Kathleen R. Stevens

Management of mild chronic hypertension during pregnancy: a review☆

Objective: To conduct a systematic review of evidence relating to management of mild chronic hypertension during pregnancy, including associated risks, benefits, and harms of treatment with antihypertensive agents, nonpharmacologic measures, and aspirin and benefits of various monitoring strategies. Data Sources: Using four broad search strategies, we searched English and non–English-language citations in 16 electronic databases from their inception to February 1999 and consulted relevant textbooks, references, and experts. Study Selection: Reviewers screened 6228 abstracts and found 215 articles that met multiple prespecified patient selection, study population, and design criteria. Tabulation, Integration, and Results: Forty-six studies consistently showed that chronic hypertension triples the risk for perinatal mortality (odds ratio [OR] 3.4; 95% confidence interval [CI] 3.0, 3.7) and doubles the risk for placental abruption (OR 2.1; 95% CI 1.1, 3.9). Thirteen small, randomized controlled trials had inadequate power to rule in or rule out moderate-to-large (20%–50%) benefits of antihypertensive treatment. Possible adverse effects were fetal renal failure when angiotensin-converting enzyme inhibitors are used in the second or third trimester and growth restriction when atenolol is used early in pregnancy. Trials showed that aspirin neither reduces nor increases perinatal and maternal morbidity, but they did not rule out possible small-to moderate beneficial or adverse effects. No studies provide guidance on benefits or consequences of various nonpharmacologic therapies or monitoring strategies. Conclusion: Mild chronic hypertension is associated with increased maternal and fetal risks. Beneficial treatment and monitoring regimens are not clear, but some treatments, such as angiotensin-converting enzyme inhibitors, are best avoided.

Systematic Reviews: The Heart of Evidence-based Practice

Research utilization approaches in nursing recently have been replaced by evidence-based practice (EBP) approaches. The heart of the new EBP paradigm is the systematic review. Systematic reviews are carefully synthesized research evidence designed to answer focused clinical questions. Systematic reviews (also known as evidence summaries and integrative reviews) implement recently developed scientific methods to summarize results from multiple research studies. Specific strategies are required for success in locating systematic reviews. Major sources of systematic reviews for use by advanced practice nurses in acute and critical care are the Online Journal of Knowledge Synthesis for Nursing, Agency for Healthcare Research and Quality, and the Cochrane Library. This discussion describes systematic reviews as the pivotal point in todays paradigm of EBP and guides the advanced practice nurse in locating and accessing systematic reviews for use in practice.

A Blueprint for Genomic Nursing Science

PURPOSE This article reports on recommendations arising from an invitational workshop series held at the National Institutes of Health for the purposes of identifying critical genomics problems important to the health of the public that can be addressed through nursing science. The overall purpose of the Genomic Nursing State of the Science Initiative is to establish a nursing research blueprint based on gaps in the evidence and expert evaluation of the current state of the science and through public comment. ORGANIZING CONSTRUCTS A Genomic Nursing State of the Science Advisory Panel was convened in 2012 to develop the nursing research blueprint. The Advisory Panel, which met via two webinars and two in-person meetings, considered existing evidence from evidence reviews, testimony from key stakeholder groups, presentations from experts in research synthesis, and public comment. FINDINGS The genomic nursing science blueprint arising from the Genomic Nursing State of Science Advisory Panel focuses on biologic plausibility studies as well as interventions likely to improve a variety of outcomes (e.g., clinical, economic, environmental). It also includes all care settings and diverse populations. The focus is on (a) the client, defined as person, family, community, or population; (b) the context, targeting informatics support systems, capacity building, education, and environmental influences; and (c) cross-cutting themes. It was agreed that building capacity to measure the impact of nursing actions on costs, quality, and outcomes of patient care is a strategic and scientific priority if findings are to be synthesized and aggregated to inform practice and policy. CONCLUSIONS The genomic nursing science blueprint provides the framework for furthering genomic nursing science to improve health outcomes. This blueprint is an independent recommendation of the Advisory Panel with input from the public and is not a policy statement of the National Institutes of Health or the federal government. CLINICAL RELEVANCE This genomic nursing science blueprint targets research to build the evidence base to inform integration of genomics into nursing practice and regulation (such as nursing licensure requirements, institutional accreditation, and academic nursing school accreditation).

Assessment, etiology, and intervention in obesity in children.

Obesity is a common nutritional disturbance of children and affects 25% to 30% of children and adolescents. This paper examines obesity in childhood, the measurement of obesity in children, and the relationship of obesity to coronary heart disease risks and discusses weight reduction issues in children. Clinically useful definitions of obesity in children have not been established, although the body mass index, together with anthropometric measurements, may provide the practitioner with useful assessment parameters. Discussions of weight in children must acknowledge the nutritional requirements of the normally occurring growth process. Because growth (and subsequently weight) varies widely among children even of the same age, measurement, classification, and control of weight must take into account the growth process and growth requirements. Interventions in childhood obesity should be directed toward family involvement in the chosen strategy and nutritional prudence coupled with typical activity.

Methodology issues in implementation science.

Background:Putting evidence into practice at the point of care delivery requires an understanding of implementation strategies that work, in what context and how. Objective:To identify methodological issues in implementation science using 4 studies as cases and make recommendations for further methods development. Research Design:Four cases are presented and methodological issues identified. For each issue raised, evidence on the state of the science is described. Results:Issues in implementation science identified include diverse conceptual frameworks, potential weaknesses in pragmatic study designs, and the paucity of standard concepts and measurement. Conclusions:Recommendations to advance methods in implementation include developing a core set of implementation concepts and metrics, generating standards for implementation methods including pragmatic trials, mixed methods designs, complex interventions and measurement, and endorsing reporting standards for implementation studies.

Using New Resources to Teach Evidence-Based Practice

This article describes an innovative strategy used to teach evidence-based practice (EBP) concepts in an undergraduate research course and explains the underlying framework used to design the strategy. The strategy for the Evidence-Based Practice Project was based on new resources: undergraduate nursing student competencies for EBP, national health care improvement priorities, evidence rating systems, and a model of knowledge transformation for EBP. Groups of students selected a priority area, categorized and critically appraised the evidence supporting the recommendation for change in health care practice, and compared the recommendation to actual practice. An oral and poster presentation of the project provided the opportunity to discuss the significance, influence, and strength of the evidence supporting the recommendation to change health care practice. Student presentations and faculty perceptions of the project indicated beginning competencies in EBP were achieved.

Evidence-based practice and the road to Magnet status.

Conducting research and using evidence-based practice play a major role in achieving Magnet status, the sought-after recognition awarded by the American Nurses Credentialing Center to healthcare institutions that exhibit nursing excellence. The authors present a synopsis of a conference sponsored by a Sigma Theta Tau International consortium in which a panel of nurse leaders distinguishes between research and evidence-based practice and discusses strategies to achieve both in the journey to Magnet status.

Cultural consideration in promoting wellness.

This article discusses culture as it relates to the cardiovascular health promotion needs of various cultural groups. The promotion of cardiovascular wellness among cultural groups can be facilitated by the use of culturally appropriate models, interventions, and strategies. Those major characteristics that extend across cultures that may guide cardiovascular nurses in providing culturally appropriate care include communication, family and kinship models, and access to and acceptance of medical involvement in health care matters.

Critical Thinking Outcomes of Computer-Assisted Instruction versus Written Nursing Process

Abstract Emphasis placed on the development of critical thinking in higher education and nursing education has been accompanied by the challenge to develop effective teaching strategies. While the connection between critical thinking development and computer-assisted instruction (CAI) is logical and theoretically plausible, scant empirical support has been published in the nursing literature. • The opportunity to use CAI in the curriculum will grow as additional software programs become available and as their impact is demonstrated through evaluation. If it is demonstrated that CAI programs support critical thinking, which was added to accreditation standards by the National League for Nursing in 1991 (1), additional CAI strategies can be integrated into curricula. Further, there is a need for information on the reliability of the California Critical Thinking Skills Test (CCTST) as an approach to measuring critical thinking in nursing. The purpose of this study was to increase knowledge about facilitating...

Variations in Institutional Review Board Approval in the Implementation of an Improvement Research Study

The purpose of this paper is to report the variance in institutional review board (IRB) reviews as part of the implementation of a multisite, quality improvement study through the Improvement Science Research Network (ISRN) and recommend strategies successful in procuring timely IRB approval. Using correspondence documents as data sources, the level of review was identified and time to submission, time to approval, and time to study start were analyzed. Thirteen of the 14 IRBs conducted independent reviews of the project. Twelve IRBs approved the study through expedited review while two IRBs reviewed the project at a full board meeting. Lastly, 11 of the 14 sites required documented consent. The greatest delay in approval was seen early on in the IRB process with site PIs averaging 45.1 ± 31.8 days to submit the study to the IRB. IRB approvals were relatively quick with an average of 14 ± 5.7 days to approval. The delay in study submission may be attributed to a lack of clear definitions and differing interpretations of the regulations that challenge researchers.