Situating nursing science and public health within a shared context.

The purpose of this editorial is to discuss the opportunities associated with situating nursing science and public health within a shared context as an avenue for nursing to capitalize on its strong foundation for promoting health equity and mitigating the many social and structural determinants of poor health. We highlight one example of how this might be done, by housing departments of nursing in larger colleges of public health. Conducting nursing science within a college of public health presents both opportunities and challenges which are discussed here. Considering the benefits and challenges of collectively situating nursing and public health with a shared context creates numerous natural starting points for productive conversation, collaboration, and discovery that can benefit both public health and nursing's ability to interrogate past harms and transform our approach to move towards a more healthy and equitable future for all.

Mitigating Barriers to Doctoral Education for Nurses.

AIM: This article reports preliminary outcomes of the Guiding Initiative for Doctoral Education, which promotes success in doctoral study. BACKGROUND: Nurses face challenges as they move intentionally, effectively, and expediently toward earning the doctorate. Selecting the doctoral education best suited to individual career goals is essential for success. METHOD: An intensive, daylong program focused on setting goals, generating personal action plans, and mobilizing resources to promote success in application and return to the role of student. RESULTS: Based on 70 nurses who participated in seven programs, 22 (31 percent) were admitted to their doctoral program of choice (6 PhD, 15 DNP, 1 EdD). CONCLUSION: Nurses benefit from and value learning about the options for doctoral study, requirements for educational opportunities, the nature of the commitment required, challenges commonly encountered during the process, and the impact advanced education can be expected to have on immediate and long-term career opportunities.

Flying Lessons for Clinicians: Developing System 2 Practice.

There is a long history of adopting lessons learned from aviation to improve health care practice. Two of the major practices that have successfully transferred include using a checklist and simulation. Training and simulation technology is currently underdeveloped for nurses and health care providers entering critical care transport. This article describes a pedagogical approach adopted from aviation to develop a new simulation platform and program of research to develop the science of critical care transport nursing education.

Becoming Parent and Nurse: High-Fidelity Simulation in Teaching Ambulatory Central Line Infection Prevention to Parents of Children with Cancer.

BACKGROUND: Ambulatory central-line infections in children with cancer are life-threatening. Infections are two to three times more frequent in outpatients than inpatients, for whom evidence-based bundles have decreased morbidity. Most cancer care now takes place at home, where parents perform many of the same tasks as nurses. However, parents often feel stressed and unprepared. To address this, high-fidelity simulation, which has been effective for teaching novice nurses, was evaluated for parent central-line education. METHODS: In a feasibility study using a pretest/posttest design, after completion of usual central-line education, parents participated in a high-fidelity simulation practice session. Parents were assessed in three domains: (1) knowledge of infection prevention; (2) psychomotor skill competence; and (3) ability to recognize health care provider nonadherence to best practices. Parents also completed a 5-point Likert simulation experience survey. RESULTS: A convenience sample of 17 parents participated between December 2015 and March 2016. Knowledge median scores increased from pre- to posttest from 10 to 15 of 16 points possible (p ≤ 0.001; Wilcoxon signed rank test). Median skills scores increased from pre- to posttest from 8 to 12 points of 12 possible (p ≤ 0.001). Following simulation, median recognition scores increased from 3 to 6 with 6 points possible (p ≤ 0.001). For the parent experience survey, 100% of participants strongly agreed or agreed that simulation was meaningful for learning central-line care. CONCLUSIONS: As an adjunct to usual care central-line education, translation of high-fidelity simulation to parent education is a novel approach that shows promise for improving central-line care at home in children with cancer.

Using Clinical Decision Support and Dashboard Technology to Improve Heart Team Efficiency and Accuracy in a Transcatheter Aortic Valve Implantation (TAVI) Program.

Heart Team meetings are becoming the model of care for patients undergoing transcatheter aortic valve implantations (TAVI) worldwide. While Heart Teams have potential to improve the quality of patient care, the volume of patient data processed during the meeting is large, variable, and comes from different sources. Thus, consolidation is difficult. Also, meetings impose substantial time constraints on the members and financial pressure on the institution. We describe a clinical decision support system (CDSS) designed to assist the experts in treatment selection decisions in the Heart Team. Development of the algorithms and visualization strategy required a multifaceted approach and end-user involvement. An innovative feature is its ability to utilize algorithms to consolidate data and provide clinically useful information to inform the treatment decision. The data are integrated using algorithms and rule-based alert systems to improve efficiency, accuracy, and usability. Future research should focus on determining if this CDSS improves patient selection and patient outcomes.

Using Dashboard Technology and Clinical Decision Support Systems to Improve Heart Team Efficiency and Accuracy: Review of the Literature.

AIM: This review aimed to provide a comprehensive overview of the current state of evidence for the use of clinical dashboards and clinical decision support systems (CDSS) in multidisciplinary teams. METHODS: A literature search was performed for the dates 2004-2014 on CINAHL, Medline, Embase, and Cochrane Library. A citation search and a hand search of relevant papers were also conducted. RESULTS: (One hundred and twelve full text papers were retrieved of which 22 were included in the review.) There was considerable heterogeneity in setting, users, and indicators utilized. Information on usability and human-computer interaction was thoroughly reviewed. There was evidence that dashboards were associated with improved care processes when end-user input was incorporated and information was concurrent, pertinent and intuitive. CONCLUSION: There is some evidence that implementing clinical dashboards and/or CDSS that provide immediate access to current patient information for clinicians can improve processes and patient outcomes.

The Doctor of Nursing Practice: From Start-Up to Impact.

AIM: This article reflects on the progress of the doctor of nursing practice (DNP) degree and its place in health care. BACKGROUND: The DNP originated over 10 years ago, long enough for a comprehensive evaluation. METHOD: Rogers' Diffusion of Innovation Theory is used to trace the history of the DNP. Nurse leaders from service and academia (n = 120) share strategies and innovations, and evaluate DNP education with a focus on outcomes and impact. RESULTS: As schools of nursing target DNPs to become faculty to mitigate the shortage, participants agreed it is time to focus on graduating strong leaders prepared to transform health care. CONCLUSION: A growing number of nurses practicing in diverse roles have earned the DNP from programs that vary considerably in rigor. Demand for the competencies, skills, and experience which DNPs bring to practice is high as organizations adapt to the accountable care environment.

The Preparation-Practice Gap: An Integrative Literature Review.

BACKGROUND: The purpose of this integrative literature review was to evaluate and synthesize the evidence regarding the existence, extent, and significance of a preparation-practice gap-namely, the deficits in knowledge and skills that novice nurses may demonstrate on entry into the clinical setting and the identified best practices to narrow this gap. METHOD: An integrative literature review was performed. RESULTS: A final set of 50 articles were included in the review. Three main themes permeate the evidence: a preparation-practice gap exists; this gap is costly; and closing the preparation-practice gap will likely rely on changes in undergraduate education and on-the-job remediation (i.e., nurse residency or preceptor programs). CONCLUSIONS: The preparation-practice gap is a challenge that has faced the nursing profession for years. Efforts to close this gap can be justified on the hopes of decreasing turnover (and its attendant costs), boosting morale of novice nurses and their preceptors, decreasing stress among the novice nurses, and improving patient safety.

Scholarly work products of the doctor of nursing practice: one approach to evaluating scholarship, rigour, impact and quality.

AIMS AND OBJECTIVES: The aim of this investigation was to evaluate, monitor and manage the quality of projects conducted and work produced as evidence of scholarship upon completion of Doctor of Nursing Practice education. BACKGROUND: The Doctor of Nursing Practice is a relatively new degree which prepares nurses for high impact careers in diverse practice settings around the globe. Considerable variation characterises curricula across schools preparing Doctors of Nursing Practice. Accreditation assures curricula are focused on attainment of the Doctor of Nursing Practice essentials, yet outcomes have not been reported to help educators engage in programme improvement. This work has implications for nursing globally because translating strong evidence into practice is key to improving outcomes in direct care, leadership, management and education. The Doctor of Nursing Practice student learns to accomplish translation through the conduct of projects. Evaluating the rigour and results of these projects is essential to improving the quality, safety and efficacy of translation, improvements in care and overall system performance. DESIGN: A descriptive study was conducted to evaluate the scholarly products of Doctor of Nursing Practice education in one programme across four graduating classes. METHODS: A total of 80 projects, conducted across the USA and around the globe, are described using a modification of the Uncertainty, Pace, Complexity Model. RESULTS: The per cent of students considered to have produced high quality work in relation to target expectations as well as the per cent that conducted means testing increased over the four study years. CONCLUSIONS: Evaluation of scope, complexity and rigour of scholarly work products has driven improvements in the curriculum and informed the work of faculty and advisors. RELEVANCE TO CLINICAL PRACTICE: Methods, evaluation and outcomes conformed around a set of expectations for scholarship and rigour have resulted in measurable outcomes, and quality publications have increased over time.

A systematic approach incorporating family history improves identification of cardiovascular disease risk.

BACKGROUND: Although family history (FH) is an independent predictor of cardiovascular disease (CVD) risk, traditional risk scores do not incorporate FH. Nurse practitioners routinely solicit FH but have no mechanism to incorporate the information into risk estimation. Underestimation of risk leaves clinicians misinformed and patients vulnerable to the CVD epidemic. OBJECTIVE: We examined a systematic approach incorporating FH in CVD risk assessment, validating risk reclassification using carotid intima-media thickness (CIMT), a surrogate measure of atherosclerosis. METHODS: Of 413 consecutive patients prospectively enrolled in the Integrative Cardiac Health Project Registry, a subgroup of 239 was low or intermediate risk by the Framingham Risk Score. A systematic approach for the assessment of FH was applied to this subgroup of the registry. A positive FH for premature CVD, defined as a first-degree relative having a CVD event before the age of 55 years in men and 65 years in women, conferred reclassification to high risk. Reclassification was validated with CIMT results. RESULTS: Chart audits revealed adherence to the systematic approach for FH assessment in 100% of cases. This systematic approach identified 115 of 239 (48%) patients as high risk because of positive FH. Of the reclassified patients, 75% had evidence of subclinical atherosclerosis by CIMT versus 55% in the patients not reclassified, P < 0.001. Logistic regression identified positive FH for premature CVD (odds ratio, 2.6; P = 0.001) among all variables, as the most significant predictor of abnormal CIMT, thus increasing risk for CVD. CONCLUSIONS: The Integrative Cardiac Health Project systematic approach incorporating FH into risk stratification enhances CVD risk assessment by identifying previously unrecognized high-risk patients, reduces variability in practice, and appropriately targets more stringent therapeutic goals for prevention.

An approach to clinical data management for the doctor of nursing practice curriculum.

Strong data management skills are essential to doctor of nursing practice (DNP) education and necessary for DNP practice. Completion of the DNP scholarly project requires application of these skills to understand and address a complex practice, process, or systems problem; develop, implement, and monitor an innovative evidence-based intervention to address that problem; and evaluate the outcomes. The purposes of this paper were to describe the demand and context for clinical data management (CDM) within the DNP curriculum; provide an overview of CDM content; describe the process for content delivery; propose a set of course objectives; and describe initial successes and challenges. A two-pronged approach of consultation and a CDM course were developed. Students who participated in this approach were more likely to create and implement an evaluation plan; apply techniques for data cleansing and manipulation; apply concepts of sample size determination using power analysis; use exploratory data analysis techniques to understand population attributes and sampling bias; apply techniques to adjust for bias; apply statistical significance testing; and present project results in a meaningful way. On the basis of this evaluation, CDM has evolved from an elective to a required course integrated in a thread that crosses the entire curriculum.

Improving assessment of cardiovascular disease risk by using family history: an integrative literature review.

BACKGROUND: Cardiovascular disease (CVD) is the number one killer in the United States. Although the causes of CVD are multifactorial, including genetic and environmental influences, it is largely a preventable disease. The cornerstone of CVD prevention is accuracy in risk prediction to identify patients who will benefit from interventions aimed at reducing risk. Nurse practitioners commonly perform CVD risk assessments and are well positioned to impact preventive therapy. Cardiovascular disease risk scoring systems currently in use substantially underestimate risk in large part because these do not include family history of premature CVD as a high-risk factor. PURPOSE: We sought to examine the state of evidence for the use of family history as a predictor in CVD risk stratification. CONCLUSIONS: A comprehensive literature search using the Medical Subject Headings terms of family history of CVD, family history of premature CVD, risk assessment, and risk estimation displayed 416 articles; a review of the titles and subsequent evaluation of the articles eliminated 392 references, leaving 24 for review. By incorporating family history in risk assessment, categorization of CVD risk improves substantially. The evidence demonstrates that family history is an independent contributor to risk appraisal and unequivocally supports its incorporation to improve accuracy in global CVD risk estimation. CLINICAL IMPLICATIONS: Underestimation of CVD risk leaves patients and providers misinformed, promoting the ongoing epidemic of chronic disease. Translating this evidence into practice by establishing a clinical algorithm that incorporates family history into risk prediction will standardize CVD risk assessment, improve the identification of high-risk patients, and provide the indicated aggressive care to prevent CVD.

The toxigen initiative: targeting oxygen saturation to avoid sequelae in very preterm infants.

UNLABELLED: Supplemental oxygen plays a critical role in the care of infants born at the lower limits of viability, but not without the risk of morbidity resulting from high levels or prolonged exposure. PURPOSE: The purpose of this quality improvement project was to reduce exposure to hyperoxia as evidenced by SpO2 values within the established target range (88%-92%) among very preterm infants (VPIs) in a level 3 neonatal intensive care unit (NICU). Reducing exposure to hyperoxia in this population of exquisitely vulnerable infants has been associated with reduced morbidity, including retinopathy of prematurity, chronic lung disease, and brain injury. SUBJECTS: Two populations of interest were identified: VPIs receiving supplemental oxygen and NICU clinicians. DESIGN: Interventions were employed to (1) improve knowledge regarding hyperoxia and associated outcome sequelae in an interdisciplinary sample of clinicians (pretest posttest design) and (2) reinforce content of the educational intervention by triggering caregiver behaviors to reduce time the VPIs is above target SpO2 range while receiving supplemental oxygen (cohort design). METHODS: : Retrospective chart review, baseline clinician knowledge assessment, education, posteducation assessment, collaborative rounds with regular feedback citing time VPIs spent above target oxygen saturation levels (SpO2), and evaluation of impact on time infants spent above target SpO2 range aligned with the project purpose. OUTCOME MEASURES: Pre- and postintervention dependent variables included clinician knowledge of hyperoxia and related evidence as measured by a 24-item multiple-choice Knowledge Assessment Tool before and after attending an educational presentation. Time VPIs were exposed to hyperoxia was evaluated using SpO2 readings and calculating the percentage of time readings were above target range before and after the introduction of educational and behavioral interventions. PRINCIPAL RESULTS: Outcome 1 was to increase knowledge about hyperoxia among clinician caregivers. Paired-samples t test showed a significant difference between preintervention and postintervention Knowledge Assessment Tool scores (P = .000). Outcome 2 measured reduction in time spent with SpO2 readings above target range. An independent-samples t test was used to compare outcomes in preintervention and postintervention VPI cohorts. Mean time spent with SpO2 greater than target range increased in the postintervention cohort, reaching statistical significance with P = .047. CONCLUSIONS: Knowledge acquisition on the subject of hyperoxia in VPIs was achieved. Decreasing the percent time VPIs were exposed to hyperoxia was not attained. The postintervention VPI cohort spent more time above the target saturation range despite greater knowledge among clinicians.

Development of an institutional review board preapproval process for Doctor of Nursing Practice students: process and outcome.

As Doctor of Nursing Practice (DNP) programs proliferate, effective collaboration with institutional review boards (IRBs) is important to protect human subjects. It is particularly important that faculty and students recognize which DNP students' projects should be considered as "human subjects research" or "quality improvement." The former require IRB review, whereas the latter may be eligible for expedited review or may be considered exempt. We report outcomes following implementation of a combination of didactic training, one-to-one consultation, and a decision support protocol to improve preparation for and collaboration with the IRB at a large university. In the first year of using this protocol, 53% of projects were deemed human subjects research and received IRB review. The other 47% were deemed quality improvement projects and did not require IRB review. We offer our experience as an approach for teaching students how to protect the subjects included in their quality improvement activities.

Designing an outcome-focused model for orienting new graduate nurses.

A new outcome-focused orientation model was developed in response to poor preceptor satisfaction and a high nurse graduate turnover. Progression through the program was determined by the orientee's accomplishment of the target or strategic outcomes across seven progressive phases-not by time and budget. At the conclusion of the first year, decreased turnover, increased preceptor satisfaction, and substantial financial savings were documented.

Hyperoxia in very preterm infants: a systematic review of the literature.

Supplemental oxygen plays a critical role in the management of infants born at the lower limit of viability, but not without the risk of complications resulting from high levels or prolonged exposure. Longitudinal studies of very premature infants, born at less than 28 weeks' gestation, establish a clear relationship between pulse oximetry saturation readings above 92%, or hyperoxia, and development of severe retinopathy of prematurity, chronic lung disease, and brain injury. Hyperoxia is neither natural nor random. It is an unintended consequence of intervention. A comprehensive review of the literature reveals a strong association between exposure to hyperoxia and subsequent expression of comorbidities. Owing to this knowledge, eradication of hyperoxia, and consequent reduction of sequelae, is a significant public health concern that deserves attention by the neonatal community. Although prospective, collaborative meta-analyses will soon provide needed additional data to inform practice, existing compelling evidence supports urgent practice change to reduce exposure to hyperoxia in very preterm infants.

Translating infant safe sleep evidence into nursing practice.

The authors describe a 4-year demonstration project (2004-2007) to reduce infant deaths related to sleep environments by changing attitudes and practices among nurses who work with African American parents and caregivers in urban Michigan hospitals. An approach was developed for creating sustainable change in nursing practice by implementing nursing practice policies that could be monitored through quality improvement processes already established within the hospital organization. Following the policy change effort, nurses changed their behavior and placed infants on the back to sleep.

Using Maslow's pyramid and the national database of nursing quality indicators(R) to attain a healthier work environment.

The strongest predictor of nurse job dissatisfaction and intent to leave is that of stress in the practice environment. Good communication, control over practice, decision making at the bedside, teamwork, and nurse empowerment have been found to increase nurse satisfaction and decrease turnover. In this article we share our experience of developing a rapid-design process to change the approach to performance improvement so as to increase engagement, empowerment, effectiveness, and the quality of the professional practice environment. Meal and non-meal breaks were identified as the target area for improvement. Qualitative and quantitative data support the success of this project. We begin this article with a review of literature related to work environment and retention and a presentation of the frameworks used to improve the work environment, specifically Maslow's theory of the Hierarchy of Inborn Needs and the National Database of Nursing Quality Indicators Survey. We then describe our performance improvement project and share our conclusion and recommendations.