The Evolution of Professional Nursing Culture in Italy: Metaphors and Paradoxes.

We explored the perceptions of Italian nurses regarding their developing culture as a health profession. We sought to understand the ongoing evolution of the nursing profession and the changes that were central to it becoming an intellectual discipline on par with the other health professions in Italy. In 2010, the Regulatory Board of Nursing established a center of excellence to build evidence-based practice, advocate for interdisciplinary health care, and champion health profession reforms for nursing. In this study, focus groups-involving 66 nurse participants from various educational, clinical, and administrative backgrounds-were utilized to better ascertain how the profession has changed. Six themes, three of them metaphors-"vortex," "leopard spots," and "deductive jungle"-explain nurses' experiences of professional change in Italy between 2001 and 2011 and the multiple dimensions that characterize their professional identity and autonomy.

Using preappraised evidence sources to guide practice decisions.

PURPOSE: The purpose of this article is two-fold. The first is to describe preappraised evidence sources or a top-down approach to obtaining the best available evidence. The second purpose of the article is to describe how to incorporate preappraised evidence into clinical decision making with the Best Practice Decision Guide. DATA SOURCES: The Best Practice Decision Guide begins with a query of preappraised and filtered electronic sources to obtain recommended evidence summaries, or a so-called "top-down" approach to obtaining the best available evidence. CONCLUSIONS: Information on the major issues and dilemmas encountered at each step is presented, including evaluation of clinical practice guidelines and the consideration of relevant studies to particular patients or subpopulations. IMPLICATIONS FOR PRACTICE: Recommendations for other resources to use in the appraisal process and in making final practice decision are also described in the article.

Pregnancy and oral health: a review and recommendations to reduce gaps in practice and research.

This article presents a review of the research relevant to oral health during pregnancy and includes nursing practice recommendations for referral of women to a dentist for safe and effective dental care during pregnancy. In recent years, research linking periodontitis to the risk for adverse birth outcomes has resulted in increased interest in the topic of oral health during pregnancy. The achievement of optimal oral health in pregnant women as its own benefit, however, has in the past been hampered by myths surrounding the safety of dental care during pregnancy. Many women also lack access to dental care and dental insurance, which interferes with their ability to receive adequate oral care during pregnancy. Intraoral changes that occur with pregnancy because of hormonal changes, combined with lack of routine exams and delays in treatment for oral disease, place pregnant women at higher risk for dental infections.

Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum.

OBJECTIVE: To examine differences in depression symptom rates and severity and factors associated with depression ratings. PARTICIPANTS: Cross-sectional sample of 1,359 American women who had delivered a single, live infant within the previous 2 years. DESIGN: Data were collected using the Edinburgh Postnatal Depression Scale online to screen for depression symptoms as part of Listening to Mothers, a national survey sponsored by Childbirth Connection of New York City and administered by Harris Interactive between May and June 2002. RESULTS: Evidence of continued mild and moderate-to-severe depression symptom rates throughout the first 2 years postpartum was found. Age, income, education, and employment had significant negative associations with depression symptom severity, and parity had a significant positive association with depression symptom severity. Race was not associated with depression symptom severity. CONCLUSIONS: Long-term screening for childbearing women is justified based on the study findings. The ease in survey administration suggests potential for online depression screening by health care providers and researchers. Furthermore, risk factors identified from this large-scale national survey, specifically young maternal age, low income, low education, not being employed full time, and multiparity, merit evaluation in clinical practice and future research.

The evidence supporting nursing management of labor.

Although nursing practice is responsive to research findings, the practice site in which a nurse works has an impact on the ability to incorporate research changes into practice in a timely fashion. This review of the evidence base for nursing management of labor care focuses on care that typically falls within the nurses' domain and highlights the evidence in five areas in which there is research on patient preferences. These include management of admission and of progression during the first stage of labor, fetal monitoring, care and comfort practices during labor, and the management of second-stage labor. Directions for achieving progress toward practice change are highlighted.

Vaginal or cesarean birth? Application of an advocacy organization-driven research translation model.

BACKGROUND: Research translation models are needed to demonstrate a process for identifying and communicating high-quality scientific evidence that enables informed involvement of relevant stakeholders, including informed consumer participation in healthcare decision making. PURPOSE: To describe the rationale for, and elements of, a research translation model, as it is being applied to inform and support diverse end users with respect to decisions relating to vaginal versus cesarean birth. METHODS: The Maternity Center Association (MCA), the oldest national United States organization advocating on behalf of mothers and babies, identified the need to clarify and translate into practice best evidence about relative harms of cesarean and vaginal birth. MCA developed a model that included engaging leading stakeholder groups, conducting a systematic review to fill research gaps, and initiating an education and advocacy campaign to reach consumers, health professionals, and the general public with review results and related information and guidance. International standards for systematic reviews and evidence about effective professional practice, use of decision aids, and risk communication were used. RESULTS: Dozens of harms that differ by mode of delivery, with nearly all favoring vaginal birth, were found during review. Without clear, compelling, and well-supported justification for cesarean section, vaginal birth is the safest way for women to give birth and babies to be born. Despite modest resource expenditure, the implemented model is bringing review results to many individuals and organizations, incorporating elements that have been shown to be effective. The next step is to formally evaluate the decision aid in clinical settings. DISCUSSION: Advocacy organizations are uniquely positioned to carry out research translation. Given the importance of research translation and the challenges of carrying out this work, programs and policies should be established to support and evaluate advocacy organizations in this role.

Use of upright positioning with epidural analgesia: findings from an observational study.

PURPOSE: To present research findings and related nursing implications from an observational study designed to evaluate the use of upright positioning during second stage labor with patients who had received low-dose epidural analgesia. STUDY DESIGN AND METHODS: This descriptive study evaluated outcomes from a sample of 74 healthy women having their first childbirth. They had all received epidural analgesia during the first and second stages of labor. Data were also collected by nurses on the use of birthing beds, and the extent of physical and emotional support the women needed while following the upright positioning study protocol. RESULTS: All women were able to maintain upright positions throughout the second stage of labor following epidural analgesia administration. No adverse neonatal outcomes or maternal problems (such as excessive vaginal bleeding) were documented. CLINICAL IMPLICATIONS: Although women were capable of assuming upright positions during second stage, the study results indicated that constant physical and emotional support was necessary for most women. Future research on methods to prepare women for multiple position options after administration of low-dose epidural analgesia should be undertaken. In addition, nurses should evaluate the benefits of upright positioning in terms of facilitating progress of labor.

Epidural analgesia side effects, co-interventions, and care of women during childbirth: a systematic review.

The purpose of this article is to profile research findings targeting the intrapartum care implications of the most common side effects and co-interventions that go along with the use of epidural analgesia during labor. Randomized, controlled trials published in English from 1990 to 2000 that addressed each of the targeted side effects and 3 specified co-interventions were evaluated for inclusion in this report. Side effects such as pruritus, nausea, and hypotension during labor are common, but they are usually mild and necessitate treatment infrequently. However, even with the advent of newer low-dose epidurals, the extent of impaired motor ability remains variable across studies. The incidence of "walking" epidurals during labor is likely to be complicated by multiple factors, including individual patient desires, safety considerations, and hospital policies. In response to risks for a decrease in uterine contractions that could prolong labor, oxytocin augmentation is likely to be administered after epidural analgesia. The use of "delayed" pushing may be an effective way to minimize the risk for difficult deliveries. Upright positioning even when confined to bed may be advantageous and desirable to women; however, additional research to determine actual outcome benefits with epidurals is needed. Implications for further research linked to epidural analgesia also include informed consent, modification of caregiving procedures, and staffing/cost issues.

Use of Care, Outcomes and Costs of a Culturally-based Perinatal Program for Asian American and Pacific Islander Women in Hawaii.

PURPOSE. This study examines whether psychosocial perinatal care services developed through community partnerships and cultural deference with attention to individual women's health issues, had an assocaited impact on use of prenatal care, birth outcomes and perinatal care costs for the three participating Asian Pacific Islander American ethinc groups. METHODS. The use of prenatal care visits and birth outcomes for women in the Malama program were compared to those for women of the same etnic groups in the community prior to the introduction of the program. Data on program participants from 1992 to 1994 were compared to birth certificate data on Hawaiian, Filipino and Japanese women from 1988 to 1991. Costs of providing Malama prenatal services were determined from data provided by cost accounting and encounter data systems for the program. SUMMARY OF IMPORTANT FINDINGS. The use of prenatal care visits and birth outcomes were significantly lower for Malama program participants than for women of the same ethnic groups prior to the introduction of the program. The costs of the prenatal program services were $846 to $920 per woman. The expected savings in medical costs per infant with the improved preterm birth rates were $680 per infant. Thus 75% to 80% of the costs of the services were likely to be saved in lower medical costs of the infants. MAJOR CONCLUSIONS. Programs that use community approaches and caring servies delivered in a cultural context, like the Malama model, have a potential for improving the use of prenatal care and birth outcomes at reasonable costs. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. The Malama approach to ascertaining cultural preferences for the content and delivery of care should prove useful in addressing public health goals of improved pregnancy outcomes for diverse groups of Asian Americans and Pacific Islanders. KEY WORDS. Asian Americans/Pacific Islanders, pregnancy, prenatal care, low birthweight, preterm birth, cultural competency, community partnerships, costs, cost effectiveness.

Associations of the Use of Prenatal Care with Low Birthweight in Asian Pacific Women in Hawaii.

PURPOSE. This study examines ethnic-specific differences in associations of inadequate use of prenatal care with poor birthweight outcomes to determine whether ethnic specific improvements in the use of prenatal care in a rural district could potentially reduce infant morbidity or mortality there. METHODS. Data from 1988 to 1990 birth certificates of the state of Hawaii were used to study Filipino, Hawaiian and Japanese births. Stratified multivariate logistic regression analyses of the association of inadequate use of prenatal care visits with low birthweight were performed for each group adjusting for potentially confounding sociodemographic risk characteristics. SUMMARY OF IMPORTANT FINDINGS. Results indicate that the adjusted odds of low birthweight for the Hawaiians in the rural district with inadequate amounts of prenatal care visits were higher than for those with adequate visits (OR 2.1; CI 1.4, 3.1) and those relative odds were higher than for Hawaiians in the rest of the state (OR 1.2; CI 1.1, 1.5). Births to Japanese women in the area had a similar pattern (OR 2.3, CI 0.97, 5.6; rest of state OR 1.2, CI 0.98, 1.5), but the ratios were not statistically significant. Births to Filipino women did not have the same pattern (OR 0.73, CI 0.34, 1.6; rest of state OR 1.4, CI 1.2, 1.6). MAJOR CONCLUSIONS. There is substantial heterogeneity in the associations of inadequate care use with poor birthweight outcomes in different groups of Asian Pacific women and in different locations in which they settle. RELEVANCE TO ASIAN AND PACIFIC ISLANDER AMERICAN POPULATIONS. Communities need to determine the associations of poor birth outcomes with poor prenatal care usage of Asian Pacific women to determine whether ethnic specific improvements in prenatal care could potentially improve such outcomes in their areas. KEY WORDS. pregnancy, health services research, outcome and process assessment (health care), regression analysis (logistic models), low birth weight, patient compliance.