Exploring Factors Affecting Parental Psychological Vulnerability During Their Child's PICU Admission: A Prospective Pilot Cohort Study.

INTRODUCTION: Parental psychological responses during their child's pediatric intensive care unit (PICU) admission are often overlooked. This study aimed to identify pre-existing and peri-traumatic factors explaining parental stress and anxiety during their child's PICU admission and one-month follow-up. METHOD: A prospective pilot study included 60 PICU parents. Parental Stressors Scale and State-trait Anxiety Inventory measured stress and anxiety during PICU admission, and the State-trait Anxiety Inventory and Perceived Stress Scale at a one-month follow-up. RESULTS: During PICU admission, parental stress correlated with age, race, and adverse childhood experiences (ACEs), anxiety was linked to income. At one-month follow-up, anxiety related to child's health worries, perceived stress was linked to parental ACEs and education. Parental ACEs predicted perceived stress (b = 0.83, p = .028). Children's diagnoses explained anxiety, particularly respiratory and cardiac diagnoses (b = -13.44, p = .023; -10.03, p = .045). DISCUSSION: Identifying factors helps teams understand parental vulnerability and provide appropriate support.

Pain assessment & management decision-making in pediatric critical care.

PURPOSE: The aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed. DESIGN AND METHODS: A qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes. RESULTS: Three major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made. CONCLUSIONS: Variation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. "Assume pain present" was identified as a concept and documentation practice that may guide decisions; further research is needed. PRACTICE IMPLICATIONS: Development of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.

Using a Cascading Approach to Improve Multisite Study Procedures.

BACKGROUND: Multisite studies offer larger, more diverse samples to successfully capture populations and clinical practices of interest at the point of care. However, investigators face challenges with site recruitment and sampling, differences in clinical practices across sites, and data integrity. Addressing these issues a priori can improve the rigor and reproducibility of the research. OBJECTIVE: This article aims to describe a cascading approach to multisite research. An exemplar is provided of a study using this approach, which aimed to evaluate the prevalence of pain and the pain management practices provided to critically ill children in pediatric intensive care units in the United States. METHODS: The cascading approach includes two or more pilot study procedures with a progressively increasing number of sites prior to a full-scale study. Following each pilot, study procedures are evaluated; feedback was obtained from site personnel and content experts; procedures were revised accordingly; approvals were obtained; sites were trained; and the revised procedures are repeated with a larger, more diverse number of sites. RESULTS: In the exemplar provided, improvements in the efficiency and integrity of data collection were noted for the full-scale study following the pilots. All sites that completed the agreements and approvals for study participation were retained for the duration of the two pilots and full-scale study. DISCUSSION: Borrowing from principles of process improvement, the cascading approach allows knowledge to be gained regarding site differences and informs the revision of study procedures while potentially maximizing efficiency and data integrity, minimizing site burden, and maintaining site engagement for multisite studies.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation.

BACKGROUND: Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice. OBJECTIVES: To describe how PICU nurses are assessing and managing pain for children who require NMB. METHODS: A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither. RESULTS: A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent. CONCLUSIONS: These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

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.

Predicting Who Receives Nonpharmacologic Pain Interventions in the Pediatric Intensive Care Unit.

AIMS: The majority of patients in the pediatric intensive care unit (PICU) experience pain daily, while nonpharmacologic interventions are indicated for pain management in children, there is limited information on which nonpharmacologic interventions are provided in the PICU and which patients receive those interventions. The aim of this descriptive correlational secondary data analysis was to determine what nonpharmacologic interventions were recorded in the electronic health record of PICU patients and patterns in use by patient demographics. SETTING/SUBJECTS: All patients hospitalized in 15 participating PICUs are located within 12 unique children's hospitals across the United States were eligible for participation. METHODS: Nonpharmacologic interventions used in the PICU were identified and differences between patients who did and did not receive those interventions were examined using Fisher's exact test. A generalized linear mixed effects model was constructed to determine patient characteristics that predict nonpharmacologic pain intervention application. RESULTS: Of 220 enrolled patients, 97 (44%) had nonpharmacologic pain interventions recorded in their electronic health record. The most frequently recorded interventions included repositioning (65%), decreasing environmental stimuli (55%), caregiver presence (37%), distraction (23%), and music therapy (20%). Children who had moderate to severe pain were most likely to receive nonpharmacologic pain interventions. CONCLUSIONS: Nonpharmacologic pain management is applied inconsistently across PICUs and may be underdocumented or underutilized. Additional research is needed to determine when nurses use nonpharmacologic pain interventions, their rationale for applying these interventions across differing groups, and the effectiveness of these interventions in managing pain in critically ill children.

Exploring the Effects of the COVID-19 Pandemic on the Children and Families Cared for by Pediatric-Focused Advanced Practice Registered Nurses.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has significantly affected children and families. The study purpose was to better understand the perceptions of pediatric-focused advanced practice registered nurses (P-APRNs) on the impact of COVID-19 on patients and practice. METHOD: A 25-item electronic survey including Likert scales, multiple choice , and open-ended questions was sent by e-mail to electronic mailing list of the National Association of Pediatric Nurse Practitioners. RESULTS: Responses (N = 109) reflect the magnitude of challenges affecting child physical health, mental health, parental stress, and social determinants of health. P-APRNs expect greater refusal of the COVID-19 vaccine compared with other vaccines. Telehealth use continues at an increased rate and greater resources are needed to support clinical practice. DISCUSSION: The COVID-19 pandemic has transformed the lives of children, families, and P-APRN practice. These findings reflect challenges and opportunities moving forward. P-APRNs are well-prepared to lead change to support better and more equitable outcomes for all.

Emergency Medication Access and Administration in Schools: A Focus on Epinephrine, Albuterol Inhalers, and Glucagon.

Access to emergency medications is a growing concern, particularly regarding the availability, safety, and use of these medications in schools. The purpose of this article is to report results not previously published from a national survey, specifically regarding the emergency use of epinephrine, albuterol inhalers, and glucagon. A nonexperimental, cross-sectional design was utilized for this descriptive study. An online survey was distributed to school nurses in 2015, and data from 6,298 school nurse respondents are presented in the analysis. Findings related to stock and student-specific emergency medication use and storage, epinephrine usage data, and delegation of emergency medication administration to unlicensed assistive personnel are presented in this article. Further development of policies and procedures regarding emergency medication administration in schools is needed. School nurses are a valuable resource for obtaining knowledge in this area and keeping students safe at school.

Strategies to enhance the success of mid-career nurse scientists.

BACKGROUND: The mid-career nurse scientist, defined as an associate professor with/without tenure, is often faced with a multitude of challenges and opportunities PURPOSE: This paper shares strategies to assist mid-career scientists as they juggle required career demands and navigate the mid-career phase in pursuit of the rank of full professor. METHOD: A review of the literature was performed on mid-career nurse scientists. DISCUSSION: A combination of increased research responsibilities, increased institutional teaching and service demands, and dwindling support can result in a sense of overwhelm and burnout. The mid-career nurse scientist must balance several balls in the air at one time to remain successful. CONCLUSION: Strategies aligned with the Ecological Framework, focus on intrapersonal, interpersonal, institutional, organizational, and public policy domains to provide a wide scope of strategies that target the mid-career scientist and engage the larger nursing community.

Toolkit to Increase Provider Knowledge, Comfort, and Adoption of POLST: Portable Medical Orders in a Primary Care Setting.

BACKGROUND: POLST-Portable Medical Orders-abbreviated as POLST, is a nationwide initiative to help providers document and meet a patient's end-of-life wishes. PROBLEM: Provider completion of POLST documents in primary care can promote continuity and implementation of patient preferences at the end of life in community-dwelling adults. Educating and providing a clinical process to support POLST use may improve implementation. APPROACH: A POLST toolkit was developed for primary care providers with measurement of knowledge, comfort, and likelihood of use with pre- and postsurvey data collection. The POLST toolkit was used to engage primary care providers in an educational session to enhance understanding and increased utilization. OUTCOMES: Providers reported increased knowledge, self-reported comfort, and likelihood of using POLST documents. CONCLUSIONS: Utilization of a POLST toolkit, with an educational component, improved provider interest in POLST implementation.

Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations.

Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.

Pathways from pain to physical and mental health-related quality of life during the third trimester of pregnancy: an exploratory mediation analysis.

AIMS AND OBJECTIVES: To understand how pain affects physical and mental health-related quality of life during the third trimester of pregnancy. BACKGROUND: Poor health-related quality of life during pregnancy is associated with adverse maternal foetal health outcomes such as increased risk of low-birth-weight neonates. Poor health-related quality of life is linked to pain, pain interference and anxiety in the general adult population. However, we do not know how pain, pain interference (i.e., interference of pain with patient function), and anxiety are interrelated during the third trimester of pregnancy. METHODS: This exploratory cross-sectional study followed STROBE guidelines. A mobile educational and tracking pregnancy application was used to obtain a racially/ethnically diverse convenience sample of 141 third trimester pregnant women from the U. S. In this sample, 58.2% of women had commercial health insurance, 68.8% were Caucasian, 86.5% were younger than 35 years, and 85.1% had a partner. Women completed demographics, Edinburgh Postnatal Depression Scale and the Brief Pain Inventory on REDCap. Path analysis was used to investigate a model for the relationships among pain intensity, pain interference, anxiety and physical and mental health-related quality of life. RESULTS: Pain intensity affected health-related quality of life indirectly by increasing pain interference, which in turn, decreased both physical and mental health-related quality of life. In addition, pain interference also increased anxiety, which in turn worsened mental health-related quality of life, but not physical health-related quality of life. CONCLUSIONS: Treating perinatal pain may improve health-related quality of life by decreasing pain interference and anxiety. RELEVANCE TO CLINICAL PRACTICE: Nurses should assess for pain interference and anxiety in women experiencing moderate to severe pain during the third trimester of pregnancy. With this knowledge, nurses may advocate for women in receiving effective treatment for their conditions and improvements in their physical and mental health-related quality of life.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth.

OBJECTIVE: To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records. DESIGN: A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group. SETTING: A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers. PARTICIPANTS: All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization. MEASUREMENTS: Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff. RESULTS: Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample. CONCLUSION: The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

Development and Pilot of a REDCap Electronic Informed Consent Form for Research: An Example from the ROPE Study.

A study that describes the development of an electronic informed consent, using the REDCap platform, and the results of a pilot study to assess participants' understanding and acceptance of that electronic informed consent for use in a research study.

Pain and Depression Symptoms During the Third Trimester of Pregnancy.

PURPOSE: To assess the association between depression symptoms and pain characteristics, including pain intensity, location, and effectiveness of pain management strategies, among women in their third trimester of pregnancy. DESIGN: Descriptive, exploratory cross-sectional study. SETTING: Mobile health pregnancy application (app). PARTICIPANTS: A convenience sample of women in their third trimester of pregnancy from across the United States. METHODS: Women completed demographic questionnaires, the Brief Pain Inventory, and Edinburgh Postnatal Depression Scale (EPDS) through an online Web site. RESULTS: N = 132 women participated. The sample was demographically diverse. . Women ranged in age from 18 to 39 years (M 28.1 ± SD 5.2). Most women were Caucasian (68%), with smaller percentages of Hispanic (12%) and African American (11%) women. Most had commercial insurance (59%) and a partner (85%). Of the 132 women, 79.6% reported moderate-to-severe pain. Approximately 93% experienced back and pelvic pain, whereas 27% experienced moderate-to-severe depression symptoms. Bivariate and linear regression analyses revealed that higher EPDS depression scores were associated with higher levels of pain (p < .01). Other variables significantly associated with higher EPDS scores were White race (p = .04), marital status (p = .05), and headache (p < .01). CLINICAL IMPLICATIONS: In the third trimester of pregnancy, pain affects more than two-thirds of women and may occur with and without depression symptoms. Although the value of universal depression screening during pregnancy is widely recognized, our findings suggest clinical outcomes for pregnant women would improve with a standardized, multidimensional screen for both pain and depression symptoms. Nurses are ideally positioned to assess and advocate for the combined treatment of pain and depression.

An integrated model of multimorbidity and symptom science.

BACKGROUND: Prevalence and complexity of persons with multiple chronic conditions (MCC), also known as multimorbidity, are shifting clinical practice from a single disease focus to one considering MCC and symptoms. Although symptoms are intricately bound to concepts inherent in MCC science, symptoms are largely ignored in multimorbidity research and literature. PURPOSE: Introduce an Integrated Model of Multimorbidity and Symptom Science. METHODS: Critical integrative review and synthesis process. FINDINGS: The model comprises three primary domains: 1. Contributing/ Risk Factors; 2. Symptom/Disease/Treatment Interactions; and 3. Patient Outcomes. DISCUSSION: The model highlights the multilevel nature of contributing factors and the recursive interactions among multiple etiologies, conditions, symptoms, therapies, and outcomes.