Teaching Professional Peer Review With the Use of Simulation.

BACKGROUND: Quality improvement practices such as peer review and just culture are important components of patient safety initiatives, and health professions students should be introduced to these practices during their education. PURPOSE: The purpose of this study was to evaluate a peer-review simulation learning experience using just culture principles in a graduate-level, online nursing education program. METHODS: The students rated their learning experience with high, positive scores in all 7 domains on the Simulation Learning Experience Inventory. Responses to the open-ended question indicated that the students thought the experience provided opportunities for deep learning, increased confidence, and enhanced critical thinking skills. CONCLUSION: A peer-review simulation program using just culture principles provided a meaningful learning experience for graduate-level students in an online nursing education program.

Prepregnancy Body Mass Index Is Associated with Time-Dependent Changes in Secretory Activation Measures During the First 7 Days Postpartum in Breast Pump-dependent Mothers of Premature Infants.

Background: Little is known about the biology of secretory activation (SA) in overweight and obese (OW/OB) mothers who are breast pump dependent with a premature infant in the neonatal intensive care unit. Objective: To compare time-dependent changes in daily pumped milk volume, maternal milk sodium (Na) concentration, and Na-to-potassium (K) ratios (Na:K) in the first 14 days postpartum in breast pump-dependent mothers with prepregnancy body mass index (BMI) <27 and BMI ≥27 kg/m2. Design/Methods: This secondary analysis for 39 subjects, 44% (n = 17) with prepregnancy BMI <27 and 56% (n = 22) with BMI ≥27, included transformed data of outcome measures, chi-square, t-tests, and growth curve models. Results: For days 1-7, daily pumped milk volume increased significantly more rapidly for mothers with BMI <27 (65.82 mL/d) versus BMI ≥27 (33.08 mL/d), but the daily rate of change in pumped milk volume during days 8-14 was not statistically different. Daily milk Na concentration decreased significantly faster in BMI <27 (-3.93 mM/d) versus BMI ≥27 (-2.00 mM/day) during days 1-7, but was not significantly different for days 8-14. No statistical differences were noted for Na:K ratio for either time period. Conclusion: These data add biologic evidence to previous research, suggesting delayed or impaired SA in OW/OB mothers, and suggest that the window of opportunity for research and clinical interventions is days 1-7 postpartum in this population.

The Interaction of Donor Human Milk Availability and Race/Ethnicity on Provision of Mother's Own Milk for Very Low Birth Weight Infants.

Objective: To compare (1) differences in mother's own milk (MOM) provision and enteral feeding outcomes, (2) differences in preterm formula and donor human milk (DHM) uses as bridges to exclusive MOM feedings at discharge, and (3) MOM and enteral feeding outcomes for racial/ethnic subgroups before and after the implementation of a hospital DHM feeding program. Methods: Retrospective data from 313 very low birth weight (VLBW; birth weight <1,500 g) infants born between January 2011 to December 2012 (pre-DHM, n = 157) and April 2013 to March 2015 (DHM, n = 156) were analyzed. Results: For this predominantly low-income and minority VLBW infant cohort, the percent of enteral fed hospitalization days was higher in the DHM group (pre-DHM 94% [88, 97] versus DHM 98% [95, 99], p < 0.001). Although MOM remained the predominant first enteral feeding type, significantly fewer DHM infants received MOM (pre-DHM 89% versus DHM 75%, p = 0.001). During days of life 1-14, a lower percentage of DHM infants received 100% MOM (pre-DHM 68% versus DHM 55%, p = 0.02). For the entire cohort, the risk for MOM discontinuation was significantly associated with maternal young age, multiparity, non-Hispanic Black race/ethnicity, and low income. Implementation of a DHM program did not predict duration of MOM feedings. However, non-Hispanic White infants had a longer duration of MOM feedings with DHM availability. Conclusions: Our findings highlight the importance of using precise dose and exposure period methodology to determine the impact of DHM on MOM provision. In addition, DHM availability may be associated with varying effects on MOM provision among racial/ethnic groups.

Measures of Secretory Activation for Research and Practice: An Integrative Review.

Background: Maternal concern about inadequate milk volume commonly emerges in the first 2 weeks postpartum, a critical lactation period that includes secretory activation. This review summarizes the biology of secretory activation and evaluates the accuracy and feasibility of published measures of secretory activation. Materials and Methods: A systematic search of measures of secretory activation for mothers of healthy term and preterm infants yielded 62 abstracts. Following additional screening, 15 publications qualified for quantitative synthesis review and were evaluated with respect to accuracy (validated with another measure of secretory activation in the same mother) and feasibility (accessibility, cost, and ease of use). Results:Maternal perception of milk coming in (MP) is the most feasible measure, but its accuracy has not been established. Patterns of increase in maternal milk volume have been validated with maternal milk-borne biomarkers in breastfeeding, and breast pump-dependent mothers and normal values have been published. Accuracy of serial maternal urinary lactose concentrations has not been established for secretory activation and lacks feasibility. Maternal milk biomarkers are the accurate standard to which other measures are compared but currently lack feasibility for routine use. Conclusions: Use of secretory activation measures can personalize lactation care by matching maternal risk with appropriate diagnostics. Priorities for research and practice include validation of MP as a population-based screening tool, implementation of techniques that measure patterns of increase in milk volume for moderate risk populations, and the development of milk biomarker science for point-of-care use in the most complicated lactation scenarios.

Correction: Mediators of racial and ethnic disparity in mother's own milk feeding in very low birth weight infants.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Priorities for Contraception and Lactation Among Breast Pump-Dependent Mothers of Premature Infants in the Neonatal Intensive Care Unit.

Objective: Determine the knowledge and priorities for postpartum contraception and lactation in mothers of premature infants. Design: Twenty-five mothers of premature infants (mean gestational age = 29.9 weeks) hospitalized in a tertiary neonatal intensive care unit (NICU) participated in a multi-methods study using a multiple-choice contraceptive survey and qualitative interview in the first 2 weeks postpartum. Data were analyzed using content analysis and descriptive statistics. Results: Although 60% of mothers planned to use contraception, all questioned the timing of postpartum contraceptive counseling while recovering from a traumatic birth and coping with the critical health status of the infant. All mothers prioritized providing mothers' own milk (MOM) over the use of early hormonal contraception because they did not want to "take any risks" with their milk. They had limited knowledge of risks for repeat preterm birth (e.g., prior preterm birth: n = 13, 52%; multiple birth: n = 9, 36%; no knowledge: n = 3, 12%); only two mothers (0.08%) were counseled about the risks of a short interpregnancy interval. Conclusion: The context of the infants' NICU admission and the mother's desire to "do what is best for the baby" by prioritizing MOM should be integrated into postpartum contraceptive counseling for this population.

Mediators of racial and ethnic disparity in mother's own milk feeding in very low birth weight infants.

BACKGROUND: Despite high initiation rates for mother's own milk (MOM) provision, MOM feeding at discharge from the neonatal intensive care unit (NICU) drops precipitously and reveals a racial/ethnic disparity. This study sought to identify factors that (1) predict MOM feeding at NICU discharge, and (2) mediate racial/ethnic disparity in MOM feeding at discharge. METHODS: Secondary analysis of prospective cohort study of 415 mothers and their very low birth weight infants. Variables were grouped into five categories (demographics, neighborhood structural, social, maternal health, and MOM pumping). Significant predictors from each category were entered into a multivariable logistic regression model. RESULTS: Although 97.6% of infants received MOM feedings, black infants were significantly less likely to receive MOM feeding at discharge. Positive predictors were daily pumping frequency, reaching pumped MOM volume ≥500 mL/day by 14 days, and maternal age. Negative predictors were low socioeconomic status (SES) and perceived breastfeeding support from the infant's maternal grandmother. Low SES, maternal age, and daily pumping frequency mediated the racial/ethnic differences. CONCLUSIONS: Multiple potentially modifiable factors predict MOM feeding at NICU discharge. Importantly, low SES, pumping frequency, and maternal age were identified as the mediators of racial and ethnic disparity. Strategies to mitigate the effects of modifiable factors should be developed and evaluated in future research.

Milk Volume at 2 Weeks Predicts Mother's Own Milk Feeding at Neonatal Intensive Care Unit Discharge for Very Low Birthweight Infants.

OBJECTIVE: This study sought to determine the maternal prepregnancy, pregnancy, and delivery risk factors that predicted coming to volume (CTV; achieving pumped mother's own milk [MOM] volume ≥500 mLs/day) and the continuation of MOM provision through to discharge from the neonatal intensive care unit (NICU) in mothers and their very low birthweight (VLBW; <1,500 g at birth) infants. STUDY DESIGN: Secondary analysis of prospectively collected data from 402 mothers of VLBW infants admitted to an urban NICU, including detailed MOM pumping records for a subset (51%) of the cohort. Analyses included inverse probability weighting, multivariate regression, and chi-square statistics. RESULTS: In this high-risk cohort (51.2% black, 27.1% Hispanic, 21.6% white/Asian; 72.6% low income; 61.4% overweight/obese prepregnancy), CTV by day 14 was the strongest predictor of MOM feeding at NICU discharge (odds ratio [OR] 9.70 confidence interval [95% CI] 3.86-24.38, p < 0.01.). Only 39.5% of mothers achieved CTV by postpartum day 14, an outcome that was predicted by gestational age at delivery (OR 1.41, 95% CI 1.15-1.73, p < 0.01), being married (OR 3.66, 95% CI 1.08-12.39, p = 0.04), black race (OR 7.70, 95% CI 2.05-28.97, p < 0.01), cesarean delivery (OR 0.22, 95% CI 0.08-0.63, p = 0.01), and chorioamionitis (OR 0.14, 95% CI 0.02-0.82, p = 0.03). CONCLUSION: Continued provision of MOM at NICU discharge can be predicted in the first 14 postpartum days on the basis of achievement of CTV. We posit that CTV can serve as a quality indicator for improving MOM feedings in the NICU and that lactation support resources should target this early critical postbirth period.

Influence of own mother's milk on bronchopulmonary dysplasia and costs.

BACKGROUND: Human milk from the infant's mother (own mother's milk; OMM) feedings reduces the risk of several morbidities in very low birthweight (VLBW) infants, but limited data exist regarding its impact on bronchopulmonary dysplasia (BPD). OBJECTIVE: To prospectively study the impact of OMM received in the neonatal intensive care unit (NICU) on the risk of BPD and associated costs. DESIGN/METHODS: A 5-year prospective cohort study of the impact of OMM dose on growth, morbidity and NICU costs in VLBW infants. OMM dose was the proportion of enteral intake that consisted of OMM from birth to 36 weeks postmenstrual age (PMA) or discharge, whichever occurred first. BPD was defined as the receipt of oxygen and/or positive pressure ventilation at 36 weeks PMA. NICU costs included hospital and physician costs. RESULTS: The cohort consisted of 254 VLBW infants with mean birth weight 1027±257 g and gestational age 27.8±2.5 weeks. Multivariable logistic regression demonstrated a 9.5% reduction in the odds of BPD for every 10% increase in OMM dose (OR 0.905 (0.824 to 0.995)). After controlling for demographic and clinical factors, BPD was associated with an increase of US$41 929 in NICU costs. CONCLUSIONS: Increased dose of OMM feedings from birth to 36 weeks PMA was associated with a reduction in the odds of BPD in VLBW infants. Thus, high-dose OMM feeding may be an inexpensive, effective strategy to help reduce the risk of this costly multifactorial morbidity.

"It's Somebody Else's Milk": Unraveling the Tension in Mothers of Preterm Infants Who Provide Consent for Pasteurized Donor Human Milk.

BACKGROUND: Pasteurized donor human milk (DHM), rather than preterm infant formula, is recommended for premature infants when mother's milk is not available. OBJECTIVE: This study explored the maternal decision-making process in providing consent for DHM feedings. METHODS: In-depth semistructured interviews were conducted with 20 mothers of premature (mean gestational age = 27 weeks, birth weight = 942 grams) infants hospitalized in the neonatal intensive care unit (NICU) in this qualitative, descriptive study. Conventional content analysis was used to analyze the data. RESULTS: Although only 1 mother had any previous knowledge of DHM, all mothers provided consent for DHM because they "wanted what is best for my baby." Mothers trusted that DHM was better than formula when their infant's feeding requirements exceeded their own milk supply. However, most mothers described a tension between wanting their infants to receive only "their" milk and DHM being "somebody else's milk." This desire to be the only provider of human milk was more common than concerns about the quality and safety of DHM. The mothers' tension was mediated by trusting the NICU clinicians' recommendations, having adequate time to make an informed decision, observing the positive outcomes of DHM, and feeling empowered that they made the best decision for their infant. CONCLUSION: The experiences of these mothers reflect the importance of approaching mothers for consent only when DHM is needed, respecting mothers' beliefs and values about DHM, and providing help in mediating any tension with regard to their infants receiving "somebody else's milk."

Systematic Preparation for Teaching in a Nursing Doctor of Philosophy Program.

Lack of preparation for the faculty role, particularly for teaching, has long been an area of concern in graduate nursing education. This article describes a systematic approach to preparing students in a doctor of philosophy (PhD) program for their future roles as nurse educators. All PhD students at Rush University are required to take a nursing education course that contains four modules: the teacher, learner, and learning environment; the basics of curriculum and course design; evaluation of the learner, course, program, and institution; and the new faculty member. Students also complete a practicum in the course. Students are interviewed before the course begins and complete a self-assessment of their teaching experiences. Based on their learning needs, students are enrolled in the course for variable credit. The course has received excellent evaluations since its inception. The success of this course demonstrates that an education course can be an essential component of the nursing PhD curriculum.

Health Care Workers' Beliefs and Practices Around Pap Screening for Adolescents Seeking Contraception.

Adolescents often avoid seeing a health care provider to obtain contraception because they do not want to undergo a pelvic exam and Pap screening for fear of stress, pain or embarrassment. The purpose of this quality improvement project was to study health care workers, attitudes and beliefs about Pap screening and to educate them on the latest evidence-based guidelines, with the hope of ultimately decreasing unnecessary screening. Results showed a modest reduction in the frequency of Pap screening; however, many adolescents continued to undergo unnecessary Pap screening. The reluctance of health care workers to change their practice demonstrates the need for better methods of translating evidence-based guidelines into practice.

Cost savings of human milk as a strategy to reduce the incidence of necrotizing enterocolitis in very low birth weight infants.

BACKGROUND: Necrotizing enterocolitis (NEC) is a costly morbidity in very low birth weight (VLBW; <1,500 g birth weight) infants that increases hospital length of stay and requires expensive treatments. OBJECTIVES: To evaluate the cost of NEC as a function of dose and exposure period of human milk (HM) feedings received by VLBW infants during the neonatal intensive care unit (NICU) hospitalization and determine the drivers of differences in NICU hospitalization costs for infants with and without NEC. METHODS: This study included 291 VLBW infants enrolled in an NIH-funded prospective observational cohort study between February 2008 and July 2012. We examined the incidence of NEC, NICU hospitalization cost, and cost of individual resources used during the NICU hospitalization. RESULTS: Twenty-nine (10.0%) infants developed NEC. The average total NICU hospitalization cost (in 2012 USD) was USD 180,163 for infants with NEC and USD 134,494 for infants without NEC (p = 0.024). NEC was associated with a marginal increase in costs of USD 43,818, after controlling for demographic characteristics, risk of NEC, and average daily dose of HM during days 1-14 (p < 0.001). Each additional ml/kg/day of HM during days 1-14 decreased non-NEC-related NICU costs by USD 534 (p < 0.001). CONCLUSIONS: Avoidance of formula and use of exclusive HM feedings during the first 14 days of life is an effective strategy to reduce the risk of NEC and resulting NICU costs in VLBW infants. Hospitals investing in initiatives to feed exclusive HM during the first 14 days of life could substantially reduce NEC-related NICU hospitalization costs.

Effects of the 2011 flood in Thailand on birth outcomes and perceived social support.

OBJECTIVE: To determine the effects of displacement due to flooding during pregnancy on birth outcomes (infant birth weight and gestational age) and the moderating effect of perceived social support on the relationship between displacement and birth outcomes. DESIGN: A descriptive, longitudinal study. SETTING: A university-affiliated hospital in Pathum Thani, Thailand. PARTICIPANTS: Pregnant women (N = 175) in the third trimester that had uncomplicated pregnancies and no history of mental illness. METHODS: During pregnancy, the participants completed standardized measurements of depression symptoms, perceived social support, and questionnaires concerning the effect of the flood. After giving birth, infant birth weight and gestational age at birth were retrieved from delivery records. RESULTS: Seventy percent (n = 123) of the participants experienced displacement during the flood. The displaced women had a mean infant birth weight of 175 grams less than that of the nondisplaced women, t(173) = -2.38, p = .02, whereas infant gestational age was not different. Displacement and other variables explained approximately 8% of the variance in infant birth weight. The interaction term between displacement and perceived social support was statistically significant and additionally explained the variance in infant birth weight, F(6, 168) = 3.24, p = .005. CONCLUSION: Being displaced during pregnancy due to a natural disaster affected fetal growth rather than length of gestation. Health care providers should closely monitor maternal weight gain and fetal growth of pregnant women who experience displacement. Among the displaced women, social support was associated with higher infant birth weight; therefore, high levels of perceived social support may be protective for pregnant women who experience stressful events such as displacement from flooding.

Economic benefits and costs of human milk feedings: a strategy to reduce the risk of prematurity-related morbidities in very-low-birth-weight infants.

Infants born at very low birth weight (VLBW; birth weight <1500 g) are at high risk of mortality and are some of the most expensive patients in the hospital. Additionally, VLBW infants are susceptible to prematurity-related morbidities, including late-onset sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, and retinopathy of prematurity, which have short- and long-term economic consequences. The incremental cost of these morbidities during the neonatal intensive care unit (NICU) hospitalization is high, ranging from $10,055 (in 2009 US$) for late-onset sepsis to $31,565 for BPD. Human milk has been shown to reduce both the incidence and severity of some of these morbidities and, therefore, has an indirect impact on the cost of the NICU hospitalization. Furthermore, human milk may also directly reduce NICU hospitalization costs, independent of the indirect impact on the incidence and/or severity of these morbidities. Although there is an economic cost to both the mother and institution for providing human milk during the NICU hospitalization, these costs are relatively low. This review describes the total cost of the initial NICU hospitalization, the incremental cost associated with these prematurity-related morbidities, and the incremental benefits and costs of human milk feedings during critical periods of the NICU hospitalization as a strategy to reduce the incidence and severity of these morbidities.

Job strain and psychological distress among employed pregnant Thai women: role of social support and coping strategies.

Most Thai women continue to work throughout their pregnancy; however, little is known about job strain and its relation to psychological distress. This study aimed to examine: (1) the direct effects of job strain, perceived workplace support, perceived family support, and coping strategies on psychological distress and (2) the moderating effect of perceived workplace support, perceived family support, and coping strategies on the relationship between job strain and psychological distress. Lazarus and Folkman's transactional model of stress and coping guided this cross-sectional study. Full-time employed pregnant women (N = 300) were recruited from three antenatal clinics in Thailand. Thai versions of the following instruments were used: the State-Anxiety Inventory and Center for Epidemiological Studies-Depression Scale (psychological distress), the Job Content Questionnaire (job strain and perceived workplace support), the Medical Outcome Study Social Support Survey (perceived family support), and the Ways of Coping Checklist-Revised (coping strategies). Job strain with other predictors explained 54% of the variance in psychological distress. In the separate hierarchical multiple linear regression models, two types of coping strategies, seeking social support and wishful thinking, moderated the effects of job strain on psychological distress. Perceived family support had a direct effect in reducing psychological distress. Job strain is a significant contributor to psychological distress. The average levels of seeking social support and wishful thinking were most beneficial in moderating the negative impact of job strain on psychological distress. Since perceived workplace and family support did not have moderating effects, stress management programs for decreasing the levels of job strain should be developed.

Management of breastfeeding during and after the maternity hospitalization for late preterm infants.

Among infants born moderately and late preterm or early term, the greatest challenge for breastfeeding management is the late preterm infant (LPI) who is cared for with the mother in the maternity setting. Breastfeeding failure among LPIs and their mothers is high. Evidence-based strategies are needed to protect infant hydration and growth, and the maternal milk supply, until complete feeding at breast can be established. This article reviews the evidence for lactation and breastfeeding risks in LPIs and their mothers, and describes strategies for managing these immaturity-related feeding problems. Application to moderately and early preterm infants is made throughout.

The institutional cost of acquiring 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit.

BACKGROUND: Human milk from the biologic mother (HM) reduces disease burden and associated costs of care during and after neonatal intensive care unit (NICU) hospitalization for very low birth weight (VLBW; birth weight < 1500 g) infants, when compared to feedings of donor human milk (DHM) or commercial formula (CF). However, compared to DHM and CF, little is known about the institutional cost to acquire HM from the biologic mother. OBJECTIVE: This study aimed to determine the institutional cost of acquiring HM for VLBW infant feedings during the NICU hospitalization. METHODS: This analysis examined 157 maternal pumping records from a prospective cohort study evaluating health outcomes and cost of HM feedings for VLBW infants. The costs for the breast pump rental fee, 1-time pump kit purchase, and disposable food-grade containers for storing expressed HM were evaluated using standard cost analysis techniques. RESULTS: The median cost of acquiring 100 mL of HM varied from $0.51 when mothers pumped ≥ 700 mL daily to $7.93 for those who pumped < 100 mL daily. Mothers who pumped ≥ 100 mL daily had lower acquisition cost compared to both DHM ($14.84/100 mL) and CF ($3.18/100 mL). For mothers who pumped > 100 mL daily, the exact day of pumping where the cost of HM was less expensive than DHM or CF was 4 to 7 days and 6 to 19 days, respectively. CONCLUSION: Human milk from the biologic mother has lower acquisition cost than DHM and CF when mothers provided ≥ 100 mL daily and pumped for a sufficient number of days (range, 4-19). Neonatal intensive care units should prioritize resources to ensure that mothers achieve this daily milk volume.

Breastfeeding peer counselors as direct lactation care providers in the neonatal intensive care unit.

In 2005, the Level III neonatal intensive care unit (NICU) at Rush University Medical Center initiated a demonstration project employing breastfeeding peer counselors, former parents of NICU infants, as direct lactation care providers who worked collaboratively with the NICU nurses. This article describes the conceptualization, implementation, and evaluation of this program and provides templates for other NICUs that wish to incorporate breastfeeding peer counselors with the goal of providing quality, evidence-based lactation care.