Organizational Factors Associated with Evidence-Based Practice Knowledge, Attitudes, and Implementation among Nurses in Saudi Arabia.

Evidence-based practice (EBP) is crucial in keeping nurses aware of the current knowledge and improving clinical decision-making. The integration of nurses' EBP competencies and organizational support has been suggested to create an effective arena in implementing EBP. The purpose of the study was to examine organizational factors influencing nurses' EBP knowledge, attitudes, and implementation and identify staff nurses' perceptions of EBP nursing leadership and hospital supports in Saudi Arabia. Data were collected from a convenience sample of staff nurses (N = 227) working in four hospitals using a cross-sectional, correlational descriptive design. Level of education (p < 0.05), EBP training (p < 0.05), unit type (ICU (p < 0.001) and ER (p < 0.01)), perceived nursing leadership (p < 0.001), and work environment (p < 0.05) supports were found significantly associated with nurses' knowledge. Magnet recognition (p < 0.01) and knowledge (p < 0.001) had significant influence on nurses' attitudes. Unit type (ER) (p < 0.05), knowledge (p < 0.001), and attitudes (p < 0.001) were associated with implementation. Encouragement to attend EBP trainings from nursing leadership was perceived by most nurses (51.1%). Nurses reported their hospitals support EBP through training (68.2%). Findings support the need for healthcare systems to create a culture that facilitates EBP implementation to enhance nurses' EBP competencies and improve patients' outcomes. Nursing managers may consider preparing nurses through education.

Nurses' evidence-based practice knowledge, attitudes and implementation: A cross-sectional study.

AIM AND OBJECTIVES: To examine the influence of staff nurses' individual factors on knowledge, attitudes and implementation of evidence-based practice in Saudi Arabia and to identify facilitators and barriers to evidence-based practice implementation. BACKGROUND: Evidence-based practice has been considered as a key for healthcare quality measure. The literature, however, shows that nurses worldwide are not implementing evidence-based practice as expected and recommended by governing agencies. In Saudi Arabia, evidence-based practice implementation has not been addressed sufficiently. DESIGN: A cross-sectional, correlational design was used. We have complied with the guidelines of STROBE Checklist in presenting this research. A convenience sample of staff nurses (n = 227) was selected from four hospitals in Riyadh, Saudi Arabia. The survey questions included the Evidence-based Practice Questionnaire and individual factors. Data were analysed using multiple linear regression models. RESULTS: Attitudes towards evidence-based practice had the highest mean followed by evidence-based practice knowledge and implementation means. Evidence-based practice training and research involvement were associated with knowledge in the bivariate and multivariate analyses. None of the individual factors were associated with attitudes. However, knowledge was associated with attitudes. Knowledge and attitudes influenced evidence-based practice implementation positively. Unexpectedly, receiving evidence-based practice training made it more difficult for nurses to participate in evidence-based practice implementation process. We found that attitudes partially mediated the relationship between knowledge and evidence-based practice implementation. CONCLUSION: Nurses in Saudi Arabia are willing to be involved in the evidence-based practice process. However, nurses identified that they need to improve their knowledge and skills in order to be active participants in the process. RELEVANCE TO CLINICAL PRACTICE: Organisations and nursing leadership may benefit from developing a comprehensive strategy to promote staff nurses' involvement in the evidence-based practice process through providing continuing education and mentoring programmes about evidence-based practice.

Self-rated health among American adolescents with type 1 diabetes in the T1D Exchange Clinic Registry.

BACKGROUND: The goal of this study was to examine the self-rated health (SRH) of adolescents with type 1 diabetes (T1D). METHODS: A logistic regression analysis of baseline data from adolescents in the United States included in the T1D Exchange Clinic Registry in 2010-2012 was conducted. Participants were 13-18years old at the time of enrollment in the registry and had been diagnosed with T1D at least one year before enrollment (n=5799). RESULTS: Half (49.0%) of the participants were female, 46.3% were ages 16-18years, 22.5% were non-white, 35.7% did not have private/military health insurance, and 78.8% had HbA1c levels >7.5%, indicating poor T1D management, 20.7% reported having diabetes-related stress often or very often, and 46.4% used insulin injections or pens rather than a pump. In total, 10.3% (n=600) of the participants rated their health as poor or fair and 59.3% (n=3439) rated their health as very good or excellent. Participants with poor or fair SRH were more likely than those with very good or excellent SRH to be female (adjusted OR=1.7(1.4, 2.1)), 16 to 18years old (OR=2.1(1.7, 2.5)), and non-white (OR=2.7(2.2, 3.4)), to be without private or military insurance (OR=2.4(2.1, 3.0)), to have HbA1c levels >7.5% (OR=3.3(2.4, 4.7)), to report having diabetes-related stress often or very often (OR=6.1(5.1, 7.2)), and to use an injection or pen rather than a pump (OR=2.1(1.6, 2.4)). CONCLUSIONS: Because adolescents with T1D who report lower SRH are more likely to have uncontrolled blood glucose and frequent diabetes-related stress, use of pumps and stress-reduction strategies may improve SRH among adolescents with T1D.

The Development and Testing of the Psychometric Properties of the Emotional Response and Disclosure of Errors in Clinical Practice Instrument.

BACKGROUND AND PURPOSE: A tool to measure the nurses' emotional response after an error in clinical practice and the potential impact emotion can have on disclosure is lacking. This study tested the psychometric properties of the Emotional Response and Disclosure of Errors in Clinical Practice instrument. METHODS: The instrument was tested among 497 nurses with psychometric evaluation for validity, reliability, and exploratory factor analysis. RESULTS: Exploratory factor analysis revealed a 3-factor solution which accounted for 55.4% of the total variance. Internal consistency results were Cronbach's alpha = .935 for the overall scale and each domain: concern = .907, anxiety = .888, and disbelief = .775. CONCLUSIONS: Use of this valid and reliable instrument in practice and education can assist with patient safety efforts. Further testing of the instrument is recommended among other health care professionals.

Evaluating Diabetes Educational Interventions With a Skill Development Component in Adolescents With Type 1 Diabetes: A Systematic Review Focusing on Quality of Life.

PURPOSE: Adolescents with type 1 diabetes mellitus (T1DM) may have reduced quality of life (QOL) when compared with their peers. This systematic review evaluated the effectiveness of diabetes self-management education (DSME) interventions with a skills development component on the QOL of adolescents with T1DM. METHODS: Six databases were systematically searched for studies on the QOL outcomes of DSME interventions for adolescents with T1DM. Fourteen studies published between 1994 and 2014 met the inclusion criteria. RESULTS: Of the 14 studies, only 4 had significant QOL outcomes for the intervention participants. Successful DSME interventions had indirect behavioral skills foci or a combination of indirect and direct behavioral skills foci and a duration ≥2 months. CONCLUSION: This review provides evidence that educational interventions with an indirect behavioral skills development that facilitates diabetes management may improve QOL among adolescents with T1DM. Structured interventions targeting adolescents' QOL are needed to determine which are most effective in improving QOL. Adolescents with T1DM should be routinely screened and monitored for low QOL and referred to QOL-improving interventions.

Medical Home Implementation in Small Primary Care Practices: Provider Perspectives.

BACKGROUND: CareFirst BlueCross BlueShield of Maryland implemented a voluntary patient-centered medical home (PCMH) program in 2011 that did not require formal certification to participate. This study assessed attitudes and awareness of PCMH programs among participating providers in Maryland and Northern Virginia. METHODS: This qualitative study used information from 13 focus groups. In addition, 39 telephone interviews were conducted. An experienced facilitator moderated the focus groups. Written transcripts were analyzed using NVivo software. RESULTS: Several cross-cutting themes emerged. First, the payment bump of 12% was a motivating factor to participate but did not have long-term effects on participation. Second, nurse care coordinators were perceived as the key element of the PCMH program. Third, providers had limited awareness of an external data portal. Finally, small practices were generally receptive to the externally supported program elements. CONCLUSIONS: Implementation of PCMH program elements can be facilitated in small primary care practices even if third-party certification is not a requirement. Participating providers viewed having an external nurse care coordinator as the key element of the PCMH program. Small practices were receptive to external supports, but a lack of trust was viewed as a barrier to implementing a payer-based medical home program.

An integrated randomized intervention to reduce behavioral and psychosocial risks: pregnancy and neonatal outcomes.

While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (<37 weeks), low birth weight (<2,500 g), very low birth weight (<1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and >2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04-1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and >2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes. Level of evidence I.

African American and Latino patient versus provider perceptions of determinants of prenatal care initiation.

Few studies have compared provider and patient perceptions of barriers, motivators and facilitators of prenatal care (PNC) initiation. The current study compared these perceptions in providers and patients in Washington, DC, a city characterized by infant mortality and low birth weight rates that are among the highest in the nation, and poor utilization of PNC, particularly among minority groups. The results reported here were part of a larger study of barriers, motivators and facilitators influencing PNC utilization in Washington, DC. A convenience sample of 331 African American and Latino patients and 61 providers were interviewed to identify which of 63 motivators, facilitators, and barriers significantly influenced PNC initiation. Both sample groups were recruited at 14 PNC facilities, selected to represent all sites in DC known to serve high-risk, low-income minority women, including hospital-based clinics, community-based clinics, and private practices. Data were analyzed using Fisher exact tests and Kendall's concordance tests. Results indicated that there was good agreement between patients and providers about the relative importance of the various barriers (especially psychosocial), motivators, and facilitators. However, differences were found between patients and providers in the response frequencies. Providers were more likely to report barriers while patients were more likely to report certain motivators (especially learning better health habits and how to protect health). These results indicate that despite widespread agreement on most issues, especially psychosocial barriers, patients rated health education higher than providers.

Efficacy of a randomized cell phone-based counseling intervention in postponing subsequent pregnancy among teen mothers.

Adolescent mothers in Washington, DC have a high rate of subsequent teen pregnancies, often within 24 months. Children of teen mothers are at risk for adverse psychosocial outcomes. When adolescents are strongly attached to parents, schools, and positive peers, they may be less likely to repeat a pregnancy. This study tested the efficacy of a counseling intervention delivered by cell phone and focused on postponing subsequent teen pregnancies by strengthening healthy relationships, reproductive practices, and positive youth assets. The objective of this study was to compare time to a repeat pregnancy between the intervention and usual care groups, and, secondarily, to determine whether treatment intensity influenced time to subsequent conception. Primiparous pregnant teens ages 15-19, were recruited in Washington, DC. Of 849 teens screened, 29.3% (n = 249) met inclusion criteria, consented to participate, and completed baseline measures. They were then randomized to the intervention (N = 124) or to usual care (N = 125). Intervention group teens received cell phones for 18 months of counseling sessions, and quarterly group sessions. Follow-up measures assessed subsequent pregnancy through 24 months post-delivery. A survival analysis compared time to subsequent conception in the two treatment groups. Additional models examined the effect of treatment intensity. By 24 months, 31% of the intervention and 36% of usual care group teens had a subsequent pregnancy. Group differences were not statistically significant in intent-to-treat analysis. Because there was variability in the degree of exposure of teens to the curriculum, a survival analysis accounting for treatment intensity was performed and a significant interaction with age was detected. Participants who were aged 15-17 years at delivery showed a significant reduction in subsequent pregnancy with increased levels of intervention exposure (P < 0.01), but not those ≥ 18 years. Adolescents ≥ 18 years faced considerable challenges to treatment success. Individual, social, and contextual factors are all important to consider in the prevention of repeat teen pregnancy. Cell phone-based approaches to counseling may not be the most ideal for addressing complex, socially-mediated behaviors such as this, except for selective subgroups. A lack of resources within the community for older teens may interfere with program success.

Patterns of alcohol consumption among pregnant African-American women in Washington, DC, USA.

The objective of this paper is to describe the patterns and associated behaviours related to alcohol consumption among a selected sample of pregnant women seeking prenatal care in inner city Washington DC. Women receiving prenatal care at one of nine sites completed an anonymous alcohol-screening questionnaire. Questions concerned the amount, type and pattern of alcohol consumption. Women were categorised as at no, low, moderate or high risk for alcohol consumption during pregnancy. For comparisons of risk levels of drinking, bivariate associations were examined using Fisher's exact test. Odds ratios (ORs) and 95% confidence intervals (CIs) were also computed. Although 31% of current/recent drinkers stated that they continued to drink during pregnancy, responses to quantity/frequency questions revealed that 42% continued to do so. Women who were at high compared with moderate risk acknowledged that others were worried about their consumption [OR=4.0, 95% CI 1.5, 10.6], that they drank upon rising [OR=6.7, 95% CI 1.8, 26.9], had a need to reduce drinking [OR=3.2, 95% CI 1.3, 8.1] and in the past 5 years had had fractures [OR=4.2, 95% CI 1.0, 17.8] or a road traffic injury [OR=3.4, 95% CI 1.0, 12.2]. Women in the high/moderate compared with low-risk group were more likely to have been injured in a fight or assault [OR=2.7, 95% CI 1.3, 5.6]. This study validated the usefulness of our questionnaire in identifying women who were at risk for alcohol consumption during pregnancy across a range of consumption levels. Using our screening tool, women were willing to disclose their drinking habits. This low-cost method identifies women appropriate for targeting of interventions.

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women.

BACKGROUND: African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format. METHODS: Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported. RESULTS: Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended > or = 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed. CONCLUSION: While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.

Determinants of inadequate prenatal care utilization by African American women.

A convenience sample of city-dwelling African American women (n=246) was interviewed during each woman's postpartum stay at one of five hospitals in Washington, D.C. to determine their perceptions of factors influencing their prenatal care utilization. The Kotelchuck Adequacy of Prenatal Care Utilization Index was used to classify prenatal care utilization as either adequate (Adequate Plus and Adequate groups combined) or inadequate (Intermediate and Inadequate groups combined). Of the 246 women studied, 40% (99) had adequate prenatal care utilization. Using Classification and Regression Trees analysis, the following risk groups for inadequate prenatal care utilization were identified: women who reported psychosocial problems as barriers and who were not participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (percent adequate=8.8); women who reported psychosocial problems as barriers, were participants of the WIC program, and reported substance use (percent adequate=13.8); and women who reported psychosocial problems as barriers, were participants of the WIC program, denied substance use, and reported childcare problems as barriers (percent adequate=20.0).

Perceptions about prenatal care: views of urban vulnerable groups.

BACKGROUND: In the United States, infant mortality rates remain more than twice as high for African Americans as compared to other racial groups. Lack of adherence to prenatal care schedules in vulnerable, hard to reach, urban, poor women is associated with high infant mortality, particularly for women who abuse substances, are homeless, or live in communities having high poverty and high infant mortality. This issue is of concern to the women, their partners, and members of their communities. Because they are not part of the system, these womens' views are often not included in other studies. METHODS: This qualitative study used focus groups with four distinct categories of people, to collect observations about prenatal care from various perspectives. The 169 subjects included homeless women; women with current or history of substance abuse; significant others of homeless women; and residents of a community with high infant mortality and poverty indices, and low incidence of adequate prenatal care. A process of coding and recoding using Ethnograph and counting ensured reliability and validity of the process of theme identification. RESULTS: Barriers and motivators to prenatal care were identified in focus groups. Pervasive issues identified were drug lifestyle, negative attitudes of health care providers and staff, and non-inclusion of male partners in the prenatal experience. CONCLUSIONS: Designing prenatal care relevant to vulnerable women in urban communities takes creativity, thoughtfulness, and sensitivity. System changes recommended include increased attention to substance abuse treatment/prenatal care interaction, focus on provider/staff attitudes, and commitment to inclusion of male partners.