Parental stress is associated with increased obesogenic family lifestyle behaviors contributing to childhood obesity. Novel interventions are needed to reduce parental stress and improve healthy lifestyle behaviors for preschool-age children and families. The primary study aim was to analyze preliminary effects of a digitally enhanced evidence-based cognitive- behavior skill-building (CBSB) intervention on parental stress and healthy lifestyle behaviors (diet and physical activity) among parents of preschool-age children. A secondary aim was to evaluate feasibility/acceptability of this school-based virtual intervention during the COVID-19 pandemic. The 12-week intervention involved text messaging and three pre-recorded CBSB educational video presentations accessed by parents of preschool-age children (n=21) from a password-protected website. The Healthy Child Healthy Family Behavior Checklist (HCHF) measured lifestyle behaviors. Parent stress was measured using the self-reported Parental Stress Scale (PSS) and parents' hair cortisol concentration (HCC) levels. Paired t-tests/Wilcoxon signed rank tests determined pre/post-intervention differences among healthy family lifestyle behaviors and parental stress. Pearson/Spearman Rho correlations determined if significant relationships existed between parent stress and healthy family lifestyle behaviors. Both parent stress measures were significantly reduced post-intervention (p< .05). A modest increase in HCHF from baseline (M=60.38; SD=6.48) to post-intervention (M=61.43; SD=6.85); [t(20)= -0.695, p=0.487)] was non-significant. No significant correlations were found among the parental stress and HCHF variables. All parental responses about text messaging were positive and most (86%) reported that messages motivated healthy behavior changes. Digitally enhanced CBSB virtually delivered interventions with parents in a school-based setting are feasible/acceptable and may potentially improve parental stress and family lifestyle behaviors.

Clinical practice benchmarking is a new quality improvement benchmarking approach that involves structured learning from others in order to improve, accepting the subjective nature of health care. Evaluative research of clinical practice benchmarking requires mixed methods, quantitative and qualitative. This challenges the current reliance upon quantitative consideration of the effectiveness of quality improvement approaches. A worked quantitative example is provided and demonstrates that descriptive statistics support comparison activity only. It rejects the value of inferential statistics, since benchmark scores relate to subjective statements. Therefore, inter-rater reliability is poor and it is not possible to directly attribute any change in clinical practice benchmark scores to actual changes in practice. Following the quantitative analysis, a qualitative research study was undertaken from an interpretative perspective to evaluate the effectiveness of clinical practice benchmarking as a quality improvement approach. Particular emphasis was given to exploring the organisational factors that support its effectiveness. Data were gathered through semi-standardised interviews of nursing leaders of local paediatric benchmarking activity and frontline nurses, with rigour ensured through reflexivity and a critical approach to the analysis. The main empirical contribution of this work provided new knowledge about nurses' understanding of clinical practice benchmarking. They defined it as using all evidence to agree best practice, focusing upon collaboration to support sharing, rather than competition. The findings identified the organisational factors that ensured the effectiveness of clinical practice benchmarking. The main enablers were motivation of those involved and supportive leadership, underpinned by an organisation that promotes learning and innovation. This research provides compelling evidence that clinical practice benchmarking is an effective approach to quality improvement in health care. However, it requires acceptance of the importance of the subjective nature of health care and the necessity for qualitative approaches to evaluation. Methodological insights from this study also inform future evaluative research.

In the current context of health care, the registered nurses’ perception and enactment of accountability may be constrained by many factors out of their control. The purpose of this research was to examine how registered nurses perceive accountability and translate this to professional practice. A Grounded Theory approach was adopted to explore 11 registered nurses’ understanding and experiences enacting accountability in clinical practice. Data were obtained through semi structured interviews. The theory that emerged provides a detailed portrait of the process of enacting and/or retreating from accountability. The process encompasses 4 stages where the registered nurses: develop personal understanding, then gain professional knowledge, find their way in the complex healthcare system and concludes with becoming professionally confident. The development of the stages exposed a multitude of challenges faced by the registered nurses in fulfilling accountability expectations. Importantly, the registered nurses’ expended significant effort in finding a balance between their individual accountability and the collaborative accountability of the healthcare team and organization which contributed to retreating from accountability. The contextual factors of financial and human resources, institutional culture and healthcare system processes were found to contribute to the registered nurses enacting and/or retreating from accountability. The study findings illustrate the importance of ongoing reflective practice, mentorship and continuing education, all of which have implications for nursing educators and healthcare executives in preparing and supporting registered nurses’ in practice. Further research on the concepts of this theory of accountability is needed to obtain a greater understanding of how the concepts can be operationalized within the context of current healthcare systems.

The study answers the question: 'How can nurses' properly considered decisions relating to patient care be demonstrated?' Nurses in the United Kingdom have a professional requirement to demonstrate': the properly considered clinical decisions relating to patient care' (UKCC, 1994; NMC, 2002). However, their decisionmaking has been reported as complex and poorly understood, and apart from nursing records, little evidence exists to demonstrate their decisions. The development of the nurses' role as a decision-maker is traced from an origin in Nightingale's text (1860) through to the present day. This role is shaped by organisational, nursing and medical profession influences. Having established that nurses have a role as decision-makers, a conceptual framework is used to examine different explanations about the decision process, outcome, context and how decisions are made. Before undertaking fieldwork, a survey of nurses' decision-making in general medical and surgical wards was conducted. The findings were compared with the conceptual framework to generate questions and avenues for enquiry. An ethnographic study was undertaken in 1999 - 2000 in four general medical wards in two English provincial NHS Trusts with registered nurses (general). A model of decision-making was developed as a mid range theoretical explanation of how they made decisions. This involved a narrative based approach in which nurses generated an account (narrative) of knowing a patient and used this to identify needs. The patient was known in a narrative through three categories of information: nursing, management and medical. These categories were constructed through nurses' information seeking and processing using a tripartite conceptual lens. These facets correspond to different aspects of the nurse's role as a carer, care manager and medical assistant. The patient is known in three ways in a narrative, as a person to care for, an object to be managed, and as a medical case. An oral tradition surrounded its use, and nursing records were not central to decision-making. The narrative was used to make decisions and influence medical decisions. Once it was established how nurses made decisions, a method was developed to show how they could demonstrate their properly considered clinical decisions relating to patient care. This involved using the narrative based decision-making model as an analytical framework applied to nurse decision narratives. Narrative based decisionmaking offers a development of existing descriptive theoretical accounts and new explanations of some features of the decision process. This particularly includes the use of personal note sheets, the role of judgements and the cycle of communicating the narrative to nurses and its subsequent development as a process of developing an explanation of how the patient is known. Having addressed how nurses can demonstrate their properly considered clinical decisions relating to patient care, conclusions are drawn and implications explored in relation to practice, professional regulation, education and method. Recommendations include a challenge to the assumption about decision-making underpinning existing NMC guidance on recordkeeping, and the need to recognise diversity of decision-making practice across different nursing sub-groups. The narrative revealed nurses' ways of constructing knowing patients and rendering this visible. Nurses' not only have a duty, but also a need, to demonstrate decisions so that they can render visible what it is they are and do.

Abstract Purpose: With the US reporting 20 million newly diagnosed STI/HIV cases annually, clinical guideline compliance and EBP recommendation implementation necessitate provider practice changes for high-quality routine sexual and reproductive health services. The project's purpose was to improve sexual health history-taking (SHH) and documentation in a private primary care practice (PPCP) serving high-risk populations. The DNP project aims to determine the effect of conducting a 30-minute educational session and implementing the CDC's 5Ps on a PCP's clinical guideline adherence to SHH recommendations and documentation with patients presenting for annual wellness exams, well-woman exams, family/contraceptive counseling, or acute urogenital complaints in an urban, southeastern PPCP. Methodology: The quality improvement (QI) project implemented a standardized clinical practice change using the Stetler model's practitioner-oriented knowledge translation design. PPCP-employed NPs (n = 3) completed anonymous pre-/post-implementation surveys using SurveyMonkey, received educational resources, and implemented the CDC's 5Ps SHH tool for clinically appropriate patient encounters identified by eligible ICD-10 codes. Athena's Report Builder compiled data on SHH completion/EMR documentation and providers' intervention compliance from 2-weeks before and 2-weeks after implementation. Results: Over the four-week project period, a total of n = 1,031 EMR charts [pre-implementation (n = 513)/post-implementation (n = 518)] were reviewed for SHH completion/EMR documentation. Analysis of eligible encounters’ charts showed significant improvement in post-implementation SHH completion/EMR documentation rates (37% in pre-intervention; 82% in post-intervention). The chi-square test findings [X2 (1, N = 1031) = 43.637, p < .01] displayed a significant relation between the variables, indicating an increased likelihood of sexual health history EMR documentation by implementing the CDC'S 5Ps SHH tool. Provider survey results indicated providers support implementation and routine clinical practice of the CDC's 5Ps. Limitations: Provider sample size (n =3), geographical location, demographics served, private ownership, and SUD treatment center association limit the study's generalizability. Implications for Practice: The PPCP’s SHH tool availability for clinically relevant encounters increased SHH EMR documentation completion and frequency rates––utilizing the brief, cost-effective intervention for evaluating sexual health risks and behaviors to decrease the likelihood of adverse outcomes. Through positive, nonjudgmental sexual health information acquisition, providers can better facilitate difficult conversations with patients, promote sexual health awareness, and improve STI/HIV screening/treatment rates in a private primary care practice setting. Keywords: sexual health history

The recent study by Goossens et al. (2012) concluded that, “By means of an Advanced Practice Nursing (APN) team, malfunctions can be effectively managed, giving staff nurses more time but less stress in their daily care for patients with TIVADs [totally implantable venous access devices]”. However, that conclusion is not supported by their study because there was not a control group and no data was provided that had any bearing on whether the malfunctions were effectively managed or whether the staff nurses had more time or less stress.

The Doctor of Nursing Practice (DNP) Family Nurse Practitioner (FNP) curriculum was developed to incorporate learning outcomes and experiential opportunities for students to attain the core FNP knowledge for doctoral education. Historically, challenges related to developing clinical skills in blended/online programs has been problematic. The appeal of online FNP education has challenged educators to develop new ways to provide students opportunities to experience hands-on clinical skills within the subspecialties of the DNP, FNP role. With limited clinical sites, and now with more clinical access constraints imposed by the COVID-19 pandemic, it is imperative that new models of instruction provide students opportunities for skills training. The purpose of this project is to describe use of scaffolding methodology to design student skills learning activities using synchronous online and on-ground sessions during DNP intensives. Student and faculty input identified the types of practice skills and procedures needing improvement, such as suturing, electrocardiogram, etc. An intensive task force was organized to evaluate curricular elements; content was then mapped to analyze gaps. The first step included aligning advanced practice nursing skills sessions in each intensive with the related clinical courses offered within that semester. Then, students were organized into a skills rotation plan based on their date of admission and place within their program of study. Modifications required by COVID-19 on-ground restrictions necessitated re-thinking intensive skills sessions. Student satisfaction scores significantly improved after the intensive sessions were restructured. Faculty continue to seek feedback from the students to provide beneficial practice opportunities during the DNP intensives.

<p>To date most research on long-term outcomes of childhood trauma has focused on traumatic brain injuries, but less is known about traumatic injuries not involving the brain. Since traumatic brain injuries can have persistent effects on child behaviour, I investigated whether other types of traumatic injuries could also affect child behaviour in the long term. Currently, limited information is available on possible associations between family function and child behaviour after child trauma; knowledge of the long-term costs of pediatric trauma is also lacking. The main goal of this study was to determine whether family function was associated with behaviour in children who experienced a traumatic injury eight to ten years ago. Additional goals were to determine current expenditures and use of health and social services by child trauma victims and their parents. Pediatric trauma victims were selected from a trauma database at a tertiary care hospital in the Hamilton-Wentworth region. The parents of these children were interviewed to obtain children’s current behaviours and the family’s use of health and social services. The results showed that injury severity was not associated with child behaviour, but associated with family functioning. No relationship was found between health and social service expenditures for children and their injury severity, but there was a relationship between parent health and social service expenditures and child injury severity. The results do not support an association between child behaviour and injury severity following trauma, but they do suggest that expenditures and use of services by injured children and their families are affected long-term. The results suggest that future health and social service uses of injured children and their families may be better understood and planned for by recognizing the continuing effects of trauma. This information could help making appropriate health and social service programs more available to this population.</p> / Master of Science (MSc)

Abstract Title Reducing Adverse Events: Medication Reconciliation in Primary Care Purpose Primary care patients experience high levels of adverse drug reactions due to inaccurate medication reconciliation practices. Project Aims The project aims to improve medication reconciliation in a primary care setting. Outcome Measures Outcomes measures include identified medication discrepancies, staff satisfaction related to the use of the MATCH tool, and patient age ranges and gender. Methods Over a 4 week period, the clinic staff integrated the evidenced based instrument, Medication at Transitions and Clinical Handoff (MATCH) tool. Initially, the office manager provided a MATCH tool and a copy of the patients current medication list. The patient entered new and discontinued medications on the tool. The medical assistant reconciled the medication list in the electronic medical record. The nurse practitioner then reviewed the medications and compared the data to the MATCH tool. Lastly, the office manager scheduled the next patient appointment and attached a reminder to bring current medications. The completed MATCH tools (n=88) were collected for analysis. Findings Eighty-eight (n=88) MATCH tools with patient medication discrepancies, age ranges, genders, and staff responses were completed. Limitations included a 4-week time frame to use the tool, medical assistant buy-in related to the MATCH tool use, patient compliance to bring in medications to their next appointment, and patients ability to recall home medications. Implications Medication reconciliation is essential to patient care and safety in primary care settings. The MATCH tool is evidenced based and can improve medication reconciliation and reduce adverse drug reactions.

Background: Due to arduous demands of graduate education, advanced practice nursing (APN) students who are classified as adult learners are at risk for suffering sleep deprivation. Factors contributing to sleep deprivation include stress, expected academic challenges, and everyday life stressors. Purpose: This study investigated if APN students’ grade-point average (GPA), gender, and employment status predicted levels of daytime sleepiness. Theoretical Framework. The psychological well-being model selected for this study was consistent with the theory that sleep is a resource essential to well-being; adequate sleep is the resource needed to optimally manage stressful life demands. Methods. Bivariate and multiple regression were employed to examine the relationship between GPA, gender, and employment status with daytime sleepiness on a sample of APN students (N = 123) in their second academic year. The Epworth Sleepiness Scale and a demographic questionnaire were used to record data on GPA, gender, and employment status. Results. Results showed ESS and GPA were negatively correlated and statistically significant (r = -.24, p < .05). This indicates that as the tendency for sleepiness increased, GPA decreased, thereby supporting the alternative hypothesis. Although not statistically significant, employed participants reported greater daytime sleepiness, as did women. Conclusions: When GPA, gender, and employment were combined, multiple correlation showed a statistically significant shared variance of 8% with daytime sleepiness, due primarily to the correlation between GPA and daytime sleepiness. The effect size of shared variance was between small and medium with respect to magnitude of importance.