Center of Excellence to build nursing scholarship and improve health care in Italy.

PURPOSE: This article profiles the establishment and initial phase (2010-2014) of a Center of Excellence (CoE) as an instrument to strengthen nursing scholarship and improve health care in Italy. APPROACH: This CoE is unique as a non-university-based center. The National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses (IPASVI) designated substantial administrative and funding support to the CoE for advancing nursing education, clinical practice, research development, and research training. Boyer's Model of Scholarship underpinned the CoE's conceptual framework, and its operational infrastructure was adapted from the U.S. National Institutes of Health P20 program award mechanism. Diverse methods included sponsoring research studies by nurse-led teams, research training courses, nursing education longitudinal studies, evidence-based practice training, and related pilot studies. FINDINGS: Multiple collaborative projects were conducted via the CoE in conjunction with the successful launch of an expansive digital library and communication system accessible to nurses. The introduction of English proficiency courses was also a unique contribution. CONCLUSIONS: The CoE concept is a potential instrument to strengthen nursing scholarship in Italy with potential scalability considerations to other global settings. CLINICAL RELEVANCE: An overlapping focus on research, education, and practice under the umbrella of nursing scholarship within a CoE while engaging all levels of nursing is important to impact healthcare changes.

The Evolution of Professional Nursing Culture in Italy: Metaphors and Paradoxes.

We explored the perceptions of Italian nurses regarding their developing culture as a health profession. We sought to understand the ongoing evolution of the nursing profession and the changes that were central to it becoming an intellectual discipline on par with the other health professions in Italy. In 2010, the Regulatory Board of Nursing established a center of excellence to build evidence-based practice, advocate for interdisciplinary health care, and champion health profession reforms for nursing. In this study, focus groups-involving 66 nurse participants from various educational, clinical, and administrative backgrounds-were utilized to better ascertain how the profession has changed. Six themes, three of them metaphors-"vortex," "leopard spots," and "deductive jungle"-explain nurses' experiences of professional change in Italy between 2001 and 2011 and the multiple dimensions that characterize their professional identity and autonomy.

Using preappraised evidence sources to guide practice decisions.

PURPOSE: The purpose of this article is two-fold. The first is to describe preappraised evidence sources or a top-down approach to obtaining the best available evidence. The second purpose of the article is to describe how to incorporate preappraised evidence into clinical decision making with the Best Practice Decision Guide. DATA SOURCES: The Best Practice Decision Guide begins with a query of preappraised and filtered electronic sources to obtain recommended evidence summaries, or a so-called "top-down" approach to obtaining the best available evidence. CONCLUSIONS: Information on the major issues and dilemmas encountered at each step is presented, including evaluation of clinical practice guidelines and the consideration of relevant studies to particular patients or subpopulations. IMPLICATIONS FOR PRACTICE: Recommendations for other resources to use in the appraisal process and in making final practice decision are also described in the article.

Cultural context of school communities in rural Hawaii to inform youth violence prevention.

BACKGROUND: Escalation of youth violence within a large geographic school-complex area in southeastern rural Hawaii became a major problem in 2006. How cultural forces impact the problem was an impetus to examine youth violence from perspectives of adults and children in rural communities. Gathering these data was an essential first step toward school-based youth violence prevention program development. METHODS: Eight focus groups involving 86 community stakeholders included 51 adults (parent, teachers, school staff, community leaders) and 35 children aged 8-15 years old (3rd- to 10-th grade). Qualitative narrative analysis elicited major themes. RESULTS: Five themes emerged: (1) School-community violence takes on many forms that become entrenched in local culture. (2) Disintegration of community resources and a sense of learned helplessness underlie the escalation of youth violence. (3) Inadequate role modeling coupled with behavioral ambivalence among adults has sustained a climate of local cultural acceptance with youth violence. (4) Connection to cultural values has diminished, leading to a sense of loss in cultural identity among students. (5) Cultural values and practices are potential strategies for youth violence prevention. CONCLUSIONS: Cultural and community contextual factors contributed to youth violence in rural Hawaiian communities. Study implications include the need to further investigate the impact of vigilant, community involvement of stakeholders in school-based youth violence prevention program development. Cultural revitalization at family, school, and community levels may be critical success factors of such programs.

Blueprint for action: steps toward a high-quality, high-value maternity care system.

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Pregnancy and oral health: a review and recommendations to reduce gaps in practice and research.

This article presents a review of the research relevant to oral health during pregnancy and includes nursing practice recommendations for referral of women to a dentist for safe and effective dental care during pregnancy. In recent years, research linking periodontitis to the risk for adverse birth outcomes has resulted in increased interest in the topic of oral health during pregnancy. The achievement of optimal oral health in pregnant women as its own benefit, however, has in the past been hampered by myths surrounding the safety of dental care during pregnancy. Many women also lack access to dental care and dental insurance, which interferes with their ability to receive adequate oral care during pregnancy. Intraoral changes that occur with pregnancy because of hormonal changes, combined with lack of routine exams and delays in treatment for oral disease, place pregnant women at higher risk for dental infections.

Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum.

OBJECTIVE: To examine differences in depression symptom rates and severity and factors associated with depression ratings. PARTICIPANTS: Cross-sectional sample of 1,359 American women who had delivered a single, live infant within the previous 2 years. DESIGN: Data were collected using the Edinburgh Postnatal Depression Scale online to screen for depression symptoms as part of Listening to Mothers, a national survey sponsored by Childbirth Connection of New York City and administered by Harris Interactive between May and June 2002. RESULTS: Evidence of continued mild and moderate-to-severe depression symptom rates throughout the first 2 years postpartum was found. Age, income, education, and employment had significant negative associations with depression symptom severity, and parity had a significant positive association with depression symptom severity. Race was not associated with depression symptom severity. CONCLUSIONS: Long-term screening for childbearing women is justified based on the study findings. The ease in survey administration suggests potential for online depression screening by health care providers and researchers. Furthermore, risk factors identified from this large-scale national survey, specifically young maternal age, low income, low education, not being employed full time, and multiparity, merit evaluation in clinical practice and future research.

The evidence supporting nursing management of labor.

Although nursing practice is responsive to research findings, the practice site in which a nurse works has an impact on the ability to incorporate research changes into practice in a timely fashion. This review of the evidence base for nursing management of labor care focuses on care that typically falls within the nurses' domain and highlights the evidence in five areas in which there is research on patient preferences. These include management of admission and of progression during the first stage of labor, fetal monitoring, care and comfort practices during labor, and the management of second-stage labor. Directions for achieving progress toward practice change are highlighted.

Nursing implications of the 2006 NIH State of the Science Conference Statement: Cesarean Delivery on Maternal Request.

Will the nation's higher rate of cesarean deliveries (CDs) (over 29%) lead to increased health risks for mothers and their babies? In March 2006, a National Institutes of Health State of the Science Conference was convened to assess available research on the topic. The focus was to identify outcomes from research studies addressing "cesarean delivery on maternal request" (CDMR), defined as CD without a medical indication for either the mother or the fetus. This conference concluded that it is currently unknown whether CDMR is really a trend in the United States, or whether the emergence of this phenomenon is associated with any specific benefits and harms to mothers and babies. More research is needed to determine if a trend exists. On the basis of systematic review of studies, no "strong quality-evidence" was found comparing CD and normal vaginal delivery outcomes. Future research was recommended to develop studies for this purpose in areas such as placental abnormalities (placenta previa and accreta) and various neonatal outcomes. Research on "modifiable" factors during labor and delivery which might decrease maternal and neonatal complications, including the risk for future pelvic floor disorders, was also recommended in the 2006 Conference Statement.

Vaginal or cesarean birth? Application of an advocacy organization-driven research translation model.

BACKGROUND: Research translation models are needed to demonstrate a process for identifying and communicating high-quality scientific evidence that enables informed involvement of relevant stakeholders, including informed consumer participation in healthcare decision making. PURPOSE: To describe the rationale for, and elements of, a research translation model, as it is being applied to inform and support diverse end users with respect to decisions relating to vaginal versus cesarean birth. METHODS: The Maternity Center Association (MCA), the oldest national United States organization advocating on behalf of mothers and babies, identified the need to clarify and translate into practice best evidence about relative harms of cesarean and vaginal birth. MCA developed a model that included engaging leading stakeholder groups, conducting a systematic review to fill research gaps, and initiating an education and advocacy campaign to reach consumers, health professionals, and the general public with review results and related information and guidance. International standards for systematic reviews and evidence about effective professional practice, use of decision aids, and risk communication were used. RESULTS: Dozens of harms that differ by mode of delivery, with nearly all favoring vaginal birth, were found during review. Without clear, compelling, and well-supported justification for cesarean section, vaginal birth is the safest way for women to give birth and babies to be born. Despite modest resource expenditure, the implemented model is bringing review results to many individuals and organizations, incorporating elements that have been shown to be effective. The next step is to formally evaluate the decision aid in clinical settings. DISCUSSION: Advocacy organizations are uniquely positioned to carry out research translation. Given the importance of research translation and the challenges of carrying out this work, programs and policies should be established to support and evaluate advocacy organizations in this role.

Use of upright positioning with epidural analgesia: findings from an observational study.

PURPOSE: To present research findings and related nursing implications from an observational study designed to evaluate the use of upright positioning during second stage labor with patients who had received low-dose epidural analgesia. STUDY DESIGN AND METHODS: This descriptive study evaluated outcomes from a sample of 74 healthy women having their first childbirth. They had all received epidural analgesia during the first and second stages of labor. Data were also collected by nurses on the use of birthing beds, and the extent of physical and emotional support the women needed while following the upright positioning study protocol. RESULTS: All women were able to maintain upright positions throughout the second stage of labor following epidural analgesia administration. No adverse neonatal outcomes or maternal problems (such as excessive vaginal bleeding) were documented. CLINICAL IMPLICATIONS: Although women were capable of assuming upright positions during second stage, the study results indicated that constant physical and emotional support was necessary for most women. Future research on methods to prepare women for multiple position options after administration of low-dose epidural analgesia should be undertaken. In addition, nurses should evaluate the benefits of upright positioning in terms of facilitating progress of labor.

Doctoral education internationally: questions for the 21st century

There are a number of challenges that will face nursing science and education in the 21st century. Nurse scientists only began to be prepared at the doctoral level in the 1930's and there was very little growth in doctoral education until the 1970's. Doctoral education for nursing has now become well established around the globe but the average age of students and the lack of diversity may diminish their productivity. Doctoral faculties are also ôgrayingõ and as demands on their time increase questions about the best method of providing doctoral education arise. Strategies for improving doctoral education globally are provided...

Existe um certo número de desafios a serem enfrentados pela ciência e educação de enfermagem no século XXI. Cientistas enfermeiros só começaram a ser preparados em nível de doutorado na década de 1930, e houve muito pouco crescimento na educação em nível de doutorado até de 1970. Educação em nível de doutorado para enfermagem tornou-se agora bem estabelecida em todo o globo, mas a média de idade dos estudantes e a falta de diversidade são fatores que podem diminuir a sua produtividade. Os membros do corpo docente em nível de doutorado estão também tornando-se ôgrisalhosõ, e conforme aumentam as exigências acadêmicas a que são submetidos, surgem questões sobre como prover melhor método de educação em nível de doutorado. São oferecidas estratégias para melhorar mundialmente a educação em nível de doutorado...

Existe un cierto número de desafios a ser enfrentados por la ciencia y la Educación en Enfermería en el siglo XXI. Investigadores en Enfermería sólo comenzaron a ser preparados en nivel de doctorado en la década de 1930, y hubo muy poco crecimiento en la educación en nivel de doctorado hasta 1970. La Educación en nivel de Doctorado para Enfermería se tornó ahora bien establecida en todo el mundo, así la edad media de los estudiantes y la falta de diversidad son factores que pueden disminuir su productividad. Los miembros del cuerpo docente en nivel de doctorado están también tornándose ôgrisáseosõ, y conforme aumentan las exigencias académicas a que estan sometidos surgen cuestiones sobre como proveer un método de educación en nivel de doctorado. Son ofrecidas estratégias para mejorar mundialmente la Educación en nivel de doctorado...

The nature and management of labor pain: executive summary.

This report describes the background and process for a rigorous project to improve understanding of labor pain and its management, and summarizes the main results and their implications. Labor pain and methods to relieve it are major concerns of childbearing women, with considerable implications for the course, quality, outcome, and cost of intrapartum care. Although these issues affect many women and families and have major consequences for health care systems, both professional and public discourse reveal considerable uncertainty about many questions, including major areas of disagreement. An evidence-based framework, including commissioned papers prepared according to carefully specified scopes and guidelines for systematic review methods, was used to develop more definitive and authoritative answers to many questions in this field. The papers were presented at an invitational symposium jointly sponsored by the Maternity Center Association and the New York Academy of Medicine, were peer-reviewed, and are published in full in this issue of the journal. The results have implications for policy, practice, research, and the education of both health professionals and childbearing women.

Epidural analgesia side effects, co-interventions, and care of women during childbirth: a systematic review.

The purpose of this article is to profile research findings targeting the intrapartum care implications of the most common side effects and co-interventions that go along with the use of epidural analgesia during labor. Randomized, controlled trials published in English from 1990 to 2000 that addressed each of the targeted side effects and 3 specified co-interventions were evaluated for inclusion in this report. Side effects such as pruritus, nausea, and hypotension during labor are common, but they are usually mild and necessitate treatment infrequently. However, even with the advent of newer low-dose epidurals, the extent of impaired motor ability remains variable across studies. The incidence of "walking" epidurals during labor is likely to be complicated by multiple factors, including individual patient desires, safety considerations, and hospital policies. In response to risks for a decrease in uterine contractions that could prolong labor, oxytocin augmentation is likely to be administered after epidural analgesia. The use of "delayed" pushing may be an effective way to minimize the risk for difficult deliveries. Upright positioning even when confined to bed may be advantageous and desirable to women; however, additional research to determine actual outcome benefits with epidurals is needed. Implications for further research linked to epidural analgesia also include informed consent, modification of caregiving procedures, and staffing/cost issues.

Use of Care, Outcomes and Costs of a Culturally-based Perinatal Program for Asian American and Pacific Islander Women in Hawaii.

PURPOSE. This study examines whether psychosocial perinatal care services developed through community partnerships and cultural deference with attention to individual women's health issues, had an assocaited impact on use of prenatal care, birth outcomes and perinatal care costs for the three participating Asian Pacific Islander American ethinc groups. METHODS. The use of prenatal care visits and birth outcomes for women in the Malama program were compared to those for women of the same etnic groups in the community prior to the introduction of the program. Data on program participants from 1992 to 1994 were compared to birth certificate data on Hawaiian, Filipino and Japanese women from 1988 to 1991. Costs of providing Malama prenatal services were determined from data provided by cost accounting and encounter data systems for the program. SUMMARY OF IMPORTANT FINDINGS. The use of prenatal care visits and birth outcomes were significantly lower for Malama program participants than for women of the same ethnic groups prior to the introduction of the program. The costs of the prenatal program services were $846 to $920 per woman. The expected savings in medical costs per infant with the improved preterm birth rates were $680 per infant. Thus 75% to 80% of the costs of the services were likely to be saved in lower medical costs of the infants. MAJOR CONCLUSIONS. Programs that use community approaches and caring servies delivered in a cultural context, like the Malama model, have a potential for improving the use of prenatal care and birth outcomes at reasonable costs. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. The Malama approach to ascertaining cultural preferences for the content and delivery of care should prove useful in addressing public health goals of improved pregnancy outcomes for diverse groups of Asian Americans and Pacific Islanders. KEY WORDS. Asian Americans/Pacific Islanders, pregnancy, prenatal care, low birthweight, preterm birth, cultural competency, community partnerships, costs, cost effectiveness.

Associations of the Use of Prenatal Care with Low Birthweight in Asian Pacific Women in Hawaii.

PURPOSE. This study examines ethnic-specific differences in associations of inadequate use of prenatal care with poor birthweight outcomes to determine whether ethnic specific improvements in the use of prenatal care in a rural district could potentially reduce infant morbidity or mortality there. METHODS. Data from 1988 to 1990 birth certificates of the state of Hawaii were used to study Filipino, Hawaiian and Japanese births. Stratified multivariate logistic regression analyses of the association of inadequate use of prenatal care visits with low birthweight were performed for each group adjusting for potentially confounding sociodemographic risk characteristics. SUMMARY OF IMPORTANT FINDINGS. Results indicate that the adjusted odds of low birthweight for the Hawaiians in the rural district with inadequate amounts of prenatal care visits were higher than for those with adequate visits (OR 2.1; CI 1.4, 3.1) and those relative odds were higher than for Hawaiians in the rest of the state (OR 1.2; CI 1.1, 1.5). Births to Japanese women in the area had a similar pattern (OR 2.3, CI 0.97, 5.6; rest of state OR 1.2, CI 0.98, 1.5), but the ratios were not statistically significant. Births to Filipino women did not have the same pattern (OR 0.73, CI 0.34, 1.6; rest of state OR 1.4, CI 1.2, 1.6). MAJOR CONCLUSIONS. There is substantial heterogeneity in the associations of inadequate care use with poor birthweight outcomes in different groups of Asian Pacific women and in different locations in which they settle. RELEVANCE TO ASIAN AND PACIFIC ISLANDER AMERICAN POPULATIONS. Communities need to determine the associations of poor birth outcomes with poor prenatal care usage of Asian Pacific women to determine whether ethnic specific improvements in prenatal care could potentially improve such outcomes in their areas. KEY WORDS. pregnancy, health services research, outcome and process assessment (health care), regression analysis (logistic models), low birth weight, patient compliance.