Identification and measurement of nurse sensitive outcomes in pediatric nephrology nursing.

Patient outcomes are increasingly the focus of research and are seen as primary indicators of nursing care quality. The identification and measurement of nurse-sensitive outcomes that actually reflect nursing care are more difficult than it seems. Many of the outcomes currently in use for nephrology patients are global in scope and influenced by many health professionals as well as patients and families. Further, outcomes appropriate for adult nephrology patients may need modification for pediatric patients or may not work at all. This article explores issues related to identifying outcomes related to the nursing care of pediatric nephrology patients, reviews selected outcomes, and describes measurement strategies.

School-based research: problems of access and consent.

Public schools are enticing yet intimidating places to conduct research on children and adolescents. A public school provides a large potential subject pool; however, obtaining access to that subject pool can seem impossible with all the layers of permissions that must be obtained. If the study is federally funded, additional regulations apply. This article presents practical and proven approaches to obtaining access to and approval from schools or school systems, as well as parental consent, to conduct school-based research.

Evolution of the nursing process.

The nursing process, long considered the basic intellectual tool for nursing, has continued to evolve through use by advanced practice nurses (APNs). Traditionally, the nursing process has been comprehensive in guiding the assessment and intervention phases but has left unspecified the cognitive processes involved in clinical decision making. In an effort to compensate for that weakness, nurses in advanced practice have typically integrated medical diagnostic reasoning into the nursing process. The work of Benner and colleagues (1984, 1996) in explicating the unique reasoning process used by APNs has helped further our understanding of clinical decision making in advanced practice. The evolved nursing process, as described in this article, includes the array of clinical decisions that must be made during a patient encounter, including assessment decisions, diagnosis, choice of interventions, and identification of outcomes. This article reviews the nursing and medical literature related to both clinical decision making and diagnostic reasoning, and applies that literature to the evolution of the nursing process.

Nursing assessment and intervention for adult hemodialysis patients: application of Roy's Adaptation Model.

A comprehensive assessment tool and intervention typology for adult hemodialysis patients, based on the Roy Adaptation Model, is presented. The Roy model is reviewed, and examples from the assessment tool and intervention typology are presented. A case study illustrates application of the tool and typology to nephrology nursing. Comparison of the tool and typology with the ANNA Standards of Clinical Practice revealed that the Roy Adaptation Model includes additional important aspects of nephrology nursing practice.

School-based interventions improve heart health in children with multiple cardiovascular disease risk factors.

OBJECTIVE: To determine the immediate effects of two types of elementary school-based interventions on children with multiple cardiovascular disease (CVD) risk factors. DESIGN: Randomized, controlled field trial. SETTING: Conducted in 18 randomly selected elementary schools across North Carolina. STUDY PARTICIPANTS: Four hundred twenty-two children age 9 +/- 0.8 years with at least two risk factors at baseline: low aerobic power and either high serum cholesterol or obesity. INTERVENTION: Both 8-week interventions consisted of a knowledge and attitude program and an adaptation of physical education. The classroom-based intervention was given by regular teachers to all children in the 3rd and 4th grades. The risk-based intervention was given in small groups only to children with identified risk factors. Children in the control group received usual teaching and physical education. OUTCOME MEASURES: The primary outcome measure was cholesterol; additional measures were blood pressure, body mass index, body fat, eating and activity habits, and health knowledge. RESULTS: Both interventions produced large reductions in cholesterol (-10.1 mg/dL and -11.7 mg/dL) compared with a small drop (-2.3 mg/dL) in the controls. There was a trend for systolic blood pressure to increase less in both intervention groups than in the controls. Both intervention groups had a small reduction in body fat and higher health knowledge than the control group. CONCLUSIONS: Both brief interventions can improve the CVD risk profile of children with multiple risk factors. The classroom-based approach was easier to implement and used fewer resources. This population approach should be considered as one means of early primary prevention of CVD.

Survey of nephrology nurses' interest in graduate education.

OBJECTIVE: The purpose of the survey was to determine interest in a Master's nephrology nursing program among ANNA members residing in North Carolina, South Carolina, and Virginia. DESIGN: Needs assessment. SAMPLE/SETTING: 153 ANNA members residing in South Carolina, North Carolina, and Virginia. METHOD: Mailed survey. RESULTS: Response rate was 27%; 54 (35%) expressed interest in attending such a program, with 62 others (41%) interested "depending." Part-time study was the most commonly desired program option. Almost half (48%) were not currently baccalaureate prepared, a requirement for admission. CONCLUSIONS: Enrollment was inadequate to support the program despite numerous marketing efforts, bringing into question the adequacy of needs surveys for program planning.

Comparison of measures for prospective identification of venous stenoses.

OBJECTIVE: To compare two methods, venous dialysis pressure (VDP) and intra-access static flow pressure (VPO), for the prospective identification of venous stenoses in high-risk PTFE grafts. DESIGN: Comparative. SAMPLE/SETTING: Twenty patients with upper extremity loop grafts in an outpatient chronic hemodialysis population. METHODS: VDP and VPO were measured for three consecutive treatments within subjects followed by angiography. VDP > 150 mmHg/200 ml/min, VPO > 0.40, and stenoses > 50% were considered positive findings. RESULTS: In paired t-tests, VPO identified elevated venous pressure more frequently than VDP in patients positive on angiography (mean difference = 77.8%, p < 0.0001). Frequency analysis yielded a sensitivity of 36% for VDP and 93% for VPO (p < 0.05). CONCLUSION: This study found that while VDP is the simpler method to use, VPO is significantly more accurate at predicting venous stenoses.

Toilet training for the child with chronic illness.

Toilet training is as necessary a developmental step for the child with chronic illness as it is for the healthy child. Helping families and children to achieve this task, despite the demands of the illness, may require modification of usual techniques. Assessment of readiness and impediments to toilet training along with suggested intervention approaches are addressed. Case examples demonstrate individualization to specific children's needs.

Rehabilitation and social and adaptive development of young renal transplant recipients.

OBJECTIVE: To survey a group (n = 37) of children and adolescents, who had received renal transplants, along with a parent, to determine their rehabilitation status and social and adaptive development. Additionally, subjects were asked to identify factors perceived as interfering with development and rehabilitation. DESIGN: This primarily descriptive study used a comparative data analysis strategy. There was also an exploratory component to the study. SAMPLE/SETTING: Potential subjects included all children more than 5 and less than 21 years of age who had received at least one renal transplant at a large university medical center in the Midwest. Subjects' actual ages were 5 to 20 (mean = 13.1); 14 were female, 23 were male. Twenty-five had a functioning transplant at the time of the study. METHODS: Telephone interviews were conducted with the child and a parent. The Vineland Adaptive Behavior Subscales for communication, daily living skills and socialization were administered. RESULTS: The mean communication score was 86.5 (19th percentile), mean daily living skills score was 88.1 (21st percentile), and the mean socialization score was 89.0 (23rd percentile). There was no significant difference on any domain score by whether or not the child had a functional transplant at the time of the study. Factors reported by child and parent as interfering with age-appropriate activities were explored. CONCLUSIONS: Nurses working with children and adolescents who have received renal transplants have many opportunities to incorporate developmental assessments and interventions into their nursing care to help these children to lead fuller and more satisfying lives.

Effects of a school-based intervention to reduce cardiovascular disease risk factors in elementary-school children: the Cardiovascular Health in Children (CHIC) study.

OBJECTIVE: To test a classroom-based intervention to reduce cardiovascular disease risk factors in elementary school children. STUDY DESIGN: This was a randomized, controlled field trial in 12 schools across North Carolina, stratified by geographic region and urban/rural setting. Subjects were 1274 third and fourth graders (48% boys). The intervention, taught by regular classroom and physical education teachers, provided all children an 8-week exercise program and 8 weeks of classes on nutrition and smoking. Data were analyzed at the school level with survey regression models and at the individual level with multivariate analysis of variance and analysis of covariance models; 95% confidence intervals were computed. RESULTS: Children in the intervention group had significantly greater knowledge (7.9% more correct) and a significant increase in self-reported physical activity than children in the control group. Trends for the intervention group were a reduction in total cholesterol level (-5.27 mg/dl), an increase in aerobic power, a reduction in body fat, and smaller rise in diastolic blood pressure than control children. CONCLUSIONS: This classroom-based, public health approach improved children's cardiovascular disease risk profiles; it is practical and fairly easy to incorporate into the school day. All children directly receive the potential benefits of the intervention without a risk of labeling. This program can improve health knowledge, habits, and health outcomes of young children at a time when health habits are being formed.

Advanced practice in nursing: conceptual issues.

The issue of defining advanced practice nursing roles is increasingly a subject of national discussion and debate. Central to this discussion has been the issue of merging nurse practitioner (NP) and clinical nurse specialist (CNS) roles and the tendency for the term "nurse practitioner" to replace that of "clinical nurse specialist" in denotation of these roles. The authors note the lack of any attempt to use a broader conceptual approach in these discussions. In this article, the development of each role is reviewed, and the strengths and weaknesses of each role in current practice and education are evaluated. The authors conclude that inadequate justification exists for continuing both roles, but that the answer is not in simply replacing the CNS with the NP. Ongoing careful and thoughtful dialogue should be used to guide the merging of these two roles.

Cardiovascular health promotion in children: program and policy implications.

Cardiovascular disease is the leading cause of death in the United States; it is also a major factor in rising health care costs. Risk factors for the disease are present in childhood, at the time when lifelong health habits are forming. Thus, strategies for improving the cardiovascular health of children through programs and policy may be expected to have a maximum effect. The cardiovascular health in children study identified the prevalence of cardiovascular risk factors in 2209 children age 8 to 11 years, attending 21 rural and urban public schools in North Carolina. Schools were randomly selected from three regions of the state (coastal, piedmont, mountain) in which the frequency of cardiovascular disease differs. Initial results of the study demonstrate the use of such findings in formulating health policy and in designing intervention programs.

Cognitive, psychosocial, and physical development in infants and children with end-stage renal disease.

The purpose of this article is to synthesize research related to the cognitive, physical, and psychosocial development of children with end-stage renal disease who are receiving conservative management, hemodialysis or peritoneal dialysis, or who have received transplants. An impressive array of research in these three areas of development was found, but more work is needed. Suggestions are made for more multicenter research with larger sample sizes and greater generalizability. In addition, more developmental research that includes measures of renal disease, such as age at onset, severity of disease, and length of time in renal failure, is needed.

Parental influences on childhood fitness and activity patterns.

The purpose of this study was to determine the effect of parental attitudes and self-reported exercise habits on the fitness and activity levels of their children. One parent from each of 1,253 families was asked about exercise habits and completed the Exercise Benefits and Barriers Scale (EBBS) to determine their personal attitudes toward exercise. The children completed a self-reported activity questionnaire (SRA) and had their aerobic power predicted using a cycle ergometer test. Multiple regression indicated that the parents' EBBS scores were weakly associated with the child's maximal oxygen uptake (VO2max); the mothers' association was significant, but the fathers was not. The children's SRA scores were not correlated with parents' attitudes or exercise habits. These results suggest either that factors other than parental attitudes and exercise habits are more influential in determining the fitness and activity levels of children or that the instruments lack precision. Thus, to improve the cardiovascular fitness of children, we need to examine factors in the child's environment that may be more influential than parental attitudes and examples.

Images of nephrology nursing practice: report of a survey.

The results of a survey designed to identify existing images of nephrology nursing practice are reported. The sample included 374 attendees at meetings sponsored by the American Nephrology Nurses' Association (ANNA). Content analysis revealed that the typical nephrology patient is elderly, has a chronic illness and negative affect, is not compliant, and is dependent on others. The typical nephrology nurse-patient interaction emphasizes teaching and support. The most common nursing activities are assessment, teaching, dialysis treatment, and psychological support.

Predictors of a health-promoting life-style among well adult clients in a nursing practice.

The self-reported health-promoting life-style (HPL) of 130 well adults in a primary care clinical population was examined in relation to the cognitive/perceptual and sociodemographic factors hypothesized in Pender's Health Promotion Model (1987) to predict this behavior. Subjects were randomly drawn from the clients of a group nurse practitioner practice emphasizing health maintenance. Data were collected by mailed survey (response rate, 59%) with one telephone prompt. The mean age of the subjects was 39.7 years; 72.3% were female; 51.2% were married; 47.7% had college degrees; and 67.4% were white. Blacks were underrepresented in the sample compared to the practice population (chi = 7.56, p = .006). Using multiple regression, the definition of health, importance of health, health locus of control, age, gender, marital status, race, education, income, and rural/urban residence were studied to determine their effects on health-promoting behavior. Results generally supported the Pender Model. Defining health eudiamonistically, that is, as exuberant well-being (rather than adaptive, functional, or absence of disease), predicted HPL. Ranking health above other values such as achievement and harmony had no effect; chance health locus of control had a negative relationship. In the final regression model, predictors of HPL were eudiamonistic conception of health and college education (p = .0001, R2 = 17). Based on this data, considerations of a clients' health conception when framing health-promotion messages is warranted in this population.