Implementation of a Nurse-Empowered Renal Anemia Protocol in Children

A high proportion of patients on hemodialysis persist with low hemoglobin levels despite receiving treatment with erythropoiesis-stimulating agents. A registered nurse-driven renal anemia protocol was designed and implemented by a team in a pediatric hemodialysis unit. We compared proportion of patients achieving the target hemoglobin (Hgb) and transferrin saturation (TSAT) before and after the implementation of the protocol. There was an increase in patients achieving the target Hgb and TSAT range, with an increase in the Hgb concentration. There were no differences in the proportion of patients with left ventricular hypertrophy, erythropoiesis-stimulating agents or intravenous iron dose, transfusion rates, or hospitalization rates. The implementation of a nurse-driven anemia protocol in a pediatric hemodialysis unit increased the proportion of patients achieving target Hgb and TSAT range without a rise in medication doses.

Pediatric pain management in the emergency department

Adequate analgesia is critical in the management of pediatric patients in the emergency department. Suboptimal treatment of pain can have deleterious effects in the short term, and it can also affect a patient's development and reaction to future painful experiences. Tools exist to quantify a patient's pain level regardless of age or developmental stage. Both pharmacologic and nonpharmacologic methods can be effective in the management of pediatric pain. Emergency clinicians must remain vigilant in the recognition, treatment, and reassessment of pediatric pain, as patients' developmental level may limit their ability to independently express their pain experience without prompting or tools. This issue reviews pain scales that are suitable for pediatric patients and discusses pediatric pain management using nonpharmacologic methods, topical, local, and regional anesthesia as well as systemic agents.

[The lead nurse in a paediatric haemostasis unit]

In an approach of global collaboration, the lead nurse in a paediatric haemostasis unit uses her technical and educational role to participate in the management of the child's specific disorder. As a resource person, she coordinates the care and ensures the continuity of the child's care.

Developing and nurturing a community practice clinical network for community children's nurses in Wales

Working as a children's community nurse (CCN), especially in remote and rural locations, can evoke feelings of professional isolation. Humans are by nature 'social animals' and the consequences of feeling isolated, and coping with distances, adverse weather and risky situations, could mean that nurses choose to work instead in more familiar and comfortable environments. This can affect retention issues and increase the risk of CCNs experiencing stress, burnout and illness-related absenteeism. The children they care for often have complex needs and parents want their CCN to be 'on the ball'; they will feel concerned and frustrated if the CCN team lets them down. Two academics were approached by CCNs in Wales seeking ways of overcoming isolation. It was decided that the best course of action was to develop a community of practice clinical network for band 5 and 6 CCNs working in Wales, with the aim of supporting staff, sharing best practice, and promoting safe and quality-driven care. Alternating the networks among health boards, whereby the nurses decided the agenda, booked the venue, invited guest speakers, led the meeting and wrote up the minutes, was an excellent way to achieve the designated aim: reducing professional isolation. A range of clinically focused topics were discussed and debated, and the first six meetings were so effective in meeting the aim of the network that each health board is starting the cycle of hosting the network again.

The children's nursing workforce in Kenya, Malawi, Uganda, South Africa and Zambia: generating an initial indication of the extent of the workforce and training activity

BACKGROUND

This study sought to identify, as far as possible, the extent of the specialist children's nursing workforce in five selected African countries. Strengthening children's nursing training has been recommended as a primary strategy to reduce the under-five mortality rate in African nations. However, information about the extent of the specialist children's nursing workforce in this region is not routinely available. Developing an accurate depiction of the specialist children's nursing workforce is a necessary step towards optimising children's health service delivery.

METHODS

This study used a convergent parallel mixed methods design, incorporating quantitative (surveys) and qualitative (questionnaire and interview) components, to generate data addressing three related questions: how many children's nurses are believed to be in practice nationally, how many such nurses are recorded on the national nursing register and how many children's nurses are being produced through training annually.

RESULTS

Data provide insights into reported children's nursing workforce capacity, training activity and national training output in the five countries. Findings suggest there are approximately 3728 children's nurses across the five countries in this study, with the majority in South Africa. A total of 16 educational programmes leading to a qualification in paediatric nursing or child health nursing are offered by 10 institutions across the countries in this study, with Kenya, Malawi and Zambia having one institution each and South Africa hosting seven. Data suggest that existing human resources for health information systems do not currently produce adequate information regarding the children's nursing workforce. Analysis of qualitative data elicited two themes: the role of children's nurses and their position within health systems, and the capacity of HRH information systems to accurately reflect the specialist children's nursing workforce.

CONCLUSION

The data generated provide an initial indication of the size of the children's nursing workforce in these five countries, as well as an overview of associated training activity. We hope that they can start to inform discussion about what would represent a viable and sustainable regional children's nursing workforce for the future.

[Development and implementation of pediatric and neonatal nursing information system in an hospital setting: the pediatric PAI]

The Professional Assessment Instrument (PAI) is a clinical nursing information system used in the adult inpatient units of the A. Gemelli university hospital in Rome (Italy). The PAI allows for the systematic collection of nursing care data in order to improve the quality of care. So far, few clinical nursing information systems have been developed in the neonatal and pediatric care setting. The aim of this study is to describe the development and implementation of a clinical nursing information system (PAIped) for the neonatal and pediatric care setting.

METHODS

The Patient-and Family-Centered Care model was used to develop the contents of the PAIped. A web platform application was developed for the PAIped. The standard nursing terminology Clinical Care Classification System was used. A decisionmaking support system was developed within the PAIped to support nurses in making diagnoses and in selecting the most appropriate nursing interventions.

RESULTS

A clinical nursing information system using a standard nursing terminology was developed in the pediatric and neonatal care setting. After a test phase, the PAIped was implemented in all the pediatric and neonatal inpatient units of the A. Gemelli university hospital.

CONCLUSION

The development and implementation of the PAIped in the A. Gemelli university hospital allowed the monitoring of nursing care processes and accurate nursing documentation.

Factors Associated With Stability of Health Nursing Services for Children With Medical Complexity

The objectives of our study are to: (1) identify the factors associated with lack of stable home healthcare nursing services for children with medical complexity, and (2) describe the implications of unstable home healthcare nursing for children, caregivers, nurses, and home healthcare agencies. We collected qualitative data in 20 semistructured in-depth interviews (15 English, 5 Spanish) with 26 primary caregivers of children with medical complexity, and 4 focus groups of 18 home healthcare nurses inquiring about their experiences about home healthcare nursing services for children with medical complexity. During an iterative analysis process, we identified recurrent themes related to stability of home healthcare nursing. Lack of stability in home healthcare nursing was common. These include: (1) not finding nurses to cover shifts, (2) nurse turnover, (3) nurses calling out frequently, and (4) nurses being fired by caregivers. Reasons for lack of stability of home healthcare nursing services were multifactorial and included: nurse-level, child-level, caregiver-level, residence-level, agency-level, and system-level factors. Lack of stable home healthcare nursing affected the well-being of children with medical complexity, and contributed to substantial caregiver burden. There were negative implications of unstable home healthcare services for nurses and home healthcare agencies as well. Lack of stable home healthcare nursing services is a major problem in the home care of children with medical complexity. Although some of the factors for unstable home healthcare nursing services are not modifiable, there are others that are potentially modifiable. Ensuring stable home healthcare nursing services will likely improve care of children and reduce caregiver burden.

Listening to paediatric primary care nurses: a qualitative study of the potential for interprofessional oral health practice in six federally qualified health centres in Massachusetts and Maryland

OBJECTIVES

To explore the opportunities for interprofessional collaboration (IPC) to improve paediatric oral health in federally qualified health centres (FQHCs), to identify challenges to IPC-led integration of oral health prevention into the well-child visit and to suggest strategies to overcome barriers.

SAMPLE

Nurse managers (NMs), nurse practitioners (NPs), paediatric clinical staff and administrators in six FQHCs in two states were interviewed using a semistructured format.

DESIGN

Grounded theory research. Topics included feasibility of integration, perceived barriers and strategies for incorporating oral health into paediatric primary care.

MEASUREMENTS

Qualitative data were coded and analysed using NVivo 10 to generate themes iteratively.

RESULTS

Nurses in diverse roles recognised the importance of oral health prevention but were unaware of professional guidelines for incorporating oral health into paediatric encounters. They valued collaborative care, specifically internal communication, joint initiatives and training and partnering with dental schools or community dental practices. Barriers to IPC included inadequate training, few opportunities for cross-communication and absence of charting templates in electronic health records.

CONCLUSIONS

NMs, NPs and paediatric nursing staff all value IPC to improve patients' oral health, yet are constrained by lack of oral health training and supportive charting and referral systems. With supports, they are willing to take on responsibility for introducing oral health preventive measures into the well-child visit, but will require IPC approaches to training and systems changes. IPC teams in the health centre setting can work together, if policy and administrative supports are in place, to provide oral health assessments, education, fluoride varnish application and dental referrals, decrease the prevalence of early childhood caries and increase access to a dental home for low-income children.

Keeping sick children in hospital SAFE from harm

Emeritus Professor Alan Glasper, from the University of Southampton, discusses the quest by the Royal College of Paediatrics and Child Health to improve safety and reduce preventable deaths in UK paediatric units.

Standardization of Telephone Triage in Pediatric Oncology

Nurses in pediatric oncology are often the main resource for overwhelmed parents and deal with complex patient issues over the telephone but often not without concerns about best patient care, liability, and accountability for the advice given. The question is whether using standardization of telephone triage practices can provide opportunities for improvement in the care of pediatric oncology patients. A review of the literature pertaining to telephone triage, standardization of practice, and the practice in outpatient oncology was conducted. The utilization of easy-to-use, accessible yet nonrestrictive resources and a well-designed documentation tool can help guide the decision-making process while addressing legal concerns and ensuring best possible patient care. An advantage that nurses in outpatient oncology settings have in performing telephone triage is the knowledge they have of their patient population and the disease process and treatments. Using a balanced approach to standardization of telephone triage practices can provide opportunities for improvements in care while still capitalizing on the intuitive knowledge and experience of the nurses involved.

Cardiovascular Late Effects

This integrative literature review focuses on (1) the spectrum of cardiovascular late effects; (2) the factors that can influence the development of cardiovascular late effects; and (3) the role of the pediatric oncology nurse in minimizing the risks of cardiovascular late effects and associated disabilities in childhood cancer survivorship. The results showed that survivors who have been treated with radiation therapy, especially when the field includes the heart or the hypothalamic-pituitary axis (HPA), and specific chemotherapies are at increased risk for developing particular cardiovascular risk factors and/or cardiovascular disease. Younger age at diagnosis, longer time since treatment, and family history of early heart disease can further heighten the risks. The role of pediatric oncology nurses in the promotion of cardiovascular health for children with cancer across the illness trajectory is discussed.

Pediatric Oncology Nurses' Attitudes Related to Discussing Fertility Preservation With Pediatric Cancer Patients and Their Families

This study explores nurses' attitudes toward the discussion of fertility preservation (FP) with pediatric cancer patients and their families. A cross-sectional survey was administered to attendees of a pediatric oncology conference. Of the 115 nurses who responded and comprised the study sample, most reported discussing risks of infertility or FP ≤ 50% of the time. The 3 attitudinal factors most commonly rated by nurses to influence discussion of FP are the potential of upsetting patients' families, that boys younger than 18 years should not be given erotic materials during semen collection, and difficulty locating FP facilities. The 3 patient factors most likely to encourage the discussion of FP are the patient being recently married or engaged, the patient asking about FP, and availability of patient education materials. While the results indicate that nurses do not regularly discuss FP with their patients, nurses perceive such discussion as being within their scope of practice. Therefore, with appropriate intervention, nurses may play a key role in facilitating discussions regarding FP with patients and families.

Innovation from the inside: Collaborating for school readiness

This paper will critically reflect on a service evaluation project that was undertaken within Sussex Community NHS Foundation Trust in 2014/15. The project sought to provide a new way of working that supported health visitors (HVs) and school nurses (SNs) in developing effective collaborative and partnership working practices in order to meet the health needs and improve the health outcomes of children aged four to five years in preparation and readiness for school. HVs and SNs are well placed to work with families and provide the early interventions and health support required to support school readiness, e.g. behaviour, sleep, eating and continence advice. Historically, within Susssex Community NHS Foundation Trust, this public health approach has been taken on by the SN service. However, problems were identified locally with this model due to several factors including reduced staffing and confusion regarding transition of care from HVs to SNs. In response, a new way of working was considered locally to ensure the best possible service for families.

Better Together: A Win-Win Pediatric Academic Partnership

As healthcare facilities and academic nursing programs are challenged to be efficient and effective in light of an ever-changing healthcare system, recent literature has focused on the value of creating academic practice partnerships. Using the American Association of Colleges of Nursing (AACN) and American Organization of Nurse Executives (AONE) Academic Practice Partnership Guiding Principles, a children’s hospital and state university are working collaboratively to improve evidence-based practice and research, create innovative educational opportunities for undergraduate and advanced practice students, promote academic progression that enables nurses to advance their education, improve access to health care services for underserved families, and implement initiatives that improve patient- and family-centered care. This article will describe the initiatives, processes, and outcomes of this fruitful partnership. The examples we provide using the Academic Practice Partnership Guiding Principles can be adapted in other healthcare facilities and nursing programs.

Empowered by Nurses

Before Justice Hope Coleman was born, nurses in an antenatal testing center provided her parents with support and encouragement, the first steps in empowering them in their roles as parents of a child with multiple disabilities and complex medical needs. Over time, other nurses supported Justice's parents as they learned to communicate clearly and collaboratively with professionals; to provide a high level of care for their daughter in a loving, family-oriented way; and to advocate not only for Justice and their family as a whole, but also for other children and families in the healthcare system. This article describes the important role nurses played in empowering Justice's parents.

Central Line Placement for the Pediatric Oncology Patient: A Model of Advanced Practice Nurse Collaboration

Central lines are commonly placed in pediatric oncology patients during their therapy. Advanced practice nurses (APNs) play an important role in the coordination and facilitation of line placements so that they may be inserted in an expeditious manner. Collaboration between the Divisions of Oncology and Surgery is often key to attaining this goal. At the Children’s Hospital of Philadelphia, the APNs in Oncology and Surgery have developed a collaborative approach to the placement of central lines in oncology patients. Many positive changes ensued between these divisions after collaboration occurred and a system for line placements was put into place. A well-defined process for central line placement is currently being utilized that meets the needs of the patients. Central lines are being placed in a timelier manner, procedures are coordinated, and treatment is started earlier, which has increased the satisfaction of patients, families, and health care providers. Finally, this collaboration led to an improved relationship and better communication between the Divisions of Oncology and Surgery.

Integrating the Child into Home and Community Following the Completion of Cancer Treatment

The present article examines the period of time immediately following the completion of treatment for childhood cancer. The unique concerns experienced by families at this stage of the cancer treatment are examined, and the specific challenges that children face as they renegotiate roles and relationships that are necessary for successful reintegration into family, school, and community settings are discussed. Obstacles to successful reintegration that are frequently encountered by patients and families are reviewed, as well as variables that may promote optimal adjustment during this transitional period. The need for continued research in this area is highlighted, and specific research questions are identified. An emphasis is placed on applying a socioecological framework to research and clinical work with pediatric oncology patients at this stage of the cancer experience.

Research Priorities for Family Assessment and Intervention in Pediatric Oncology

Four broad areas of research priority related to family assessment and intervention in pediatric oncology are outlined. The importance of a contextual, systemic approach is highlighted along with the value of systematic empirical assessment of psychosocial risk at diagnosis. Research to advance the development and application of standards of care during treatment is also advocated. The chapter concludes with opportunities for family-oriented research related to survivorship and end-of-life care.

Human Suffering: The Need for Relationship-Based Research in Pediatric End-of-Life Care

Children living with and dying from advanced cancer and their families experience significant suffering. The cure of disease and the relief of suffering are dual moral obligations of our professions. To relieve suffering, health care providers must understand the multiple dimensions of the person who suffers and the complex set of relationships within the natural and the clinical social networks. Pediatric oncology research must include appropriately designed studies with sound methodology and measurement strategies to test and refine theories that account for the link between human relationships and the relief of suffering. Studies should assess as many theoretical models as possible, including the social network, perceptions of support, and provider-recipient interactions; their physical, emotional, behavioral, and spiritual concomitants; and their impact on medical decision making and health outcomes. Future directions in pediatric end-of-life care research must also include evaluating social and spiritual interventions developed on the basis of solid hypotheses regarding the positive and negative influences of interpersonal dynamics on the processes that mediate between suffering and well-being.

Complementary and Alternative Medicine Research and Cooperative Groups: Can It Happen?

The use of complementary and alternative medicine (CAM) interventions to ameliorate cancer- and treatment-related toxicities is gaining increasing attention among clinical investigators. The National Cancer Institute supports a number of clinical studies, both descriptive and interventional, of CAM interventions across the cancer trajectory, from prevention through diagnosis and treatment, survivorship, and end of life. This report highlights the unique challenges that clinical investigators face when designing and implementing CAM clinical trials through the cooperative groups. This report focuses on 2 CAM trials that opened and accrued participants in the Children’s Oncology Group. One trial is aimed at preventing or reducing mucositis and the other at preventing chemotherapy- induced nausea and vomiting.

Pediatric Cancer Research From Past Successes Through Collaboration to Future Transdisciplinary Research

Multidisciplinary collaboration in therapeutic research in childhood cancer has been responsible for enormous improvements in outcomes. Many of the improvements have resulted from large clinical trials carried out in multisite settings through the Children’s Oncology Group (COG) and its predecessors, the Children’s Cancer Group, the Pediatric Oncology Group, the National Wilms’ Tumor Study, and Intergroup Rhabdomyosarcoma Study Groups. Childhood acute lymphoblastic leukemia models the past success of 35 years of randomized clinical trials that resulted in survival rates of around 80%. However, more can be done to improve both survival rates and the quality of survival. Areas that can benefit from a transdisciplinary model of research are discussed, as well as challenges to this form of collaboration.

Delivery of Culturally Competent Care to Children With Cancer and Their Families—The Latino Experience

This article discusses selected cultural factors such as language and interpretation services, beliefs, health care practices, and communication styles of Latino families that can increase and enhance the ability of nurses to work with a child with cancer and his or her family. Suggestions for research and clinical intervention are presented.

The Art of Pediatric Oncology Nursing Practice

Pediatric oncology nursing practice must incorporate both the science and the art of the discipline to foster positive physical and psychosocial treatment outcomes for pediatric oncology patients, especially those outcomes related to their health-related quality of life. In this article, the art of nursing care is described within the context of scientifically based care, and the art of nursing practice is evident in the implementation of the scientific principles and standards for pediatric oncology nursing practice. The author proposes that the art of pediatric oncology nursing practice ought to be evident in care activities that the nurse provides within a therapeutic relationship that is steeped in nursing presence. Although the art of nursing care and the nature of an effective therapeutic relationship is tacit, valued knowledge among pediatric oncology nurses, as well as children and adolescents with cancer and their families, it is difficult to describe and challenging to quantify its effect on patient care outcomes. This article discusses the art of pediatric oncology nursing practice and its influence on treatment outcomes.

Mind-Body Therapies for the Pediatric Oncology Patient: Matching the Right Therapy With the Right Patient

Pediatric oncology nurses provide care for children across a continuum from the point of diagnostic evaluation through treatments and cure or a peaceful, dignified death. Nurses provide this care in a wide variety of settings such as the home, hospital, clinics, schools, camps, and residential facilities. Mind-body therapies are being used more frequently in the care of children receiving treatment for cancer. Matching the right therapy with the right patient is an important component of care.

Symptom Management Research in Children With Cancer

A review of the clinical research studies published within the past 5 years revealed that efforts to manage symptoms of cancer and its treatments have not kept pace with new advances in the cure for cancer. Children with cancer continue to experience distressing physical symptoms caused by the disease and treatment. The purpose of this article is to provide a concise overview of the most common symptoms experienced by children with cancer. These symptoms include pain, nausea and vomiting, nutritional concerns, mucositis, and fatigue experienced by the child with cancer. Recommendations for future research are addressed.

Unaccompanied Immigrant Minors: Where to Begin

The number of unaccompanied immigrant minors (UIMs) from Central America significantly increased in 2014. Nearly 50,000 children from El Salvador, Guatemala, and Honduras crossed the United States-Mexico border in 2014, compared with 3,933 in 2011. Few resources exist to guide pediatric nurse practitioners (PNPs) in their care of UIM. The multifactorial reasons behind migration and the state of children's health in Central America provide insight into the needs of UIMs. Guidelines for similar groups such as foreign-born children and refugees offer direction for the health care considerations of UIMs. This article provides demographic information on UIMs, highlights the unique and challenging medical and mental health issues facing UIMs, and discusses the role of the PNP. A UIM's initial visit with a PNP serves as an opportunity to build trust through culturally competent, trauma-informed care, provide preventive care, assess for unmet health needs, and screen for mental health conditions.