The Health-e Babies App for antenatal education: Feasibility for socially disadvantaged women

Background

The use of mobile technology such as phone applications (apps) has been proposed as an efficient means of providing health and clinical information in a variety of healthcare settings. We developed the Health-e Babies app as an Android smart phone application for pregnant women attending a tertiary hospital in a low socio-economic community, with the objective of providing health information about early pregnancy that would increase maternal confidence and reduce anxiety. Based on our earlier research, this form of health communication was viewed as a preferred source of information for women of reproductive age. However, the pilot study had a poor participation rate with 76% (n = 94) not completing the study requirements. These initial findings raised some very important issues in relation to the difficulties of engaging women with a pregnancy app. This paper analyses the characteristics of the participants who did not complete the study requirements in an attempt to identify potential barriers associated with the implementation of a pregnancy app.

Methods

This retrospective review of quantitative and qualitative data collected at the commencement of the Health-e Babies App trial, related to the participant’s communication technology use, confidence in knowing where to seek help and mental health status, maternal-fetal attachment and parenting confidence. Engagement and use of the Health-e Babies App was measured by the completion of a questionnaire about the app and downloaded data from participant’s phones. Mental health status, confidence and self-efficacy were measured by questionnaires.

Results

All women were similar in terms of age, race, marital status and level of education. Of the 94 women (76%) who did not complete the trial, they were significantly more anxious as indicated by State Trait Anxiety Inventory (p = 0.001 Student T-test) and more likely to be unemployed (50% vs 31%, p = 0.012 Student T-Test).

Conclusion

This study provides important information about the challenges associated with the implementation of a pregnancy app in a socially disadvantaged community. The data suggests that factors including social and mental health issues, financial constraints and technological ability can affect women’s engagement with a mobile phone app.

Factors associated with domperidone use as a galactogogue at an Australian tertiary teaching hospital

BACKGROUND

Insufficient milk supply is 1 of the most commonly reported reasons for discontinuation of infant breastfeeding. Although domperidone is often used to improve milk supply, knowledge of factors associated with the use of domperidone in clinical practice is scarce.

OBJECTIVE

This study aimed to examine factors associated with the use of domperidone as a galactogogue at the Women's and Children's Hospital (WCH), Adelaide.

METHODS

A retrospective cohort study was conducted, involving women who delivered live-born singletons (N = 21 914) at the WCH between January 2004 and December 2008. Women dispensed domperidone were identified using WCH pharmacy dispensing records. Maternal and infant clinical data were obtained from the WCH Perinatal Statistics Collection. Relationships between maternal/infant demographic and clinical variables and the use of domperidone were examined through univariate and multivariate logistic regression analyses.

RESULTS

Key factors associated with an increased likelihood of women receiving domperidone were increasing maternal age (adjusted odds ratio [aOR] = 1.04; 95% confidence interval [CI], 1.03-1.06), maternal obesity (aOR = 1.41; 95% CI, 1.16-1.77), primiparity (aOR = 1.94; 95% CI, 1.63-2.30), delivery by cesarean section (aOR = 1.31; 95% CI, 1.10-1.55), preterm birth (aOR = 3.54; 95% CI, 2.79-4.50), and neonatal hospitalization (aOR = 2.51; 95% CI, 2.01-3.14). In addition, statistically significant trends were observed between increasing socioeconomic status and year of delivery and an increased likelihood of women receiving domperidone (all Ps < .004).

CONCLUSION

These findings are of clinical importance as they not only reinforce previous findings regarding risk factors for women experiencing lactation difficulties but also highlight the need for improved research regarding the rational and efficacious use of domperidone to improve breastfeeding outcomes.

"Who's afraid?": attitudes of midwives to the use of information and communication technologies (ICTs) for delivery of pregnancy-related health information

BACKGROUND

Usage rates for information and communication technologies (ICTs) in healthcare have been increasing in recent years, but often lag behind general usage rates for populations as a whole. Research into such differential rates of ICT use across different segments of the population has identified a number of possible causal factors that limit usage.

AIM

The research investigated midwives' attitudes and experiences of ICT use to identify potential causal factors that encourage or inhibit their usage in antenatal care.

METHODS

Semi-structured interviews, focus groups and short surveys were conducted with midwives who provide antenatal education at an Australian metropolitan hospital. Thematic and statistical analyses were used to interpret the data.

FINDINGS

Although midwives recognised the potential benefits of using ICTs to deliver pregnancy-related health information many had reservations about their use in everyday work. These reservations centred on lack of training in use of ICTs, the perceived legal risks associated with social media, potential violations of patient privacy, misdiagnosis and misunderstandings between midwife and client.

CONCLUSION

Midwives face a number of barriers to effective use of ICTs in healthcare including material access, skills access, usage access and motivational access. Motivational access appears to be a key concern due to the high perception of risk associated with social media in particular. Reducing the motivational barriers through a range of interventions with midwifery staff may assist in overcoming other barriers to ICT use in antenatal care. Further research is required to determine whether these findings are generalisable to other healthcare contexts.

Documentation of pain assessment and treatment: how are we doing?

The purpose of this analysis was to evaluate documentation of practice provided by a multidisciplinary team of nurses, physicians, and pharmacists who participated in an educational program on postoperative pain management. Chart audit of 787 patient charts at 6 sites revealed documentation of pain histories in approximately 75% of the charts, most often in the surgeon's history and physical examination. Examination of multiple assessment items indicated that the experimental group, relative to the control group, experienced an increase of more than 10% in the documentation of pain intensity, pain quality, pain duration, numeric rating scale used, pain behavior, factors that increase pain, vital signs, sedation level, cognitive status, social interaction, and mood from before the program to 6 months after the program. Across all sites, documentation of assessment, treatment, and treatment outcome data was infrequent and inconsistent. Calculation of documentation of 4 items that constituted a focused assessment of postoperative pain on the surgical floor revealed a significant program effect for assessment of pain quality and pain intensity. A postprogram survey of participants in the educational program revealed an increase in discussion of postoperative pain management with other practitioners and an increase in use of a 0 to 10 scale to rate pain. More documentation of patient pain history, clinical problems, treatment, and follow-up action is needed to improve practice and research.

Surgical patients' fear of addiction to pain medication: the effect of an educational program for clinicians

OBJECTIVE

The appropriate and optimal use of analgesics is essential for the adequate management of postoperative pain. Concern that use of opioid analgesics contributes to the development of addiction is a barrier to effective pain relief. The purpose of this study was to determine the prevalence of fear of addiction in postoperative patients in relation to surgical outcomes and staff participation in an educational program.

DESIGN

Two treatment levels (program vs. control) and three data collection periods (before program, immediately after the program, and 6 months after the program).

SETTING

Six community hospitals with 100-500-bed capacities in a southeastern state.

PATIENTS

Seven hundred eighty-seven patients who had undergone orthopedic or laparotomy procedures.

INTERVENTIONS

Staff at three of the six hospitals received an educational program to promote implementation of Agency for Health Care Policy and Research acute pain management guidelines.

OUTCOME MEASURES

Patient report of preoperative and postoperative fear of addiction, satisfaction with pain treatment, communication with clinicians, and pain intensity.

RESULTS

Only 10.8% of the sample reported preoperative or postoperative fear of addiction. Staff participation in the educational program was found to decrease fear of addiction in this sample. Fear of addiction was also related to surgery type, with disc surgery patients more likely to report fear of addiction as compared with patients undergoing other types of surgery. Fear of addiction was not related to other outcomes in this sample.

CONCLUSIONS

Fear of addiction is not prevalent among postoperative patients, yet clinician education can further decrease the proportion of surgical patients who fear of addiction to pain medication.

Clinical economics: calculating the cost of acute postoperative pain medication

Few data are available that address the cost of postoperative pain management, although such knowledge would enhance our understanding of caregiver choices related to direct medical costs, such as type, frequency, and route of medication. This article describes the cost of postoperative pain medications before and after an educational program provided to nurses, pharmacists, and physicians in six community hospitals. Medication costs were calculated by averaging across all brands the average wholesale price of the most common dose administered in the sample for each medication. The median cost of postoperative pain medication across all days, all surgeries, was $9.46. Calculating the cost of acute postoperative pain medication suggested that cost over stay is highly influenced by the use of a few expensive medications. The relationship of medication cost to length of stay (LOS), function, and pain intensity is discussed.

Clinical application of the World Health Organization analgesic ladder

One resource that has spurred the development of new standards for the assessment and treatment of pain is the World Health Organization (WHO) analgesic ladder, a three-step guide to the administration of analgesia and adjuvant medication for the treatment of pain. Correct application of the ladder is dependent upon knowledge of the interactions and side effects of the nonsteroidal anti-inflammatory drugs, opioids, and adjuvants recommended at each step of the ladder. Equianalgesic conversion can help provide correct dosing when changing opioids. Because of their altered metabolism and increased risk for epigastric complications, the elderly should receive special consideration when such medications are administered.

An evaluation of facial expression displayed by patients with chest pain

OBJECTIVE

To determine whether patterns of facial expressions of patients complaining of chest pain can aid in the diagnosis of myocardial infarctions.

DESIGN

Exploratory.

SETTING

Southeastern university medical center emergency department (ED).

PATIENTS

Twenty-eight patients in the ED who presented with chest pain. Age range was 40 to 84 years, with a mean of 65.4 years.

OUTCOME MEASURES

Common patterns of facial expressions among patients diagnosed with myocardial infarction.

INTERVENTION

On admission to the ED, patients were videotaped during physical examination. Videotapes were reviewed to code the facial action units exhibited by the patients. The presence or absence of creatine kinase (CK) enzymes was determined; these results were blinded to the coders until after all facial actions were coded.

RESULTS

With use of the Facial Action Coding System, 4 facial expressions were found to be associated with true myocardial infarction: lowering the brow, pressing the lips, parting the lips, and turning the head left.

CONCLUSION

Additional research with a larger sample of patients presenting with chest pain is needed to validate the findings of this study. However, if these findings are supported, instruction regarding assessment of specific facial expressions in clinical settings may be warranted.

Organization of hospital-based acute pain management programs

BACKGROUND

The management of acute pain is an aspect of hospital-based practice that has been neglected. Control of pain is important for ethical reasons, for compliance with new guidelines and standards, and for optimizing patient satisfaction and outcomes.

METHODS

Be review the rationale for establishing priority to the control of acute pain, the importance of an institutional approach to improve pain management, and specific steps in the establishment and conduct of an acute pain program.

RESULTS

Improvement in pain control depends on an institutional approach to facilitate changes in attitude and prioritization. Pain management programs should provide for patient and staff education, adequate documentation of care, institutional standards for pain control, quality assurance/continuous quality improvement (CQI) activities, and periodic review of practice and policy.

CONCLUSIONS

Effective pain management can set the stage for a rehabilitational approach to postoperative care, which should lead to earlier recovery and improved outcomes.

Nurses counseling patients about smoking cessation--why, when, and how

In patient health education, nurses are a natural choice for on-the-spot counsellors and teachers. Yet many nurses feel uncomfortable about broaching subjects such as smoking cessation with their patients or the patients' families. The authors argue that it is time for nursing programs and hospitals to prepare and encourage nurses to take the initiative in smoking-cessation counseling.

Hospital smoking policies: who enforces them?

As opprobrium is increasingly given to the act of smoking, many institutions--hospitals especially--are seeking to curtail the amount of smoking that occurs within their buildings through various policies. This, however, raises two necessary questions: What does policy enforcement mean? And who shall enforce the rules? The article below discusses the results of a survey of North Carolina hospitals that asked these questions and more.

Changing acute pain management to improve patient outcomes: an educational approach

The United States Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines were written to provide a scientific basis for practice. Educational programs designed to promote use of the guidelines may change practice in community hospitals. This article describes the development and implementation of an education program for nurses, physicians, and pharmacists in six community hospitals. Program content addressing the use of continuous quality improvement (CQI) teams, detailed pain histories, application of algorithms and dose calculation is described; direct and indirect outcome measures are reviewed. Six months after the program, all three experimental sites reported use of the AHCPR Guidelines in practice. Nurses reported that assessment and documentation of patients' duration of pain were perceived to be the most important caregiver behaviors providing benefit to patients: Across all respondents' reports of regularly performed activities, the activity performed by the largest proportion was assessing and documenting pain using a 0-10 rating scale.

Pain management issues: the cost of medications in rural settings

Cost of analgesic and adjuvant medications used by rural patients with cancer cared for by 29 nurses participating in an in-depth education program were evaluated before and after the program. Across all time periods, the median daily cost was $5.16 across all medications. Average daily cost and maximum and median cost of all medications were $5.36, $74.38 and $3.58, respectively. Average daily cost did not change over time. Average pain intensity did not change over time and was not related to prescribing patterns or daily costs. While professional education was demonstrated to produce change in prescribing practices, further research is needed to evaluate patterns of medication administration and effectiveness patterns using reliable outcome measures other than self report of pain intensity.

Quality of life and productivity in nurses reporting migraine

A random sample survey was conducted to determine the prevalence of migraine in nurses and to study its effect on quality of life and productivity. Of the 10,000 nurses sampled, 2949 returned the questionnaire for a response rate of 29.5% The majority (99%) of respondents were employed and worked in hospitals (60%). According to the International Headache Society (IHS) criteria, 17% of the sample (n=495) were classified as having migraine. An additional 25% (n = 750) suffered severe headaches but did not meet IHS criteria for migraine, and the remaining 58% (n = 1704) were classified as not having either migraine or severe headaches. The migraineurs had significantly reduced work productivity and quality of life compared to both the severe headache and the nonmigraine nonsevere headache groups. This study will increase awareness and sensitivity of the profession to its colleagues who are migraine sufferers.

An examination of nursing attitudes and pain management practices

PURPOSE

The purpose of this evaluation is to examine the relationship among nurses' pain management attitudes and pain management practices and to begin to explore the theoretical underpinnings that may influence this relationship.

DESCRIPTION OF STUDY

A convenience sample of 29 female registered nurses working in hospice or home health settings participated in an educational program 1 day per week for 6 weeks. All participants were asked to complete the Cancer Pain Knowledge Inventory and Survey of Expectations and Pain Assessment Questionnaire 5 weeks before, immediately before, immediately after, 6 months after, and 12 months after the program. Seventeen participants completed all questionnaires at the 6-month follow-up; 16 participants completed all questionnaires at the 1-year follow-up. Personal beliefs about pain were evaluated in relation to the dimensions and treatment of pain. Intentions and expectations to perform specific activities were evaluated in relation to in-depth assessments, equianalgesic conversions, demonstration of new ideas, and communication.

RESULTS

Nurses' attitudes, beliefs, intentions, and expectations about pain and pain management influenced nurses' patient care and educational activities. Nurses who believed that patients should be pain free and nurses who focused on both the dimensions and treatment of pain implemented more pain management activities. In general, nurses who had high intentions and expectations performed more pain management activities.

CLINICAL IMPLICATIONS

Although nurses reported change in attitude, and high expectancy for change, feelings of increased credibility, and increased motivation as advocates for new approaches to practice, nurses sometimes found it difficult to implement new practices because of constraints in time and collaborative efforts. To implement new knowledge and achieve individualized goals for change, nurses must be allowed adequate time to analyze the relationships between their beliefs about pain and the ways that they solve patients' pain problems. In addition, more support for multidisciplinary collaboration is needed.

A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale

Pain is difficult to measure, regardless of etiology. Furthermore, the measurement of pain is complicated by variation in the use of visual analogue scales as well as other pain assessment measures. This brief article reviews situations contributing to confusion regarding pain intensity measures and argues for consistency in its measurements with adults not experiencing cognitive disorders in the clinical setting.

Differentiating the effects of centrally acting drugs on arousal and memory: an event-related potential study of scopolamine, lorazepam and diphenhydramine

The degree to which apparent amnesic effects of various centrally acting drugs are secondary to their effects on arousal remains a contentious issue. The present study uses two methods to dissociate memory and arousal effects of the cholinergic antagonist, scopolamine (SP), and the GABA-A/benzodiazepine receptor agonist, lorazepam (LZ). First, it compared their effects to those of an antihistamine, diphenhydramine (DPh), to provide an active control for arousal reduction. Second, it used the same measure--event-related potentials (ERPs)--as as a parallel index of both the arousal and cognitive effects of the drugs. Fifty participants were allocated to one of five parallel treatment groups (0.6 mg SP; 2 mg LZ; 25, 50 mg DPh; placebo). ERPs were recorded during a continuous word recognition task as well as during an "oddball" task. SP, LZ and 50 mg DPh produced a similar profile of effects on certain indices of arousal and on early components of ERPs. However, SP and LZ (but not DPh) produced marked impairments of episodic memory, and this pattern was similar to that on later components of ERPs. Memory impairments by SP and LZ were highly significant on retention in the continuous recognition task and further, no drug effects were found on response bias. Subsequent free recall was similarly very impaired by SP and LOR but not by the antihistamine. We conclude that benzodiazepines and anticholinergic drugs both reduce arousal and induce amnesia, but these effects are not interdependent. Our findings provide strong evidence for a dissociation between the effects on episodic memory and on arousal of these centrally acting compounds.

Changing the relationship among nurses' knowledge, self-reported behavior, and documented behavior in pain management: does education make a difference?

An educational program designed to change knowledge in order to change pain management practices and patient outcomes was offered to nurses who provide day-to-day care to patients with cancer in communities in a predominantly rural state. A quasi-experimental time-series design was used to measure the effectiveness of the program in changing nurse knowledge, attitude and behavior, and to evaluate the relationships between the outcomes. Data were collected from nurses (N = 29) and patient charts before (N = 209) and after (N = 163) the program. Nurses' knowledge increased, but the change was not statistically significant; the mean percent of correct answers on the three subtests were different and differences persisted throughout the study. Nurses believed that patients should be "pain free." Documentation of behaviors, for example, practice activities, occurred infrequently and showed little change until 6 months after the program. Increase in documentation of pain-intensity ratings, pain location, number of sites of pain, presence of confusion, anxious or depressed mood, sleep, nausea and vomiting, constipation, and general activity were noted. Documentation of the use of a propoxyphene-containing analgesic decreased; increase in the use of hydromorphone methadone and transdermal fentanyl was noted. Analysis of the relationships between correct responses to nurse knowledge questions and documentation of behavior provided interesting, statistically insignificant results that need to be reexamined in future research. Future programs should emphasize analgesic dosing and calculation of equianalgesic doses. Current practices in chart documentation may provide incomplete information regarding change in practice behaviors; more detailed documentation of pain management practices is needed. Nurses who participated in the program anecdotally reported feelings of increased credibility and effectiveness. Although change in behavior is slow to occur, education does make a difference.

The knowledge and attitudes of experience oncology nurses regarding the management of cancer-related pain

PURPOSE/OBJECTIVES

To describe the knowledge and attitudes of North Carolina nurses toward the management of cancer-related pain. The analysis focused on knowledge, attitude, and perception of barriers to pain management.

DESIGN

Exploratory, descriptive.

SETTING

North Carolina.

SAMPLE

A survey of 1,400 RNs were stratified by educational background and Area Health Education Center regions of the state; the response rate was 24%.

METHODS

An adapted version of The Wisconsin Pain Initiative Survey mailed to participants.

MAIN RESEARCH VARIABLES

Nurses' knowledge, attitudes, and perception of perceived barriers to managing cancer-related pain.

FINDINGS

Nurses who have cared for patients with cancer are more knowledgeable and have more liberal attitudes toward pain management from nurses who have not cared for patients with cancer. North Carolina nurses report knowledge and perception of barriers to pain management similar to those of Wisconsin nurses.

CONCLUSIONS

The experience of caring for patients who have cancer and pain influences nurses to report more liberal attitudes toward pain management.

IMPLICATIONS FOR NURSING PRACTICE

Although nurses report increased knowledge of pain management in general, deficits continue to exist. Further research is needed to more fully understand the effect of educational and experience on practice.

Outcomes that provide evidence of change in cancer pain management

Making improvements in the management of cancer pain is a complex process involving patient and professional factors. This article reviews the types of outcome measures that have been used to document improvement in cancer pain management. Examples from several studies are provided to illustrate the difficulty and benefit of documenting evidence of change in professional practice related to cancer pain management.

Tailoring treatment approaches to the individualized needs of cancer patients with pain

Cognitive-behavioral and behavioral interventions, which have been successfully used to manage chronic pain unrelated to cancer, are an acceptable treatment for the psychobiological factors, including the expression of feelings, associated with pain in cancer patients. However, testing the effectiveness of complex multidimensional programs is difficult because of confounding factors such as progression of disease and measurement of potentially reactive outcomes. Patients were enrolled in theoretically strong individualized treatment programs for 5 weeks, with follow-up observation at 9 and 17 weeks. Weekly strategies were chosen to contribute to the achievement of patient-selected pretreatment goals. Interventions were designed to achieve psychobiological outcomes such as a decrease in inaccurate expectations, an increase in the use of positive comparisons and positive self-statements, a decrease in autonomic arousal, and promotion of self-efficacy. Two case studies provide examples of individual differences in treatment needs and the realities of clinical care.

Managing cancer pain: content and scope of an educational program for nurses who work in predominantly rural areas

A great deal of effort is being expended at national, state and local levels to improve cancer pain management in the United States. The fact that cancer patients continue to experience "unrelieved pain" is of concern to professional caregivers and families, as well as to the patients themselves. This article describes the content and scope of an educational program for nurses who work in predominantly rural areas. Content of the program and the evaluation process are described in detail in order to provide other caregivers with a model that could be implemented in similar settings.

The evolution of a profession: where do boards of nursing fit in?

Differentiation between the structure and functions of Boards of Nursing and the professional association is important to understanding the evolution of nursing as a profession. This descriptive exploratory study revealed that Boards of Nursing usually have 5 members who are appointed by and can be removed by the governor of the state. All Boards are responsible for education and licensing at the professional entry-level but may not be responsible beyond that level. In contrast to the professional association, Boards report appreciable variability in structure and administration. Boards differ from the professional association in source of power and focus on the protection of the public rather than improvement of practice.

Narcotic analgesics. Clinical pharmacology and therapeutics

Nurses often are responsible for administering narcotic analgesics to patients with pain due to cancer or the treatment of cancer. Because of frequent use of these agents, and their various and dramatic effects throughout the body, it is important to understand their pharmacological properties and appropriate therapeutic use. This article reviews the actions and side effects, appropriate selection and use of narcotic analgesics and provides guidelines for administration.

Fear, alexithymia and cancer pain

The purpose of this study was to examine the differential role of fear, anxiety, alexithymia, family factors and coping in cancer pain. Twenty-seven patients with pain related to cancer, 26 patients with chronic non-cancer pain, 26 patients with chronic illness but no pain (hypertensives) and 24 healthy controls completed a set of questionnaires during an initial interview and recorded severity and duration of pain, pain interference with activities, thoughts, behaviors and physiological responses associated with fear of pain, and coping strategies using a diary once daily for 7 days. In general, cancer patients reported lower pain levels than patients with chronic non-cancer pain. Contrary to anecdotal reports, cancer pain patients did not report fear of pain. Cancer patients and patients with chronic non-cancer pain reported similar levels of trait anxiety which was higher than non-pain patients. Alexithymia, as a measure of emotional expression, was associated with increased duration of pain in the cancer pain patients. Cancer pain patients also reported less use of coping strategies than patients with chronic non-cancer pain. Cancer patients did not report higher levels of family modeling of pain complaints or family use of medication. The perceived family environment of the cancer pain patient did not differ significantly from the 3 other groups. These results do not support anecdotal impressions that the level of reported pain and fear of pain is significantly greater in cancer pain in contrast to non-cancer pain. The results do indicate the importance of emotional expressivity in the modulation of cancer pain where the ability to assess and express emotions was associated with reduced pain.

Nurses' perceptions of their pain assessment skills, pain management practices, and attitudes toward pain

Nursing pain assessments are influenced by the length of available tools, patient characteristics, patient pathology, concern about addictive behavior, and characteristics of the nurse. The relationship among these variables was explored in a sample of community hospital nurses (N = 59) and ONS members (N = 19). Although a number of interesting similarities were found in the two groups, age, professional and continuing education, and care setting appear to be related to differences in pain assessment practices. Implications for practice, research, and education include teaching nurses to: assess factors related to quality of life in the pain experience, assess and validate data from families, assess coping skills, and teach patients to use behavioral pain management strategies. The findings also suggest that further study is needed concerning the relationship between personal beliefs and experiences and the assessment and management of pain. Membership in professional organizations appears to be associated with comprehensive approaches to the assessment and management of cancer pain and should be addressed in further research.

The beginning of clinical pastoral care in the Philippines

Sketches the history of CPE in the Philippines from its experimental beginnings at St. Luke's Hospital in 1964 to ACPE accreditation of the first program in 1966.