COVID-19: Implications for Nursing and Health Care in the United States.

PURPOSE: COVID-19 and other recent infectious disease outbreaks have highlighted the urgency of robust, resilient health systems. We may now have the opportunity to reform the flawed health care system that made COVID-19 far more damaging in the United States (U.S.) than necessary. DESIGN AND METHODS: Guided by the World Health Organization (WHO) Health System Building Blocks framework (WHO, 2007) and the socio-ecological model (e.g., McLeroy et al., 1988), we identified challenges in and strengths of the U.S.' handling of the pandemic, lessons learned, and policy implications for more resilient future health care delivery in the U.S. Using the aforementioned frameworks, we identified crucial, intertwined domains that have influenced and been influenced by health care delivery in the U.S. during the COVID-19 pandemic through a review and analysis of the COVID-19 literature and the collective expertise of a panel of research and clinical experts. An iterative process using a modified Delphi technique was used to reach consensus. FINDINGS: Four critically important, inter-related domains needing improvement individually, interpersonally, within communities, and for critical public policy reform were identified: Social determinants of health, mental health, communication, and the nursing workforce. CONCLUSIONS: The four domains identified in this analysis demonstrate the challenges generated or intensified by the COVID-19 pandemic, their dynamic interconnectedness, and the critical importance of health equity to resilient health systems, an effective pandemic response, and better health for all. CLINICAL RELEVANCE: The novel coronavirus is unlikely to be the last pandemic in the U.S. and globally. To control COVID-19 and prevent unnecessary suffering and social and economic damage from future pandemics, the U.S. will need to improve its capacity to protect the public's health. Complex problems require multi-level solutions across critical domains. The COVID-19 pandemic has underscored four interrelated domains that reveal and compound deep underlying problems in the socioeconomic structure and health care system of the U.S. In so doing, however, the pandemic illuminates the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to better serve the health care needs of the entire population. This article highlights the pressing need for multi-level individual, interpersonal, community, and public policy reforms to improve clinical care and public health outcomes in the current COVID-19 pandemic and future pandemics, and offers recommendations to achieve these aims.

Application of the Toxic Stress Schema: An Exemplar for School Nurses.

For many children of color, the cumulative impact of pre-existing stressors, disparities, and pandemic-related losses has contributed to a toxic level of stress. Toxic stress can disrupt healthy brain development making children vulnerable to physical and mental health problems. School nurses are the primary health professionals who interact with children daily during the academic year, which positions them to identify risk factors within the social determinants of health that contribute to the development of toxic stress. The Toxic Stress Schema (TSS) provides a framework for assessment and care planning related to social determinants of health and potential sources of stress and/or buffering support for the physical and mental well-being of children. A case study approach is used to demonstrate the application of the TSS to school nursing and provide the basis for conceptualizing a plan of care and identifying resources to support the child's physical and mental health.

Web-based chlamydia education for university students: A pilot project.

AIMS: Chlamydia disproportionately affects individuals aged 15-24 years. A lack of chlamydia knowledge in this high-risk group likely contributes to decreased testing, but interventions to increase chlamydia knowledge in this population are not well-described in the literature. The purpose of this pilot project was to increase chlamydia knowledge in a sample of university students using nurse-developed web-based education. DESIGN: A pre- and post-test design was used to evaluate participant knowledge of chlamydia before and after completing a nurse-developed web-based education intervention designed for university students. METHODS: Forty-seven undergraduate students at one U.S. university participated. A focus group and scientific evidence informed the development of the web-based education. RESULTS: Participants had a significant increase in chlamydia knowledge after completing the online educational intervention (M = 8.0, SD = 0.000) compared to baseline (M = 6.5, SD = 1.5), t(33) = -5.821, p < .0001. Pilot results provide promising evidence that web-based nurse-developed education designed specifically for university students can increase chlamydia knowledge.

Addressing Psychosocial Topics in Group Well-Child Care: A Multi-Method Study With Immigrant Latino Families.

OBJECTIVE: Group Well-Child Care (GWCC) has been described as providing an opportunity to enhance well-being for vulnerable families experiencing psychosocial challenges. We sought to explore benefits and challenges to the identification and management of psychosocial concerns in Group Well-Child Care (GWCC) with immigrant Latino families. METHODS: We conducted a case study of GWCC at an urban academic general pediatric clinic serving predominantly Limited English Proficiency Latino families, combining visit observations, interviews, and surveys with Spanish-speaking mothers participating in GWCC, and interviews with providers delivering GWCC. We used an adapted framework approach to qualitative data analysis. RESULTS: A total of 42 mothers and 9 providers participated in the study; a purposefully selected subset of 17 mothers was interviewed, all providers were interviewed. Mothers and providers identified both benefits and drawbacks to the structure and care processes in GWCC. The longer total visit time facilitated screening and education around psychosocial topics such as postpartum depression but made participation challenging for some families. Providers expressed concerns about the effects of shorter one-on-one time on rapport-building; most mothers did not express similar concerns. Mothers valued the opportunity to make social connections and to learn from the lived experiences of their peers. Discussions about psychosocial topics were seen as valuable but required careful navigation in the group setting, especially when fathers were present. CONCLUSIONS: Participants identified unique benefits and barriers to addressing psychosocial topics in GWCC. Future research should explore the effects of GWCC on psychosocial disclosures and examine ways to enhance benefits while addressing the challenges identified.

A Schema of Toxic Stress Informed by Racism, Transgenerational Stress, and Disadvantage.

INTRODUCTION: The Toxic Stress Schema (TSS) is an ecological framework with a social justice lens for identifying and alleviating stress and strengthening social determinants of health for children and families of color impacted by the COVID-19 pandemic and the cumulative effects of racism and generational, systemic inequities. METHOD: Relevant literature is reviewed, and examples were provided to illustrate the differential impacts of the "stress superstorm" of 2020 had on children of color based on their family's position on the advantage-disadvantage continuum. RESULTS: The utility of the TSS framework as a model for advanced nursing practice is demonstrated, and recommendations are formulated for the pediatric nurse practitioner's role in health policy. DISCUSSION: The COVID-19 pandemic elucidated the historical inequities experienced by children and families of color. The TSS framework provides a model for recognizing, organizing, and implementing.

Long-term Effectiveness of a Peer-Led Asthma Self-management Program on Asthma Outcomes in Adolescents Living in Urban Areas: A Randomized Clinical Trial.

Importance: Long-term effectiveness of a peer-led asthma self-management program in improving asthma outcomes in adolescents living in urban areas has not been established. Objective: To determine the long-term effects of a peer-led program on asthma control, quality of life, and asthma management among predominantly racial and ethnic minority adolescents living in urban areas. Design, Setting, and Participants: A parallel-group, randomized clinical trial was conducted in 2015 to 2019 in 3 metropolitan cities in the US: Buffalo, New York; Baltimore, Maryland; and Memphis, Tennessee. Adolescents aged 12 to 17 years old with persistent asthma were recruited mainly through clinical practices and schools. Participants were followed-up for 15 months after the intervention. Double-blinding was achieved for baseline. Data analysis was performed from June 2019 to June 2020. Interventions: The intervention group received a peer-led asthma self-management program; the control group received the identical program led by adult health care professionals. Peer leaders made follow-up contacts every other month for 12 months. Main Outcomes and Measures: The primary outcome was quality of life measured by the Pediatric Asthma Quality of Life Questionnaire, which consists of 3 subscales that measure symptoms (10 items), activity limitations (5 items), and emotional functioning (8 items) in the past 2 weeks. Each item was measured on a 7-point scale, with higher mean scores indicating better quality of life. Secondary measures included the Asthma Control Questionnaire and an asthma self-management index capturing steps to prevent and manage symptoms, self-efficacy, and lung function. Results: Of 395 eligible adolescents, 35 refused, 38 did not show or were lost to contact, and 2 withdrew before randomization; 320 adolescents participated (mean [SD] age, 14.3 [1.71] years), including 168 boys (52.5%), 251 Black or African American adolescents (78.4%), and 232 adolescents (72.5%) with public health insurance. Of 320 enrolled, 303 were included in the longitudinal analysis. Response rates were 80% or higher at all time points. The peer-led group had greater improvement in outcomes than the adult-led group, with adjusted mean differences (AMDs) between baseline and 15 months of 0.75 vs 0.37 for quality of life (between-group AMD, 0.38; 95% CI, 0.07 to 0.63) and -0.59 vs -0.31 for asthma control (between-group AMD, -0.28; 95% CI, -0.51 to -0.01). Outcomes were not affected by bimonthly contact doses. Conclusions and Relevance: In this randomized clinical trial, a peer-led asthma self-management education was more effective than an adult-led program in improving asthma outcomes, with the improvements sustained for up to 15 months. These findings suggest that a peer-led asthma self-management program should be considered in addressing the disproportionate asthma burden in racial and ethnic minority adolescents living in urban communities. Trial Registration: ClinicalTrials.gov Identifier: NCT02293499.

Tragedy in Haiti: Suicidality, PTSD, and Depression Associated with Intimate Partner Violence Among Haitian Women After the 2010 Earthquake.

Across the world, suicidal behaviors are responsible for more than one million deaths each year. In Haiti, suicidal behaviors were found to be related to intimate partner violence (IPV) against women. This study was conducted after the 2010 earthquake in Haiti and women were asked about IPV before and after that event. A sample of women between 18 and 44 years of age responded to a questionnaire about physical, psychological, or sexual abuse by an intimate or non-intimate partner. The women were divided into two groups: (a) women who were abused by partners (n = 133) and (b) women who were not abused (n = 75). Those who were abused had 2.2 times higher odds for suicidal thoughts and 1.9 times higher odds for suicidal attempts and were significantly more likely to suffer from depression and PTSD. For each 1-unit increase in a measured PTSD score, the odds of being abused increased by 105.7%. For each 1-unit increase in the measured depression score, the odds of being abused increased by 14.9%.

Enhanced access to healthcare utilization data through medical record review: Lessons learned from a community-based, multi-site project.

Collecting accurate healthcare utilization (HCU) data on community-based interventions is essential to establishing their clinical effectiveness and cost-related impact. Strategies used to enhance receiving medical records for HCU data extraction in a multi-site longitudinal randomized control trial with urban adolescents are presented. Successful strategies included timely assessment of procedures and practice preferences for access to electronic health records and hardcopy medical charts. Repeated outreach to clinical practice sites to identify and accommodate their preferred procedure for medical record release and flexibility in obtaining chart information helped achieve a 75% success rate in this study. Maintaining participant contact, updating provider information, and continuously evaluating site-specific personnel needs are recommended.

Innovative Simulation Roadmap for Faculty to Prepare Advanced Practice Registered Nurses for Entry Into Practice.

ABSTRACT: Advanced practice registered nurse (APRN) programs are challenged to provide clinical learning experiences that prepare graduates with the full continuum of expected competencies. Preparing the APRN in academia, in terms of didactic and clinical application for novice entry, is often a vexing balance between board certification preparedness and the actualities of clinical practice. This article presents an innovative strategy to examine the perplexing reflective question often asked by educators: Does the current approach for simulation development prepare our APRN students sufficiently for entry into practice, and is it current to what is occurring in practice?

Influence of social support on asthma self-management in adolescents.

OBJECTIVE: Adolescents with asthma are influenced by peers and family. The objective was to better understand family social support and test its association with medication adherence, asthma control, and Emergency Department (ED) use. METHODS: This study is a cross-sectional secondary data analysis from a randomized controlled trial with urban adolescents from three U.S. cities. Participants (12-20 years old) with asthma completed the Perceived Family Support Scale (PFS) and Horne's Medication Adherence Report Scale (MARS). Data from both tools were classified into 2 categories- high and low (< 25th percentile) perceived family support and high (total score >10) and low medication adherence, respectively. Chi-square statistic and logistic regression were used for analysis. RESULTS: Of the 371 participants, the majority were young (96% ≤ 17 years), African American or Bi-racial (85%), and Medicaid-insured (72%); over one-third had maternal family history of asthma. Among those on a controller medication (n = 270), only 37% reported its use ≥8 days over 2 weeks. Asthma control was poor with 50% categorized "not well controlled," 34% "very poorly controlled." Participants responded positively to most social support items. One item, providing and receiving social support to and from family members, was less often positively reported. Low medication adherence was significantly associated with lower perceived social support (p = 0.018). CONCLUSION: This study underscores the importance of family social support in understanding the extent of adolescents' self-management, particularly medication adherence.

Long-term effects of a peer-led asthma self-management program on asthma outcomes in adolescent peer leaders.

OBJECTIVE: To examine the long-term effects of a peer-led asthma self-management program on urban adolescent peer leaders with asthma. METHODS: This longitudinal study includes 51 adolescents (16-20 years) enrolled in an asthma self-management program implemented at a one-day camp as peer leaders. Study outcomes, including quality of life, asthma control, asthma knowledge, and attitudes toward asthma were collected for 15 months post-intervention. Mixed-effects models were conducted to estimate time effects, and effect sizes were calculated for each model. RESULTS: Of 51 enrolled, 41 completed the training, of which 35 successfully participated in the camp program. A total of 17 peer leaders withdrew between enrollment and 15-months follow-up. Quality of life, asthma control, and knowledge significantly improved after peer leader training and remained elevated for 15 months, while significant improvement in attitudes emerged immediately after camp, in which they served as leaders, and sustained for 15 months. CONCLUSION: This study demonstrates the long-term positive effects of a peer-led program on a wide range of asthma outcomes in urban adolescent peer leaders. PRACTICE IMPLICATIONS: A peer-led approach to asthma education providing peer leaders with intense training and leadership experience can be effective and sustainable in improving asthma outcomes among urban adolescents.

Young People's Voices Regarding the Use of Social Networking Sites to Plan for a Night Out Where Alcohol Is Involved.

The risk of alcohol related harm is experienced disproportionality by young people aged 15-24 years. Harmful use of alcohol has serious effects on individual physical and mental wellbeing and is considered by the World Health Organization to be one of the main risk factors for poor health globally. It is crucial to understand the factors that influence drinking behavior in young people in order to inform prevention strategies to prevent problematic drinking. This is particularly paramount during the transition into young adulthood (around 18-25 years), when risky health behaviors are likely to become embedded. This pilot study adopted a qualitative descriptive methodology that facilitates exploration of what young people say about their own experiences and behavior, as it relates to SNS use and alcohol consumption. Semi-structured interviews were conducted in Newcastle, NSW Australia. An inductive, semantic approach to thematic analysis was selected to analyze the data as this method supported the exploratory nature of the pilot study and ensured that the themes identified were strongly linked to the data. Four main organizing themes that arose from the collected data were: organizing friends; safety amongst friends, planning not to plan; and different event - different plans. All of the participants stated they preferred to use Facebook Messenger™ to connect and share in a group conversation with peers. Convenience, cost and accessibility emerged as the main reasons for using SNSs to plan nights out. Planning for a night out using SNSs allows young people to impulsively plan and change plans - making planning fluid and asynchronous. To date, despite the global use of SNSs, the influence of SNSs in young adults' planning for events during which alcohol is served is relatively unknown. This pilot study gives us a some understanding of how young people use SNSs to plan and prepare for a night out where alcohol is served. Further research needs to be conducted to determine whether SNSs can be used effectively to promote health behavior change or be used as forums for advice seeking and support when attending events where alcohol is served, with the ultimate goal of lowering risky behaviors and thereby improving health outcomes for young people.

mHealth Interventions to Reduce Alcohol Use in Young People: A Systematic Review of the Literature.

Harmful use of alcohol has serious effects on public health and is considered a significant risk factor for poor health. mHealth technology promotes health behavior change and enhances health through increased social opportunities for encouragement and support. It remains unknown whether these types of applications directly influence the health status of young people in reducing harmful levels of alcohol consumption. The purpose of this systematic review is to examine current evidence on the effectiveness of mHealth technology use in positively influencing alcohol-related behaviors of young people without known alcohol addiction. Relevant articles published from 2005 to January 2017 were identified through electronic searches of eight databases. Studies with interventions delivered by mHealth (social networking sites, SMS and mobile phone applications) to young people aged 12-26 years were included. Outcome measures were alcohol use, reduction in alcohol consumption or behavior change. Eighteen studies met the inclusion criteria. Interventions varied in design, participant characteristics, settings, length and outcome measures. Ten studies reported some effectiveness related to interventions with nine reporting a reduction in alcohol consumption. Use of mHealth, particularly text messaging (documented as SMS), was found to be an acceptable, affordable and effective way to deliver messages about reducing alcohol consumption to young people. Further research using adequately powered sample sizes in varied settings, with adequate periods of intervention and follow-up, underpinned by theoretical perspectives incorporating behavior change in young people's use of alcohol, is needed.

Fidelity of a peer-led asthma self-management intervention and its attention control in a multisite study of urban adolescents.

In this paper we compare the fidelity of a Peer-Led Asthma Self-Management Program for Adolescents (PLASMA) and its attention control. A randomized controlled trial involving two groups-the PLASMA group and the attention control group-was conducted between 2015 and 2018. Adolescents 12-17 years old (N = 259) in three cities in the United States received asthma self-management education implemented at a day camp, followed by bi-monthly, follow-up contact for 12 months. Thirty-five peer leaders and six adult educators implemented education sessions for the PLASMA and the attention control groups, respectively. The intervention was the peer-led delivery of the content instead of the educational content itself. This study compares the extent to which the education sessions and follow-up contacts were implemented in accordance with the study protocol by the peer and adult educators. Most topics on asthma knowledge and skills (85-95%) were delivered as intended at an adequate pace in both groups. Peer leaders missed more content in the psychosocial domain than adult educators-14% versus 0%, respectively (t = -3.7; p = .010). PLASMA participants reported high content and time fidelity for all education sessions (94% to 97.6%). Greater success in bimonthly follow-up contacts was reported in the attention control groups, with 4.6 ( ± 1.5) contacts on average compared to 2.6 (±2.02) in the PLASMA groups (t = 9.02; p < .001). Most components of the asthma self-management program were implemented with high fidelity in both groups. The relatively low fidelity in delivering psychosocial content and performing follow-up contacts in the PLASMA groups underscores the need for intensive training to enhance peer leaders' competency with managing these aspects of PLASMA to maximize fidelity. Peer leaders can implement asthma self-management educational components of the intervention with high fidelity similar to adult educators.

Acute Kidney Injury in Hospitalized Pediatric Patients: A Review of Research.

INTRODUCTION: Pediatric patients who develop acute kidney injury (AKI) while hospitalized have longer hospital stays, increased morbidity and mortality, and are at an increased risk for developing chronic kidney disease. Early recognition of AKI is becoming a major clinical focus. There is little research focusing on nursing interventions that may affect a pediatric patient's risk for developing AKI. The purpose of this review is to summarize reported predictors of AKI to improve its early recognition and treatment among hospitalized pediatric patients. METHODS: A review of research was conducted to further identify risk factors of AKI among noncritically ill hospitalized pediatric patients. RESULTS: The current literature demonstrated inconsistent findings in early recognition of AKI among hospitalized pediatric patients. DISCUSSION: Interventions for early recognition and treatment of AKI should consider other variables, such as previous history of AKI and fluid status as risk factors, warranting additional research.

Text Message Quality Improvement Project for Influenza Vaccine in a Low-Resource Largely Latino Pediatric Population.

Children with asthma are targeted for influenza vaccine because of their vulnerability to complications, particularly those with low income or family preference for Spanish language. We used text messaging to encourage caregivers to vaccinate. Participants were children (aged >6 months), predominantly low income and Latino, with an asthma diagnosis attending a pediatric clinic. Interactive text messages that described the vaccine and how to make an appointment were sent to parents in English or Spanish, January 2016 to April 2017. Year 1 messages were evaluated by the investigators considering vaccination results and evidence in the literature. Improvements for Year 2 included timing of message, clarity of message, and using the family language of preference. Messages went to 398 (Year 1) and 485 (Year 2) families. Sixty-four percent of families preferred English; 35% preferred Spanish. Children in Spanish-speaking families were significantly more likely than children in English-speaking families to be vaccinated, 66% versus 46%. Text messaging is a straightforward, low-cost health promotion strategy with potential to improve child health. Quality improvement efforts in outpatient settings with low-income and limited English proficiency families are needed. mHealth strategies may help address the needs of vulnerable populations. SQUIRE V.2.0 guidelines were used for manuscript writing and reporting.

Academic-clinical service partnerships are innovative strategies to advance patient safety competence and leadership in prelicensure nursing students.

Nurse-graduates today must be prepared to practice in a complicated healthcare system with numerous safety challenges. Although patient safety and quality competencies are a priority in nursing education, effective strategies for applying this knowledge into practice are needed. To meet this challenge, the Helene Fuld Leadership Program for the Advancement of Patient Safety and Quality at Johns Hopkins School of Nursing has developed an academic-clinical service partnership. Students are assigned to mentored, quality improvement projects in which they complete 100 hours over 2 semesters. This partnership links the Fuld Fellows with an interprofessional network of Johns Hopkins Medical Entity clinical Quality Improvement leaders. The partnerships have lead to manuscripts, professional job opportunities, and quality networking for both our students and mentors. Our strategic, academic-service partnership has improved student knowledge of patient safety principles and promoted nursing competence in patient safety with the development of future patient safety and QI nurse leaders.

Striving for Precision: Enhancing Genetic Competency in Primary Care Nurse Practitioner Students.

BACKGROUND: Research in genetics and genomics has led to the development of precision medicine, with health care increasingly individually based on one's genetic makeup. Implementation of genetics and genomics in primary care has been challenging given the rapid development of new advances. Clinicians report difficulties incorporating genetics and genomics in practice, citing insufficient knowledge, training, confidence, and resources for genetic diagnoses, testing, and result reporting. METHOD: Three pediatric nurse practitioner students participated in elective clinical rotations in pediatric genetics, with the goals of approaching all patients with genetic thinking, gaining competence collecting family health histories, and understanding available genetic resources. RESULTS: Postrotation, students gained genetic thinking skills, competence collecting a three-generational family health history to assess genetic risk factors and aid in genetic diagnosis, and the ability to navigate genetic resources. CONCLUSION: Genetics clinical rotations during primary care nurse practitioner education is an effective strategy to learn genetic and genomic competencies. [J Nurs Educ. 2018;57(11):690-693.].

Hypertension among adults living in Haiti: An integrative review.

AIMS AND OBJECTIVES: To determine what is known about hypertension among adults living in Haiti. BACKGROUND: Hypertension is the leading cause of morbidity, the identified cause of heart failure in 45% of patients and is associated with more than 70% of cardiovascular disease-related hospital admissions in Haiti. DESIGN: An integrative review of the literature. METHODS: Searching four databases from 2007 to 2018, Whittemore and Knafl's method was used to review the literature. Three nurse researchers independently reviewed and appraised each publication applying the Johns Hopkins Evidence-based Practice Appraisal tool. RESULTS: Eight publications were identified and appraised for level and quality of evidence. The synthesis of the literature yielded common themes of (i) high prevalence of hypertension among adults living in rural areas, (ii) public health challenges, (iii) lack of knowledge and awareness of hypertension and (iv) barriers to effective treatment. CONCLUSION: Hypertension is a highly prevalent disease in Haiti that is understudied and warrants attention. To better serve this vulnerable population, culturally tailored prevention strategies and disease management programmes are recommended. RELEVANCE TO CLINICAL PRACTICE: There is a lack of quality evidence to guide nurses in the management of hypertension for this vulnerable population. Identification of barriers to effective treatment among this underserved population will assist nurses and other healthcare professionals in identifying best possible practices for patient care in clinical settings across Haiti.

Recruitment and retention strategies for an urban adolescent study: Lessons learned from a multi-center study of community-based asthma self-management intervention for adolescents.

Intervention studies with urban adolescents and families affected by asthma are critical to improving the disproportionate morbidity in this population. Community-based recruitment and retention strategies in a multi-site longitudinal project evaluating an asthma self-management intervention for adolescents are presented. Successful recruitment strategies depended on the geographic and cultural characteristics of each study site. Partnering with providers and groups known to the target population and in-person contact with target population were found effective. Flexibility accommodating modified and new approaches, securing multiple contacts and repeating mailings as well as capitalizing on the benefits of subject payment was critical to achieving long-term subject engagement of 85% in the study. Ongoing monitoring and adjustment of recruitment and retention strategies is recommended.