All (11/11) patients and 86% (12/14) of nurses preferred the self-administration of enzymes. Hospitalized pediatric CF patients and nurses had higher levels of satisfaction with enzyme self-administration. Immediate access to enzymes in room safes impact patient autonomy, reflecting home self-care practices. Decreases in wait times optimize nutritional growth and healing while hospitalized. As a result, a new limited scope policy allowing patient-administered enzymes is now in place in the pediatric inpatient CF unit.

A Collaborative Effort to Build an Evidence-Based Practice Project Repository.

The establishment of an Evidence-based Practice (EBP) project repository for clinical nurses to access via a hospital intranet allowed for hospital librarians to collaborate with nurse scientists. This project resulted in not only a repository but also led to the involvement of librarians earlier in the research process and led to more options to track how the completed projects were utilized by clinicians. These two outcomes in particular allowed for further involvement of librarians in the Magnet reaccreditation process. Additionally, the contributions of the librarians raised awareness of the roles they can take in EBP and Magnet efforts.

Oral Chemotherapy: An Evidence-Based Practice Change for Safe Handling of Patient Waste.

BACKGROUND: Safe handling practices for patient waste have focused on patients receiving IV chemotherapy, but these practices do not address safe handling for patients receiving oral chemotherapy. OBJECTIVES: The aim of this article is to evaluate evidence and formulate best practice recommendations for handling and disposing waste from patients receiving oral chemotherapy. METHODS: A literature search established a framework for the project. For healthcare providers and staff, procedures were established to access biohazard supplies and to follow safe handling of patient waste post-oral chemotherapy administration. Supply cost utilization was evaluated pre- and postimplementation. Staff perceptions were assessed six months after project implementation. FINDINGS: The cost of supplies per patient day increased minimally. Staff self-reported use of biohazard precautions when handling patients' waste increased. The majority of staff reported that they had access to supplies and were knowledgeable regarding safe handling procedures six months after this practice change.

A Pancreatic Enzyme Medication Self-Management Initiative.

This is the seventh article in a new series about evidence-based practice (EBP) that builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series features exemplars illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.