Effectiveness of nurse-home visiting in improving child and maternal outcomes prenatally to age two years: a randomised controlled trial (British Columbia Healthy Connections Project)

BACKGROUND

We investigated the effectiveness of Nurse-Family Partnership (NFP), a prenatal-to-age-two-years home-visiting programme, in British Columbia (BC), Canada.

METHODS

For this randomised controlled trial, we recruited participants from 26 public health settings who were: <25 years, nulliparous, <28 weeks gestation and experiencing socioeconomic disadvantage. We randomly allocated participants (one-to-one; computer-generated) to intervention (NFP plus existing services) or comparison (existing services) groups. Prespecified outcomes were prenatal substance exposure (reported previously); child injuries (primary), language, cognition and mental health (problem behaviour) by age two years; and subsequent pregnancies by 24 months postpartum. Research interviewers were masked. We used intention-to-treat analyses. (ClinicalTrials.gov, NCT01672060.) RESULTS: From 2013 to 2016 we enrolled 739 participants (368 NFP, 371 comparison) who had 737 children. Counts for child injury healthcare encounters [rate per 1,000 person-years or RPY] were similar for NFP (223 [RPY 316.17]) and comparison (223 [RPY 305.43]; rate difference 10.74, 95% CI -46.96, 68.44; rate ratio 1.03, 95% CI 0.78, 1.38). Maternal-reported language scores (mean, M [SD]) were statistically significantly higher for NFP (313.46 [195.96]) than comparison (282.77 [188.15]; mean difference [MD] 31.33, 95% CI 0.96, 61.71). Maternal-reported problem-behaviour scores (M [SD]) were statistically significantly lower for NFP (52.18 [9.19]) than comparison (54.42 [9.02]; MD -2.19, 95% CI -3.62, -0.75). Subsequent pregnancy counts were similar (NFP 115 [RPY 230.69] and comparison 117 [RPY 227.29]; rate difference 3.40, 95% CI -55.54, 62.34; hazard ratio 1.01, 95% CI 0.79, 1.29). We observed no unanticipated adverse events.

CONCLUSIONS

NFP did not reduce child injuries or subsequent maternal pregnancies but did improve maternal-reported child language and mental health (problem behaviour) at age two years. Follow-up of long-term outcomes is warranted given that further benefits may emerge across childhood and adolescence.

Equity Matters: Introduction to a New Column

"Equity Matters" is a new column for Neonatal Network designed to further explore and apply the concept of health equity as it relates to supporting neonatal health and family well-being. In this initial column, an overview of health equity and determinants of health is provided. Two frameworks-the Healthy People 2030 strategy (U.S. Department of Health and Human Services) and the American Hospital Association equity roadmap and health equity transformation model-are introduced. Five domains of determinants will be explored in future columns: economic stability, education, social and community context, health and health care, and neighborhood and built environment. The domains of each determinant will be described to provide theoretical and practical approaches to support integration into nursing practice. Neonatal nurses are positioned to recognize health inequities for new families, critically analyze their relationship with the determinants of health, and advocate for strategies to promote health and well-being.

Examining How Postpartum Videoconferencing Support Sessions Can Facilitate Connections between Parents: A Poststructural and Sociomaterial Analysis

Postpartum support for new parents can normalize experiences, increase confidence, and lead to positive health outcomes. While in-person gatherings may be the preferred choice, not all parents can or want to join parenting groups in person. Online asynchronous chat spaces for parents have increased over the past 10 years, especially during the COVID pandemic, when "online" became the norm. However, synchronous postpartum support groups have not been as accessible. The purpose of our study was to examine how parents experienced postpartum videoconferencing support sessions. Seven one-hour videoconferencing sessions were conducted with 4-8 parents in each group (n = 37). Nineteen parents from these groups then participated in semi-structured interviews. Feminist poststructuralism and sociomaterialism were used to guide the research process and analysis. Parents used their agency to actively think about and interact using visual (camera) and audio (microphone) technologies to navigate socially constructed online discourses. Although videoconferencing fostered supportive connections and parents felt less alone and more confident, the participants also expressed a lack of opportunities for individual conversations. Nurses should be aware of the emerging opportunities that connecting online may present. This study was not registered.

Clarifying contemporary conceptualizations of allyship with LGBTQ2S+ groups in the context of health care or health settings: a scoping review protocol

OBJECTIVE

The objective of this review is to better understand how allyship is defined in the literature from 1970 to the present with regard to lesbian, gay, bisexual, transgender, queer, two-spirit, and other (LGBTQ2S+) groups within health settings where English is the primary spoken language.

INTRODUCTION

LGBTQ2S+ individuals experience health inequities rooted in discrimination. Activism to redress this discrimination in health settings is frequently termed allyship. Definitions of allyship, however, remain ambiguous. A clearer understanding of how allyship is defined and operationalized within health settings is integral to supporting the health of LGBTQ2S+ groups.

INCLUSION CRITERIA

Literature in English from 1970 to the present that utilizes the concept of allyship within health care and/or health settings in relation to LGBTQ2S+ groups in Canada and the United States, Australia, New Zealand, and the United Kingdom will be included.

METHODS

This scoping review will be conducted in accordance with the JBI methodology for scoping reviews. Databases to be searched will include MEDLINE (OVID), CINAHL (EBSCOhost), APA PsycINFO (EBSCOhost), LGBTQ+ Source (EBSCOhost), Scopus, and Web of Science, along with ProQuest Dissertations and Theses for gray literature. Two independent reviewers will screen titles, abstracts, and full-text articles; discrepancies will be resolved by consensus or with a third reviewer. Data will be extracted using an extraction tool developed by the research team. Findings will be presented in tabular/diagram format along with a narrative summary to highlight key themes that relate to contemporary conceptualizations of allyship with LGBTQ2S+ individuals/groups within health care settings and the implications for health professional practice and health outcomes.

REVIEW REGISTRATION

Open Science Framework osf.io/2rek9.

"There's an Etiquette to Zoom That's Not Really Present In-Person": A Qualitative Study Showing How the Mute Button Shapes Virtual Postpartum Support for New Parents

Virtual spaces that allow parents in the postpartum period to connect, support each other, and exchange information have been increasing in popularity. With the COVID-19 pandemic, many parents had to rely on virtual platforms as a primary means to connect with others and attend to their postpartum health. This study explored virtual postpartum support sessions through the web-based videoconferencing software, Zoom. Guided by feminist poststructuralism and sociomaterialism, we held seven virtual support sessions for parents caring for a baby 0-12 months in age, in Canada, and interviewed 19 participants about their experiences in the sessions. Our methodological approach allowed us to analyze discourses of (1) parenthood, (2) material realities of virtual environments, and (3) support and information on this virtual platform. The purpose of this research was to understand how technology influences postpartum support and learning through online videoconferencing for parents. Our findings document an overarching discourse of Zoom etiquette by which muting was a discursive practice that all participants used. The consistent use of the mute button while not talking structured conversation in virtual postpartum sessions and resulted in three themes: (1) minimizing disruptions; (2) taking turns; and (3) staying on task. The norm of using the mute button changed how parents received and gave support and information. Based on findings and broader literature, we discuss considerations for facilitation of virtual postpartum support sessions.

Developing an Equity Mindset: How Neonatal Nurses Can Impact Health Outcomes by Reducing Disparities

The concepts of health equity and social justice are foundational to the profession of nursing. Substantial advances have been made over the past decades in the care of infants requiring support in the NICU; however, significant differences remain in health outcomes for infants and their families for groups considered to be disadvantaged. In this article, we explore the concept of health equity, introduce an action framework that provides a practical approach to advancing health equity, and describe how to apply this framework for action within the context of neonatal nursing practice. Nurses are encouraged to accept and act on their ethical responsibility toward the populations they serve, directing attention and resources to those with the greatest need.

Sustaining and Inspiring the Capacity of the Nursing Profession: The Case for Transformative Practice Education Models

Decades of commissioned reports have pointed to solutions for nurturing nursing practice environments as essential to sustaining a nursing workforce. Beyond salary compensation and other solutions, we discuss the critical need for collaborative leadership in practice and education as a priority policy agenda aimed at confronting the shortage of nurses. The COVID-19 pandemic has intensified the nursing shortage and shortage of capacity in practice education, and we explore some learning in this context. Our paper draws on two initiatives in the province of British Columbia: the development of a transformative practice education model and an expanded Collaborative Learning Unit initiative. We propose building the following learning cultures: formal collaborative governance processes, intentional supports for graduate transitions and implementation of advanced nursing practice leadership and educator roles across the system. While transformative solutions are a tough sell in crisis-oriented contexts, this paper is a call for nurse leaders in all sectors to advance deep policy solutions with lasting impact on sustainable nursing human resources.

Infants, children, and youth in foster care with prenatal substance exposure: a synthesis of two scoping reviews

Background: Infants, children, and youth in foster care have frequently experienced prenatal substance exposure (PSE), neglect, and maltreatment as well as disruptions in their relationships with families. They also have great capacity for overcoming early adversities. In this synthesis of two previously conducted scoping reviews, we aimed to identify and describe literature that identifies a range of interventions that support the health and development of this population. Methods: This review integrates and extends two previously conducted scoping reviews, one focusing on infants and one focusing on children and youth, to synthesize themes across these developmental stages. The Joanna Briggs Institute scoping review methodology was employed for the current and previous reviews. A three-step search strategy identified published studies in the English language from January 2006 to February 2020. Results: One-hundred and fifty-three sources were included in this review. Four themes were identified: (1) early screening, diagnosis, and intervention; (2) providing theoretically grounded care; (3) supporting parents and foster care providers; and (4) intersectoral collaboration. Conclusion:Infants, children, and youth with PSE are overrepresented in foster care. Child welfare system planning should take a multi-sectoral approach to addressing the cumulative needs of this population and their care providers over developmental ages and stages. Although research remains limited, early screening, diagnosis, and developmentally and fetal alcohol spectrum disorder-informed intersectoral interventions are critical for optimizing outcomes.

Creating safe relational space: Public health nurses work with mothering refugee women

OBJECTIVE

Exploring how public health nurses (PHNs) provide community-based support to women who are refugees and mothering.

DESIGN

A constructivist grounded theory (CGT) design was used where intersectionality as an analytical tool was applied. Varying data collection approaches including focus groups were used.

SAMPLE

Twelve PHNs from four public health units in Western Canada participated in this study.

RESULTS

Participants in this study described an overall process of creating safe relational space to address a basic social problem of establishing trust while managing structural forces. This overarching process was expressed through burning with passion, connecting while looking beyond, protecting from re-traumatization, and fostering independence. Findings reveal strategies PHNs used to enhance health equity. This study extends critical caring theory to include sociopolitical and economic influences on public health nursing practice. Consequences of these influences on the mothering refugee women population are also revealed. Implications include structural integration of trauma-and-violence-informed principles to support public health nursing practice.

CONCLUSIONS

This study adds to an emerging body of knowledge on PHNs work with complex populations. Innovative application of intersectionality is demonstrated as an effective approach to analyzing impacts of broad sociopolitical priorities on communities that are systemically marginalized.

Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify, critically appraise, and synthesize qualitative evidence on the experiences of nurses providing care within various health care delivery environments to involuntary migrant women who are experiencing pregnancy, birth, or post-birth.

INTRODUCTION

Nurses are central to providing care to populations experiencing inequities. These populations include forcibly displaced pregnant and/or mothering women who have migrated involuntarily. Most of these women are ethnically diverse and often experience poverty and low literacy. This review is focused on the experiences of nurses providing care to these women.

INCLUSION CRITERIA

This review considered qualitative, peer-reviewed studies published in academic journals. Studies and study abstracts that examined nurses' experiences of providing care to involuntary migrant maternal women were included. Women could be pregnant and/or mothering. All settings in which nurses practice were considered.

METHODS

Information sources that were systematically searched for this review included CINAHL (EBSCO), PsycINFO (EBSCO), MEDLINE (EBSCO), PubMed (NLM), Web of Science, and Google Scholar. A gray literature search in Google was also developed. Studies published in English from 2000 onward were considered. Final searches were conducted in January 2021 using language within database thesauruses, such as CINAHL headings and MeSH terms, as well as keywords related to qualitative inquires on experiences of nurses caring for involuntary migrant maternal women. An intersectionality lens was applied within all review methods. Study selection was conducted by two reviewers who screened titles and abstracts that aligned with the inclusion criteria. The review followed the JBI approach for critical appraisal, data extraction, and data synthesis.

RESULTS

Twenty-three qualitative studies were included in this review. Qualitative methodologies within these studies included case study, ethnography, interpretive descriptive, and grounded theory. Nine studies considered the sex of participating nurses, and three studies considered participant history of migration. A total of 115 findings were pooled into four categories and aggregated into the following two synthesized findings: i) Nurses integrate cultural and linguistic diversity within practice; and ii) Nurses assess for inequities resulting from forced migration on maternal women. Study quality was rated as moderate on ConQual scoring, with dependability rated as moderate and credibility rated as high.

CONCLUSIONS

Key implications are made within nursing education programming, nursing practice, and policy analysis. In the realm of nursing education, integration of migrant status as a health determinant will enhance nurses' skills in assessing migrant status and understanding how varying statuses contribute to barriers among involuntary migrant women accessing health services. Providing ongoing education to nurses centered on trauma and violence-informed practice is recommended. With regard to nursing practice, review findings revealed the need for creative solutions to overcome language barriers. Innovative approaches for nurses working across language barriers in acute and community health contexts when interpreter services are not available need further exploration and protocol integration. Examination of clinical care pathways is needed for inclusion of involuntary migrant women, and exploring assessment strategies targeting how migrant status contributes to limited health service accessibility. For policy, organizations need to build policies that promote examination of migrant status and its health impacts among involuntary migrant maternal women exposed to migration-related trauma and violence to support nurses in their care provision.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

Navigating conflicting value systems: a grounded theory of the process of public health equity work in the context of mental health promotion and prevention of harms of substance use

BACKGROUND

Promoting health equity and reducing heath inequities is a foundational aim and ethical imperative in public health. There has been limited attention to and research on the ethical issues inherent in promoting health equity and reducing health inequities that public health practitioners experience in their work. The aim of the study was to explore how public health providers identified and navigated ethical issues and their management related to promoting health equity within services focused on mental health promotion and preventing harms of substance use.

METHODS

Semi-structured individual interviews and focus groups were conducted with 32 public health practitioners who provided public-health oriented services related to mental health promotion and prevention of substance use harms (e.g. harm reduction) in one Canadian province.

RESULTS

Participants engaged in the basic social process of navigating conflicting value systems. In this process, they came to recognize a range of ethically challenging situations related to health equity within a system that held values in conflict with health equity. The extent to which practitioners recognized, made sense of, and acted on these fundamental challenges was dependent on the degree to which they had developed a critical public health consciousness. Ethically challenging situations had impacts for practitioners, most importantly, the experiences of responding emotionally to ethical issues and the experience of living in dissonance when working to navigate ethical issues related to promoting health equity in their practice within a health system based in biomedical values.

CONCLUSIONS

There is an immediate need for practice-oriented tools for recognizing ethical dilemmas and supporting ethical decision making related to health equity in public health practice in the context of mental health promotion and prevention of harms of substance use. An increased focus on understanding public health ethical issues and working collaboratively and reflexively to address the complexity of equity work has the potential to strengthen equity strategies and improve population health.

Public health nurses' perceptions of their interactions with child protection services when supporting socioeconomically disadvantaged young mothers in British Columbia, Canada

BACKGROUND

Children of girls and young women experiencing socioeconomic disadvantage are at risk of maltreatment and associated health and developmental problems. Nurse-Family Partnership (NFP) is an early intervention program designed to improve child and maternal health outcomes. The effectiveness of NFP is being evaluated in British Columbia (BC) through a randomized controlled trial, augmented by a process evaluation to identify influences on how NFP was implemented.

OBJECTIVE

To describe how public health nurses providing NFP perceived their interactions with child protection professionals.

PARTICIPANTS AND SETTING

Forty-seven public health nurses across BC.

METHODS

The principles of interpretive description informed the qualitative component of the process evaluation. Data from interviews and focus groups were analyzed using the framework analysis approach. A thematic framework was generated through processes of coding, charting and mapping, with a focus on organizational and systems influences.

RESULTS

Nurses' practice in supporting families often involved engagement with child protection services. Four themes about the nature of this work were identified: 1) developing a deeper understanding of the disciplinary perspectives of child protection, 2) striving for strengthened collaboration, 3) navigating change and uncertainty, and 4) responding to family and community complexity.

CONCLUSIONS

Participants valued the contribution of child protection professionals and expressed willingness to collaborate to support families. However, collaboration was constrained by multiple structural barriers. Collaborative models offer possibilities for integrated practice, although can be difficult to implement within current health and child protection systems and child protection regulatory contexts.

Characteristics and processes of the dedicated education unit practice education model for undergraduate nursing students: a scoping review

OBJECTIVE

The objective was to review literature related to the dedicated education unit practice education model for undergraduate nursing students, and identify common characteristics and processes for implementing and sustaining this model.

INTRODUCTION

Although practice education is central to undergraduate nursing education, evidence-informed practices for learning in the clinical setting remain elusive. Changes to health care over the past decades related to the role and scope of practice for nurses, gradual shifts to community- and population-based care delivery, and expectations for interprofessional practice require forward-looking education models. The dedicated education unit model was developed in 1997 as a potential solution to globally recognized challenges in nursing education amidst discourses of nursing resource scarcity. Despite more than two decades of innovation and expansion, there is still limited understanding of the effectiveness of the dedicated education unit as a solution to those challenges, or for the anticipated benefits for students and patients, through enhanced evidence-informed health care. This analysis of the characteristics and processes of the model is timely for evaluating and sustaining implementation of the dedicated education unit across nursing practice and education settings.

INCLUSION CRITERIA

English-only publications related to the dedicated education unit practice education model for undergraduate nursing students in baccalaureate and associate degree programs using qualitative, quantitative, or mixed methods research, and quality improvement, program evaluation, and opinion publications were included.

METHODS

Using selected keywords including "dedicated education unit," we searched CINAHL, Google Scholar, MEDLINE, Academic Premier Search, ERIC, Cochrane Database of Systematic Reviews, JBI EBP Database, and ProQuest Dissertations and Theses. Two independent reviewers screened titles and abstracts against inclusion criteria. We reviewed reference lists for gray literature and additional references. Data were extracted from the included articles and categorized for characteristics and processes. Eighty-two publications from January 1997 to May 2020 were included. The findings were presented descriptively with tables and figures to support the data.

RESULTS

Dedicated education unit models were based on five characteristics and four processes. Characteristics of the dedicated education unit model included effective academic-practice partnership, adaptability to diverse contexts, unit culture of educational excellence, responsive and supportive unit leadership, and clarity of roles and responsibilities. Processes included building nurse and faculty capacity, facilitating student learning, communicating regularly at systems and unit levels, and evaluating and sustaining the model.

CONCLUSIONS

Evidence demonstrated that the dedicated education unit practice education model is well-established. However, there were existing gaps in this evidence, specifically evaluation and economic analyses. There was also limited attention to long-term sustainability of the model. The common characteristics and processes identified in this review may be used to support planning, implementation, and evaluation, including development and validation of evaluation tools. Although administrative infrastructure was noted as central to the dedicated education unit strategy, it was rarely acknowledged as part of management and thus also requires further study.

Facilitators and barriers to accessing mental health care services and social supports among perinatal refugee women: a qualitative systematic review protocol

OBJECTIVE

The objective of this qualitative review is to identify, critically appraise, and synthesize evidence describing facilitators and barriers to perinatal refugee women's access to mental health care services and social supports.

INTRODUCTION

Perinatal refugee women are a vulnerable population and at risk of mental health illness. Understanding facilitators and barriers will provide a better understanding of their experiences to inform health care practices, programs, and policies.

INCLUSION CRITERIA

This qualitative review will consider all peer-reviewed qualitative studies and gray literature on perinatal refugee women's experiences of accessing mental health care services and social supports. Non-English articles and studies that do not explicitly state participants' migration status as refugees will be excluded.

METHODS

This review will adhere to the JBI methodology for conducting qualitative systematic reviews. Key information sources searched will be CINAHL, PsycINFO, PubMed, Web of Science, and the Social Sciences Citation Index. Search terms will be modified for each information source. Sources of evidence published in English between January 2011 and the present will be assessed for inclusion. Two independent reviewers will screen titles and abstracts using the inclusion criteria for study selection. The reviewers will critically appraise methodological quality and rigor. Data will be extracted on facilitators and barriers among perinatal refugee women accessing mental health care services and social supports. Synthesis will involve aggregation of these findings to generate a set of statements based on their meaning similarity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021245240.

"The health equity curse": ethical tensions in promoting health equity

BACKGROUND

Public health (PH) practitioners have a strong moral commitment to health equity and social justice. However, PH values often do not align with health systems values, making it challenging for PH practitioners to promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and prevention of harms of substance use.

METHODS

As part of a broader program of public health systems and services research, we interviewed 32 PH practitioners.

RESULTS

Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.

CONCLUSIONS

Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as a promising approach for developing ethical frameworks for PH practice.

The Social Organization of Neonatal Nurses' Feeding Work

PURPOSE

We report findings from an institutional ethnography (IE) of nurses' work of feeding infants within an increasingly technical organization of NICUs.

SAMPLE

Five primary informants; 18 secondary informants.

DESIGN

The institutional ethnographic approach included field observations, interviews, and phone and e-mail conversations. Our analysis followed accounts of what actually happened within the textual organization of nurses' work.

MAIN OUTCOME

Nurses' feeding practices are directed by protocols that arise within multiple documentation systems and clinical technologies. These systems produce barriers to nurses' efforts to skillfully feed infants.

RESULTS

Prioritization of quality and safety perspectives can obscure and constrain the ordinary yet critical clinical reasoning neonatal nurses employ during feeding work. Clinical technologies that have been developed to improve safety can paradoxically disrupt the ability of nurses to respond in the moment to neonatal feeding cues. This finding provides nurses, leaders, and policymakers with insight into why policies and procedures may not be followed as expected.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review

OBJECTIVE

The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.

INCLUSION CRITERIA

To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.

METHODS

An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.

RESULTS

A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.

CONCLUSIONS

We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

Interventions and programs that support the health and development of infants with prenatal substance exposure in foster care: a scoping review

OBJECTIVE

The objective of this scoping review was to describe the characteristics of interventions and programs that support the health and development of infants in foster care who have prenatal substance exposure, their foster care providers, and birth families.

INTRODUCTION

Infants in foster care may have experienced prenatal substance exposure, neglect, and maltreatment, as well as disruptions in their relationships with primary caregivers. Despite multiple vulnerabilities, they also have great capacity for overcoming early adversities. Enhanced foster care has been identified as a key influence on the positive development of infants in the child welfare system.

INCLUSION CRITERIA

This scoping review considered publications that described interventions and programs designed to support foster care providers who care for infants less than 12 months of age with prenatal substance exposure. This review included research studies and gray literature. This scoping review focused on sources that described caregiving interventions and elements of programs that took place within the context of family or home-based foster care.

METHODS

A three-step search strategy was used to identify publications in the English language from January 2000 to December 2019. A literature search was conducted using MEDLINE, Academic Search Premier, PsycINFO, and CINAHL databases. Titles and abstracts were initially screened to assess if publications met the inclusion criteria, followed by full-text review. Publications that met the inclusion criteria were assessed by two independent reviewers using a data extraction tool developed for this review. Findings were thematically analyzed on the basis of similarity in focus and descriptively presented with tables and figures to support the findings.

RESULTS

Eighty-one publications were included, including 48 research papers and 33 gray literature sources. Thematic analysis of the focus of each publication resulted in identification of four core themes: i) mental health promotion for infants in care; ii) child welfare program elements; iii) identification of infants and families at risk of requiring foster care; and iv) outcomes for infants in care and their families. The interventions and programs identified during this scoping review were primarily focused on supporting social-emotional development. With the significant focus on infant mental health, supporting birth parents to stay attached to their infants was a key focus of the majority of publications. The concept of being able to proactively identify risk factors that were associated with infants requiring foster care emerged in relation to how family preservation could be supported. Strategies identified as contributing to the development of successful interventions and programs included having foster care providers participate as collaborators in designing services, designing services that are adaptable to a range of contexts, involving community partners outside child welfare, and having developmentally appropriate programs.

CONCLUSIONS

Infants represent a significant proportion of children in foster care. A developmental perspective is needed for child welfare service planning to address their unique needs. Intervention during the early years holds significant potential for promoting positive developmental pathways and family preservation.

Public Health Nurses' Professional Practices to Prevent, Recognize, and Respond to Suspected Child Maltreatment in Home Visiting: An Interpretive Descriptive Study

The purpose of this analysis was to understand public health nurses’ experiences in preventing and addressing suspected child maltreatment within the context of home visiting. The principles of interpretive description guided study decisions and data were generated from interviews with 47 public health nurses. Data were analyzed using reflexive thematic analysis. The findings highlighted that public health nurses have an important role in the primary prevention of child maltreatment. These nurses described a six-step process for managing their duty to report suspected child maltreatment within the context of nurse-client relationships. When indicators of suspected child maltreatment were present, examination of experiential practice revealed that nurses developed reporting processes that maximized child safety, highlighted maternal strengths, and created opportunities to maintain the nurse-client relationship. Even with child protection involvement, public health nurses have a central role in continuing to work with families to develop safe and competent parenting skills.

Non-pharmacological care for opioid withdrawal in newborns

BACKGROUND

The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice.

OBJECTIVES

To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials.

SELECTION CRITERIA

We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication.

MAIN RESULTS

We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.

Experiences of nurses caring for maternal immigrant and refugee women: a qualitative systematic review protocol

OBJECTIVE

This review will focus on studies inquiring into nurses working across diverse health care settings and their experiences of caring for immigrant and refugee women who are pregnant or mothering. Within this review, diverse terminologies used to conceptualize "nurse," immigrant," and "refugee" will also be captured.

INTRODUCTION

Immigrant and refugee women who are pregnant or mothering experience poorer health than non-displaced women. Nurses are pivotal in providing care to this population. Understanding nursing experiences can reveal structural barriers and facilitators to equitable care provision.

INCLUSION CRITERIA

Peer-reviewed, qualitative studies that include nurses working across diverse health care settings and providing care to involuntary immigrant and refugee maternal women will be considered. Studies where nurses are described as being educated within a basic and generalized nursing program and have been authorized by a regulatory organization to practice nursing in their country will be included.

METHODS

Key information sources searched include CINAHL, PsycINFO, MEDLINE, Google Scholar, Web of Science, and PubMed. Search terms will be adapted for each information source. Study selection includes screening titles and abstracts by two independent reviewers against the inclusion criteria. These reviewers will then critically appraise for methodological quality and begin data extraction to understand experiences of nurses and diverse understandings of "nurse," "immigrant," and "refugee." Synthesis includes assembling and categorizing findings on the basis of meaning similarity. A set of statements will be generated representing this synthesis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

Nurse home visiting and prenatal substance use in a socioeconomically disadvantaged population in British Columbia: analysis of prenatal secondary outcomes in an ongoing randomized controlled trial

BACKGROUND

Nurse-Family Partnership (NFP) involves public health nurses providing frequent home visits from early pregnancy until children reach age 2 years, focusing on first-time parents experiencing socioeconomic disadvantage. Our aim was to evaluate NFP's effectiveness in improving child and maternal health.

METHODS

We conducted an analysis of prenatal secondary outcomes in an ongoing randomized controlled trial in British Columbia; the data used in this analysis were collected from January 2014 to May 2017. Participants were pregnant girls and women aged 14-24 years who were preparing to parent for the first time and experiencing socioeconomic disadvantage. They were randomly allocated 1:1 to the intervention (NFP plus existing services) or control group (existing services). Prespecified prenatal secondary outcome indicators were changes in use of nicotine cigarettes and alcohol use by 34-36-weeks' gestation. We also report on prespecified exploratory cannabis and street drug use measures. We used mixed-effect models for longitudinal and clustered data to estimate intervention effects. Analyses were by intention to treat.

RESULTS

The median gestational age at baseline for the 739 participants (368 participants in the intervention group, 371 in the comparison group) was 20 weeks, 6 days. By 34-36 weeks' gestation, NFP significantly reduced cigarette counts (over the past 2 d) (difference in changes [DIC] of count -1.6, 95% confidence interval [CI] -6.4 to -1.3) in those who smoked. NFP also significantly reduced rates of prenatal cannabis use (DIC -6.4, 95% CI -17.0 to -1.7), but not rates of street drug or "any" substance use. While we observed decreased rates of cigarette and alcohol use in both groups (DIC of proportions -2.8, 95% CI -15.3 to 0.6; DIC -0.5, 95% CI -8.7 to 1.8, respectively), these changes were not statistically significant.

INTERPRETATION

We found no evidence that NFP was effective in reducing rates of prenatal cigarette and alcohol use; however, it led to reduced prenatal cannabis use, and in smokers it led to modest reductions in cigarette use. NFP may therefore hold promise for reducing some types of prenatal substance use in disadvantaged populations. Trial registration: ClinicalTrials.gov, no. NCT01672060.