Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

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Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

Hospital emergency departments (EDs) serve a critical role in its non-discriminatory evaluation and stabilization of all individuals who present for care, regardless of ability to pay. However, EDs are not adequately prepared or capable of caring for children and adolescents who are in behavioral health crisis and require acute treatment. The frequency and duration of pediatric ED visits have also increased over time, leading to crowded EDs, suboptimal delivery of behavioral health care, and strain on hospital resources. In response, hospital systems, states, and the federal government developed a variety of policies to support EDs in the delivery of high-quality care and improve pediatric behavioral health outcomes. Numerous drivers involving the low supply of pediatric behavioral health care professionals, high demand for emergency behavioral health evaluation and treatment, and fragmentation of the behavioral health care system interact to continue to drive patients to EDs despite the implemented policies. Further investigations are needed to exactly determine patients’ unmet needs and identify root causes of pediatric behavioral health ED visits. Last, pediatric behavioral health care policy must not only expand on individual policy successes but also take innovative, value-based approaches to effectively address the worsening pediatric behavioral health crisis.

I Sverige lades 121 671 barn in för sjukhusvård år 2014. Var och en av barnen var i behov av en sjuksköterska som var ansvarig för deras omvårdnad, en omvårdnadsansvarig sjuksköterska (OAS). Enligt svensk lagstiftning har alla rätt till en fast vårdkontakt om ett behov uppstår. Syftet med denna studie var att beskriva vilka arbetsuppgifter en omvårdnadsansvarig sjuksköterska inom barnsjukvården har samt vilken kompetens som barnsjuksköterskor anser vara viktig. För att uppnå syftet genomfördes intervjuer med barnsjuksköterskor. Det transkriberade materialet har bearbetats genom en kvalitativ innehållsanalys. Resultatet utmynnade i tre kategorier, vilka speglar de arbetsuppgifter som en OAS har: Kunskap, Teamarbete och Trygghet. De tre kategorierna innefattade arbetsuppgifter såsom att inneha kunskap om barnet, samordna och planera, att vara kontaktperson och att informera. Resultatet bidrar till att belysa en OAS’s arbetsuppgifter för att kunna sprida kunskap om dess roll. / In Sweden 121 671 children were admitted to hospital care in 2014.  Each and every one of them needed a nurse responsible for their care, a primary nurse (PN). According to Swedish law, everyone has the right to a steady care taker if there is a need. The aim of this study was to describe what work assignments a PN within pediatric care has, and what competencies pediatric nurses consider important. Interviews with pediatric nurses were carried out to achieve this. The transcribed material has been worked at through a qualitative content analysis resulting in three categories that reflect a PN work assignments; Knowledge, Team work and Security. These three categories include work assignments such as: knowledge about the child, coordinate and planning, to be a patient confidant, and to educate. The results contribute to and elucidate a primary nurse’s work assignments and help spread knowledge about their role.

Bakgrund: Specialistsjuksköterskans uppgifter på en barnintensivvårdsavdelning (BIVA) är att vårda barn och det innefattar även att vårda barn i livets slutskede. Av de barn som vårdas på en barnintensivavdelning avlider cirka två procent. Att vårda barn och familjen i en situation där fortsatt vård och överlevnad för barnet är utsiktslöst är en tung och ansvarsfull uppgift. Syfte: Studiens syfte var att belysa specialistsjuksköterskors upplevelser av att ha vårdat ett barn vid livets slutskede på en BIVA. Metod: Som datasamlingsmetod användes semistrukturerade intervjuer med sju specialistutbildade sjuksköterskor. Intervjuerna genomfördes med hjälp av en intervjuguide bestående av en huvudfråga och därefter följdfrågor. Data bearbetades utifrån kvalitativ innehållsanalys med en beskrivande ansats. Resultat: Resultatet presenteras i tre kategorier och tio subkategorier. De tre kategorierna var följande: Att känna sig trygg och erfaren i att vårda ett döende barn, familjen i fokus samt upplevelsen av stöd och strategier i det komplexa vårdandet. Diskussion: Trots att upplevelsen av att vårda barn i livets slut är en tung och känslomässig uppgift ansåg samtliga informanter det som en ansvarsfull och positiv uppgift där de kunde göra föräldrarnas sista stund med sina barn till ett fint och ljust minne. / One of the caring tasks that specialist nurses, working in the (PICU) perform, and have to face in the daily profession is to care for children who are facing the end of life in Sweden. Approximately two percent of all the children being cared for in the PICU dies. To care for children and their families when further treatment is futile is a heavy surrounding life and death. The goal of this study was to investigate the experiences of specialist nurses caring for children at the end of life. Qualitative content analyze were used as a method. Seven semi-structured interviews, with a descriptive approach, were transcribed to condensed meanings. Finally, the meaning was coded into ten subcategories within three main categories. Conclusion of this study indicated that pediatric intensive care nurses indicated their work heavy emotionally. The nurses play a vital role to the family´s final time whit their children. It is in the hands of the nurses to support and make the final time as valuable and beautiful as possible for the family.

Bakgrund: Familjer har inte alltid deltagit i omvårdnaden på det sätt de gör idag. Under de senaste decennierna har begreppet familjefokuserad omvårdnad lyfts fram och blivit till en central del inom barnsjukvården. Familjefokuserad omvårdnad lägger tonvikt på familjers deltagande och engagemang i sitt barns vård. Syfte: Syftet är att undersöka hur familjer och sjukvårdspersonal beskriver familjers delaktighet inom barnsjukvården i Norden. Metod: Litteraturstudie av tio vetenskapliga artiklar med kvalitativ design. Resultat: Resultatet presenteras utifrån tre huvudteman. Stöd var en av de viktigaste beståndsdelarna och som också väckte intresse till ökad delaktighet i barnsjukvården. Stöd presenteras i avsnittet familjernas behov av stöd. När ett barn blir sjukt är det inte bara barnets liv som påverkas, utan en hel familjs, vilket presenteras i avsnittet en livsvärld som vänds upp och ner. En svår tid följde de flesta familjer under tiden de försökte vänja sig vid sin nyfunna livssituation. I avsnittet att vårda en hel familj presenteras att varje familj var unik och att de hanterar olika situationer på olika sätt.  Slutsats: Resultatet i denna litteraturstudie har visat på att stöd är en viktig faktor för familjer när ett barn är sjukt. Både stöd från vården och socialt stöd från släkt och vänner är viktigt när det kommer till att stärka familjer samt att få familjen delaktig i barnets omvårdnad. Klinisk betydelse: Denna litteraturstudie kan bidra bredare med kunskap om familjefokuserad omvårdnad samt familjers delaktighet inom barnsjukvården. Calgarymodellen i den familjefokuserade omvårdnaden kan hjälpa sjukvårdspersonal att göra familjer delaktiga genom hela omvårdnadsprocessen. / Background: Families has not always been a part of the pediatric care. Family-centered care is a phenomenon which has been highlighted during the past decades and has become a central part of pediatric care as it is today. Family-centered care includes family participation and family involvement in the child’s care. Aim: To explore how families and nurses define family participation in Nordic Pediatric care.  Method: The aim was answered with a literature review of ten scientific qualitative articles. Results: The result is presented in three head themes. Support was one of the most important elements and contributed to participation in the pediatric care. Support is presented in the theme families’ need for support. When a child becomes ill it’s not only the child’s, but the whole families lifeworld that gets affected, which is presented in another theme, a lifeworld up-side-down. Most families had a hard time adjusting to their new life situation. In the third theme, to care for the whole family, we present that every family is unique and handle situations different.  Conclusion: The result of this literature review has shown that support is an important factor when a child is ill. Good support from health care and social support from family and friends is important to the family members, especially when it comes to family strengthening and to encourage families to participate in the care. Clinical significance: This literature review can contribute knowledge about family-centered care and participation in pediatric care. The Calgary Family Assessment Model can help create good family-centered care and encourage family members to participate in care.

INTRODUCTION: Language barriers between providers and low English proficiency (LEP) families in pediatric hospital care can reduce the quality of care provided to LEP patients/families. Boston Medical Center serves a population with a large LEP patient base. Currently, there is no existing model of care that efficiently and effectively incorporates interpreters on all morning rounds to optimize communication for all patients, especially LEP patients/families. OBJECTIVE: To improve communication between providers and LEP families on morning rounds in the Pediatric Inpatient Unit of Boston Medical Center. The aim for the QI initiative was to increase the percentage of rounding episodes with LEP patients/families in which the care plan was discussed between providers and families through the use of an in-person interpreter during morning rounds by 50% by February 28, 2015. METHODS: A quality improvement initiative utilizing residents, medical students, the unit coordinator and the ward assistant to introduce, streamline and standardize a process to incorporate interpreters on all morning rounds as needed for LEP families. The Model for Improvement was used for testing this initiative. Four Plan-Do-Study-Act (PDSA) cycles of testing were conducted between October 21, 2014 and February 20, 2015. The primary outcome was the proportion of rounding episodes for LEP patients/families in which the care plan was discussed between the provider and patients/families through an in-person interpreter. This data was collected through a newly created "Interpreter Rounding Form" (IRF) that served as a checklist for the process. The secondary outcome looked at patient satisfaction for both LEP and English proficient (EP) patients. This data was collected through survey questions from the CAHPS and AHRQ patient surveys. Process measures included if interpreter was requested, if interpreter was used and if any change in care management due to having in-person interpreter present. Balancing measures included duration of rounds, interpreter arrival time, and resident satisfaction. Language being included in resident verbal signouts and written signouts between teams was also tracked. Run charts were analyzed for all outcomes and measures to determine the effectiveness of changes tested. RESULTS AND CONCLUSIONS: For the first three PDSAs, there was a significant amount of variation in data measurement, which required focused efforts on better operationalizing our measurement framework. Changes were made after each PDSA to streamline the process and enforce completion of IRF, with which data was collected. For the fourth PDSA, starting in January 2015, completion rates for the IRF slowly increased to a median of 40%. Primary outcome data for PDSA 1-4 showed a median of 52% based on the rounding episodes that were recorded on the IRF forms, which suggests that the aim for a 50% increase in using an in-person interpreter on all morning rounds was achieved by February 28, 2015. However, this data may not reflect all the requests and encounters in which an in-person interpreter was used due to the missing data from a low completion rate of forms before PDSA 4. Further analysis of PDSA 4 data showed that though an in-person interpreter was used at a median of 38% of all encounters with LEP patients/families, providers were communicating with patients/families in their preferred language at 100% of the time; if did not request interpreter, providers used a resident or medical student who spoke the family's language 43% of the time. Patient survey data suggested that out of all patients in the unit, 80% of patients/families reported having "Always" understood the doctors, with LEP patients/families at a slightly higher percent than EP patients (100% vs 88%). Patients reported "Good" or higher for the quality of the information that was provided by the doctors on morning rounds at a median of 84%, with LEP patients at 100% compared to 84% for English-speaking patients. Qualitative analysis of patient responses showed that LEP patients liked the explanations and information provided in the morning rounds while EP patients mostly liked the attitude and approach of the doctors. One major limitation to our process was the constantly rotating residents/medical students and the need to train new teams. The project is ongoing with a focus on further standardization until a goal of 90% completion rate for IRF and 80% for primary outcome can be reached. Future PDSAs will encourage using medical interpreters for all LEP patient encounters and family-centered rounding.

Bakgrund: För många barn är mötet med sjukvården en ny miljö som kan skapa ångest eller rädsla vilket kan bidra till en ökad smärta eller obehaglig upplevelse för barnen. Att enbart behandla smärta med analgetika är sällan tillräckligt varför olika distraktionsmetoder kan användas för att minimera dessa känslor. Tidigare forskning har visat att vårdhunden kan ge positiva effekter på barn där läkemedelsanvändning har kunnat begränsas, dock krävs mer sammanställd forskning. Att inkludera en vårdhund i behandlingar skulle kunna minska barnets lidande.  Syfte: Att beskriva vilken effekt en vårdhund kan ha på ett barn i barnsjukvården. Metod: Allmän litteraturstudie med en deskriptiv design valdes som metod. Artikelsökning gjordes i databaserna PubMed, CINAHL samt Scopus och resulterade i 11 vetenskapliga originalartiklar med kvantitativ ansats.  Resultat: Resultatet skiljer sig vad gäller vilken effekt en vårdhund kan ha på barns ångest/oro och smärta inom barnsjukvården. Ungefär hälften av studierna påvisar en effekt där vårdhunden har lindrat både ångest/oro och smärta hos barn. Resterande del av resultatet kan inte påvisa en effekt om att en vårdhund kan lindra barns ångest/oro eller smärta i barnsjukvården.  Slutsats: Litteraturstudien visar effekter på barns ångest/oro och smärta av att använda en vårdhund inom sjukvården. Dock visar studien ingen vetenskaplig evidens om att vårdhundens användning är en metod som fungerar för alla barn. Individuella behov bör tas i beaktande där sjuksköterskan ansvarar för att se det enskilda barnet och identifiera i vilka situationer vårdhunden kan vara behjälplig. / Background: For many children, healthcare visits can create feelings of anxiety or fear, which can contribute to increased pain or unpleasant experiences. Treating pain only with analgesics is seldom sufficient, various distraction methods can be used to minimize these feelings. Previous research shows that animal assisted therapy can have positive effects and reduce the need to use drugs as treatment, however, more compiled research is required. Including animal assisted therapy in treatments could reduce the child's suffering.  Purpose: To describe what effect animal assisted therapy can have on a child in pediatric care. Method: Literature review with a descriptive design was chosen as method. Article searches were done in databases PubMed, CINAHL and Scopus and resulted in 11 quantitative original articles. Results: The results differ in terms of what effect animal assisted therapy can have on children's anxiety and pain in pediatric care. About half of the studies show an effect where animal assisted therapy has relieved both anxiety and pain. The remaining part of the result can not show an effect that animal assisted therapy can relieve children's anxiety or pain. Conclusion: Animal assisted therapy in healthcare shows some positive effects on children's anxiety and pain. However, the review sees no scientific evidence that the use of animal assisted therapy works for all children. Individual needs should be considered and the nurse is responsible for seeing the individual child and identifying in which situations animal assisted therapy can be helpful.

This work explores the acceptability of various persuasive design principles for pediatric users of a digital, asthma self-management solution. While persuasive design methods have been shown to motivate adherence to digital self-management, effective persuasion is highly context-dependent. The gap in research on persuasive design for younger users of asthma self-management applications raises the question of which persuasive principles are acceptable for this group’s unique context. This question is explored through the Persuasive Systems Design model. Based on interviews and workshop feedback from physicians, six persuasive principles were chosen for a redesign of an existing asthma self-management solution. The prototype was evaluated for potential acceptability by user proxies. The Personalization and Simulation persuasive principles were perceived as most acceptable for pediatric, digital asthma self-management. / Detta arbete undersöker hur pediatriska användare upplever acceptansen av övertygande designprinciper av ett digitalt självhanteringsstystem för astma. Även om övertygande designmetoder har visat sig motivera att man följer digital självhantering, är effektiv övertalning mycket kontextberoende. Den vetenskapliga kunskapsluckan rörande övertygande design för yngre användare väcker frågan om vilka designprinciper som anses vara acceptabla för denna grupps unika sammanhang. Denna fråga utforskas i detta arbete genom modellen för övertygande systemdesign. Baserat på intervjuer och workshops med läkare valdes sex övertygande designprinciper ut för att designas om för ett befintligt självhanteringssystem för astma. Designprototypen utvärderades med avseende på potentiell acceptans av användarproxys. Resultatet av undersökningen visade att personifierings- och simuleringsövertygande designprinciper uppfattades som mest acceptabla för pediatrisk, digital självhantering för astma.