Brigit M. Carter

Relationship of Neonatal Treatments With the Development of Necrotizing Enterocolitis in Preterm Infants

Background:Although many therapeutic interventions are necessary for the survival of the preterm infant, understanding thepotential effects of these treatments is important to decrease the rate of necrotizing enterocolitis (NEC) in preterm infants. Objective:The aim of this study was to examine the relationship between preterm infant treatments administered prior to the development of NEC, specifically the number ofpacked red blood cell (PRBC) transfusions, weeks of antibiotic therapy for nosocomial infection, and number of mechanical ventilation days, and the development of NEC in preterm infants. Methods:A retrospective cohort controlled study design examining 4 years of raw data of preterm infants between the gestational ages of 23 and 30 6/7 weeks was used. Of the 549 infants, there were 65 cases of NEC. Using logistic regression, the relationship between NEC and PRBC transfusions administered prior to NEC, number of mechanical ventilation days prior to NEC, and number of weeks of antibiotic therapy for nosocomial infections experienced prior to NEC (proxy for nosocomial infection) were examined. Results:Preterm infants from 23 to 30 6/7 weeks who developed NEC experienced significantly more PRBC transfusions and more weeks of antibiotic therapy for nosocomial infection prior to the development of NEC than did infants who did not develop NEC. There was no relationship between mechanical ventilation days and the development of NEC. Discussion:Future research should focus on causal relationships between NEC and PRBC administration and the reduction of nosocomial infections in preterm infants to minimize risk for NEC in this population.

Recruiting and retaining a diverse workforce in nursing: from evidence to best practices to policy.

Health policy makers, providers, clinicians, and social scientists are among those who have identified racial and ethnic diversification of the health care workforce as one strategy for solving the seemingly intractable problem of health disparities in the U.S. population. But evidence supporting the impact of such diversification on narrowing health disparities is lacking, thus making it unclear if the push for workforce diversification is empirically or politically driven. Moreover, data are largely derived from the study of physicians, making it difficult to generalize findings to nursing and other health professions. This article reviews the evidence that supports the impact of a diverse workforce on patient outcomes and delivery services. Assuming a positive social value in the absence of the data, the authors review the approaches that have been successful in diversifying the nursing workforce. The authors conclude with recommendations for research and policies, including best practices, for enhancing recruitment and retention of a diverse nursing workforce.

Beginning With the End in Mind: Cultivating Minority Nurse Leaders

In response to the need for increased racial and ethnic diversity in the nursing profession, the Duke University School of Nursing (DUSON) established the Making a Difference in Nursing II (MADIN II) Program. The aim of the MADIN II Program is to improve the diversity of the nursing workforce by expanding nursing education opportunities for economically disadvantaged underrepresented minority (URM) students to prepare for, enroll in, and graduate from the DUSONs Accelerated Bachelors of Science in Nursing program. Adapted from the highly successful Meyerhoff Scholarship Program model, the program is to cultivate URM nursing graduates with advanced knowledge and leadership skills who can address health disparities and positively influence health care issues currently plaguing underrepresented populations. The article discusses the MADIN II framework consisting of four unique components: recruitment of students, the Summer Socialization Nursing Preentry Program, the Continued Connectivity Program, and the Succeed to Excellence Program, providing a framework for other academic programs interested in cultivating a pipeline of minority nurse leaders.

Nursing assessment of guaiac-positive and occult blood in preterm infant stools.

Guaiac testing the stool of very low birth weight (VLBW; <1,500 g) preterm infants has been a standard of care for many neonatal intensive care units (NICUs) and considered a diagnostic tool that could potentially provide early warning of gastrointestinal disturbances, feeding intolerance (FI), or necrotizing enterocolitis (NEC). Evidence to either support or eliminate testing stool for occult blood from standard care practices is lacking. Support to eliminate testing is often based on the knowledge that neonatal treatment interventions—such as gastric tube placement, intubation, and/or suctioning—may often result in occult blood in stools. However, there is also reasonable concern that occult blood may indicate a cascade of pathophysiological events, which may lead to FI and NEC, is in progress. Feeding intolerance remains one of the most consistent reasons VLBW preterm infants experience poor weight gain and extended hospital stays. Every nursing assessment is strategic to the early identification of contributing factors to either the development of FI or NEC. Including low-cost, noninvasive diagnostic tools to augment the findings of the nursing assessment can only help guide health care providers in appropriate decision making related to the feeding plan.

Building a Community of Health Professionals to Establish a Shared Learning Experience in Psychiatry and Substance Use Disorders for Health Professions Students

Caring for patients with psychiatric and substance use disorders requires collaboration among numerous healthcare providers in order to manage their complex medical, social, and psychological needs [1]. Typically, healthcare teammembers learn how to work together in the actual delivery of care [2]. Unfortunately, learning teamwork “by doing” can be difficult to achieve when it is perceived as competing with the demands of clinical practice, rather than in the spirit of intentionally working together. Despite the potential value of collaborative practice, numerous barriers challenge successful collaboration in clinical practice [2]. These barriers include professional concerns about autonomy and accountability, competition for financial resources, and procedural differences between disciplines. Introducing interprofessional education in the early stages of training is one strategy to improve health professions students’ appreciation of the value of collaborative practice [3–5]. Preparing learners to overcome barriers to team-based care, however, requires that the healthcare professionals from whom they learn model appropriate behaviors. Therefore, an interprofessional education course must also bring together diverse professionals who practice collaborative care. A course intentionally designed toward these goals would provide students with opportunities to develop skills in teamwork, reflect on their professional role, and resolve power struggles [2]. Creating a Community of Practice with key leaders from each student’s health professions program is one way to maximize student benefit from interprofessional education. A Community of Practice among key health professional leaders would create a shared vision for students’ learning and collaboration [6]. These leaders would represent the learning needs of their respective students, connect learning to relevant clinical applications, and lead the learning experience through barriers and challenges to successful execution [7–9]. Since a Community of Practice consists of individuals with a genuine passion for a topic who are interested in collaboration, one outcome could be the modeling of interprofessional behaviors, including sharing ideas and experiences, learning from one another, deepening expertise, exhibiting mutual respect, and building innovations [10]. Less well described in the interprofessional education literature, however, is the intentional development of a Community of Practice as a strategy to guide these training activities. Building upon an existing substance use course for health professions students [3], we developed a new course embedding the intentional modeling of an interprofessional Community of Practice. The purpose of this paper is to describe our deliberate process for using a Community of Practice framework to build a team of faculty from medicine, pharmacy, and nursing and to develop a psychiatry and substance use disorders course for medicine, physician assistant, pharmacy, and Accelerated Bachelor of Science in Nursing (ABSN) students.

A 6th Vital Sign--Potential Use of Nasogastric Tube for Intra-abdominal Pressure Monitoring Method to Detect Feeding Intolerance in Very Low Birth-Weight Preterm Infants (<1500 g).

Background:While various feeding strategies designed to optimize growth have been investigated and used in the clinical setting, the problem of not being able to recognize the warning signs of feeding intolerance early enough to prevent serious gastrointestinal complication commonly associated with very low birth-weight (VLBW) preterm infant remains. Currently, early stages of feeding intolerance are most often identified though nurse assessments. Additional methods to predict feeding intolerance in this population are needed. Currently, intra-abdominal pressure monitoring has been an effective method to predict intolerance to enteral nutrition in the adult and pediatric populations. Purpose:There is supportive evidence for the use of noninvasive methods, such as nasogastric tubes, to effectively monitor IAP. While this may not be the gold standard method of using Foley catheters for measurement, it could provide predictive levels that are indicative of progression toward bowel inflammation. Findings:This review shows the potential for using noninvasive nasogastric tubes for monitoring intra-abdominal pressure and may provide direction for evaluating intra-abdominal pressures in VLBW preterm infants as a reliable method for early identification of feeding intolerance. Implications for Practice:The use of nasogastric tubes to monitor intra-abdominal pressure may provide an effective noninvasive tool to identify VLBW preterm infants progressing toward feeding intolerance and would add to assessment data. Implications for Research:Development and testing of a reliable nasogastric tube monitoring device in the VLBW preterm infant population and identify predictive levels that indicate progression toward feeding intolerance is needed. Once IAP predictive levels are identified, provider interventions could be developed.

Strategies to Address Individual Level Social Determinants of Health Designed to Cultivate the Next Generation of Minority Nurse Leaders Committed to Health Equity

In response to the need for increased racial and ethnic diversity in the nursing profession, the Duke University School of Nursing (DUSON) established the Academy for Academic and Social Enrichment for Leadership Development in Health Equity (Health Equity Academy). The aim of the Health Equity Academy is to improve the diversity of the nursing workforce by expanding nursing education opportunities for underrepresented minority (URM) students who are economically disadvantaged to prepare for, enroll in, and graduate from the DUSON’s Accelerated Bachelors of Science in Nursing program. The goal of this program is to cultivate URM nursing graduates with advanced knowledge and leadership skills who can address health disparities and positively influence health care issues currently plaguing underrepresented populations. The article discusses the Health Equity Academy framework, which consists of two unique components: the Pre-entry Immersion in Nursing and the Pathway to Success in Nursing (PSN). These two components are designed to address the nursing student individual level social determinants which could be potential barriers to success as well as provide support in their academic and professional development goals.

Evaluation of a Sickle Cell Disease Educational Website for Emergency Providers.

Sickle cell disease (SCD) is a complex multisystem debilitating disease. Despite its complexity, health care providers who are not SCD experts receive little formal education on SCD. An open-access, educational website, “Emergency Department Sickle Cell Disease: Crisis Management and Beyond,” was created to provide education about SCD to emergency department (ED) providers who are not SCD experts but who provide care for patients with SCD. Electronic surveys were used to conduct a formal evaluation of the accuracy and relevance of the websites content, as well as the effectiveness of the education modules in improving knowledge among health care providers. The evaluation consisted of (1) individual module pre- and post-knowledge assessment, (2) content validity assessment of educational modules, (3) overall website content assessment, and (4) overall website assessment (Health on the Net core principles). A convenient sample of ED providers, accelerated bachelor of science in nursing students, SCD experts, and website experts completed the anonymous surveys. Descriptive statistics and paired t tests were used to compare mean difference in post- minus pre-knowledge test scores. Knowledge scores statistically improved for nursing students (p value less than 0.0001). Emergency department providers showed a mean improvement of 3.2 points on the eight-item knowledge assessment. Both SCD experts and ED providers agreed that the module content was clear and easy to understand, accurate, comprehensive, relevant, and met module objectives. Participants agreed that the website was clear, easy to navigate, and visually appealing. Website experts stated that the website met much of the Health on the Net criteria. The website is a useful resource for providers and nursing students, especially those who serve or plan to serve in EDs.

Nursing care of the premature infant with severe combined immunodeficiency disease.

Diagnosis and treatment of severe combined immunodeficiency disease (SCID) is documented in fetuses, term infants, and older children; however, there is very little information on its diagnosis and treatment in premature infants. When Duke University Medical Center’s first preterm infant with a known SCID history was delivered, in June 1999, there was no defined protocol for the infant’s nursing care. Although many of the guidelines for nursing care of the premature infant population (≤36 weeks) apply, there are important considerations for preterm infants with an SCID diagnosis. This article provides background on SCID and identifies those special considerations—namely, multidisciplinary communication, infection prevention, thorough physical assessments, and parental support.