Improving paediatric nurses' knowledge and attitudes in childhood fever management

Impact of an Educational Program on Improving Nurses’ Management of Fever: An Experimental Study

Background: Despite a public information campaign “To Break the Myth of Fever”, nurses continued to overtreat fever. This study hypothesized that the campaign lacked the detailed rationale essential to alter nurses’ attitudes and behaviors. Aim: To evaluate the effect of the educational program on nurses’ knowledge, attitudes, and behaviors related to fever management. Design: A randomized experimental design using a time series analysis. Methods: A random sample of 58 medical/surgical nurses was evenly divided into an intervention and a control group. The intervention group received an educational program on fever and fever management. Both groups completed a pretest and four posttests using investigator-developed instruments: a questionnaire on knowledge and attitudes about fever management and a fever treatment checklist to audit charts. Results: The intervention group had markedly higher knowledge scores and reduced use of ice pillows at all four posttests, as well as lower use of antipyretics overall, except for the first posttest, despite no sustained change in attitude. Conclusions: An educational program for fever management can effectively improve clinical nurses’ knowledge and attitudes about fever management.

Analysis of Nurses' and Physicians' Attitudes, Knowledge, and Perceptions toward Fever in Children: A Systematic Review with Meta-Analysis

CONTEXT

Fever is a common symptom in children that nurses and pediatricians treat. Although it is a common sign in clinical practice, fever instills irrational fears in parents that health professionals share.

OBJECTIVE

To investigate whether doctors' and nurses' knowledge, perceptions, and attitudes toward fever influence how this sign is managed. Furthermore, it intends to evaluate whether educational programs increase knowledge and change attitudes and/or perceptions of nurses about children's fever.

DATA SOURCES

A systematic review with meta-analysis was conducted with PRISMA international standards and the Cochrane recommendations.

STUDY SELECTION

Articles examining health professionals' (doctors and/or nurses) knowledge, perceptions, and/or attitudes toward fever in children and the use of antipyretics were selected for the study.

DATA EXTRACTION

The qualitative analysis was carried out by classifying the articles according to the applied educational programs for nurses related to fever care for children that evaluated different outcomes to determine their efficacies.

RESULTS

For the qualitative synthesis, 41 articles were included, and 5 of these were taken in meta-analysis, which measured the effectiveness of educational programs for fever management in nurses.

LIMITATIONS

All of the included studies generally had a high risk of bias.

CONCLUSION

According to the evidence reviewed, nurses' and physicians' perceptions and attitudes regarding fever management in children indicate an overtreatment of this sign. We can give a recommendation grade of D on the use of educational programs to modify attitudes, perceptions, and knowledge about fever in children and improve clinical practice in nurses.

Development and Implementation of a Pediatric Nursing-Clinical Decision Support System for Hyperthermia: A Pre- and Post-test

This article describes the development process and application of the Pediatric Nursing-Clinical Decision Support System for Hyperthermia. Firstly, we formed the Pediatric Nursing-Knowledge Base for Hyperthermia, which combines publicly available clinical practice guidelines and nursing routines of hyperthermia management. Then, following the nursing process framework, the system was developed using clinical decision support technology. Finally, a pre- and post-test were adopted to examine the effectiveness, usability, and feasibility before (1st to 31st of August 2018) and after (1st to 31st of December 2019) using the system. Its effectiveness was examined by analysis of nursing records' quality, including completeness of nursing assessment, timeliness of nursing diagnosis, individualization of nursing interventions, and timeliness of nursing evaluation. Its usability and feasibility were assessed using the Clinical Nursing Information System Effectiveness Evaluation Scale. There was a significant difference between the two groups in effectiveness, usability, and feasibility. Although the system was developed specifically for our hospital workflow and processes, the Pediatric Nursing-Knowledge Base for Hyperthermia and workflow for hyperthermia management in this study can be used as a reference to other hospitals.

Antipyretic drugs in patients with fever and infection: literature review

BACKGROUND

antipyretic drugs are routinely administered to febrile patients with infection in secondary care. However, the use of antipyretics to suppress fever during infection remains a controversial topic within the literature. It is argued that fever suppression may interfere with the body's natural defence mechanisms, and may worsen patient outcomes.

METHOD

a literature review was undertaken to determine whether the administration of antipyretic drugs to adult patients with infection and fever, in secondary care, improves or worsens patient outcomes.

RESULTS

contrasting results were reported; two studies demonstrated improved patient outcomes following antipyretic administration, while several studies demonstrated increased mortality risk associated with antipyretics and/or demonstrated fever's benefits during infection. Results also demonstrated that health professionals continue to view fever as deleterious.

CONCLUSION

the evidence does not currently support routine antipyretic administration. Considering patients' comorbidities and symptoms of their underlying illness will promote safe, evidence-based and appropriate administration of antipyretics.

Evidence use in equity focused health impact assessment: a realist evaluation

BACKGROUND

Equity-focused health impact assessment (EFHIA) can function as a framework and tool that supports users to collate data, information, and evidence related to health equity in order to identify and mitigate the impact of a current or proposed initiative on health inequities. Despite education efforts in both the clinical and public health settings, practitioners have found implementation and the use of evidence in completing equity focussed assessment tools to be challenging.

METHODS

We conducted a realist evaluation of evidence use in EFHIA in three phases: 1) developing propositions informed by a literature scan, existing theoretical frameworks, and stakeholder engagement; 2) data collection at four case study sites using online surveys, semi-structured interviews, document analysis, and observation; and 3) a realist analysis and identification of context-mechanism-outcome patterns and demi-regularities.

RESULTS

We identified limited use of academic evidence in EFHIA with two explanatory demi-regularities: 1) participants were unable to "identify with" academic sources, acknowledging that evidence based practice and use of academic literature was valued in their organization, but seen as less likely to provide answers needed for practice and 2) use of academic evidence was not associated with a perceived "positive return on investment" of participant energy and time. However, we found that knowledge brokering at the local site can facilitate evidence familiarity and manageability, increase user confidence in using evidence, and increase the likelihood of evidence use in future work.

CONCLUSIONS

The findings of this study provide a realist perspective on evidence use in practice, specifically for EFHIA. These findings can inform ongoing development and refinement of various knowledge translation interventions, particularly for practitioners delivering front-line public health services.

Tailored interventions to address determinants of practice

BACKGROUND

Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.

OBJECTIVES

To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants.

SEARCH METHODS

We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals.

SELECTION CRITERIA

Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.

MAIN RESULTS

We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.

AUTHORS' CONCLUSIONS

Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

The knowledge, attitudes and beliefs of carers (parents, guardians, healthcare practitioners, crèche workers) around fever and febrile illness in children aged 5 years and under: protocol for a qualitative systematic review

BACKGROUND

Many parents consider fever a disease in itself and feel disempowered when their child is ill. Numerous guidelines have been produced; however, their target audience remains healthcare professionals and not carers of children in general. A reliable source of information will decrease worry in parents and carers when managing a febrile child.

METHODS/DESIGN

A systematic search will be conducted in nine electronic databases. Articles published in English, or with an abstract published in English, will be eligible for inclusion in the review. Unpublished literature, grey literature and consultation with experts in the area will be used to supplement database searching. Titles and abstracts of studies will be screened for inclusion in the study by two independent reviewers against pre-determined inclusion and exclusion criteria. A data extraction form will be designed and data will be extracted to provide detail of the included studies by a further two reviewers. Quality assessment of studies will be conducted by two additional independent reviewers and results will be used to moderate included studies. All disagreements will be resolved through discussion until consensus is reached. Thematic synthesis will be used to analyse results.

DISCUSSION

Correct management of fever in children is not well understood in the general population. Although carers can identify fever and febrile illness in children, determination of the severity of fever proves challenging. Research is needed to cohere existing evidence and identify knowledge gaps. It is envisaged that results of this review will contribute to the development of trustworthy, accessible guidelines for parents and carers of children with fever or febrile illness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009812.

Educating parents on gastrostomy devices: necessary components to achieve success

Often parents leave the hospital without the education needed to care for their child's gastrostomy device. Lack of nurse knowledge and the use of various types of devices contribute to their confusion and inability to adequately educate parents. An enhanced methodology and process to standardize gastrostomy education were designed and implemented. Data results confirmed an improvement in the knowledge and competency of both staff nurses and parents. Empowering staff nurses with knowledge and the necessary resources and tools to confidently educate parents, along with a standardized process, has improved overall outcomes.

Nurses' knowledge of and attitudes towards fever and fever management in one Irish children's hospital

This study aims to describe nurses' knowledge of and attitudes towards the management of fever in one children's hospital in Ireland. A descriptive, quantitative research design was employed. One hundred and nineteen nurses working in one children's hospital completed a self-report questionnaire. Nurses' mean knowledge score about the physiology of fever, fever management and antipyretics was 51 per cent (n = 119), which was lower than expected. Nurses had both appropriate and inappropriate attitudes towards fever and fever management. Inconsistent attitudes between nurses were identified. Nurses who participated in this study are not expert managers of fever. Their lack of knowledge and inconsistent attitudes are affecting the care of febrile children, and may be fuelling parents' fever phobia. Further education is required to improve nurses' knowledge of fever and fever management. Inappropriate attitudes need to be challenged and addressed in an effort to promote evidence-based care for febrile children.

Reflecting on nurses' views on using research in practice

This paper follows a previous paper (Hewitt-Taylor et al, 2012) in which the authors summarised their reflections on the literature relating to the application of research in practice. This paper builds on these reflections and reports on the findings from one aspect of a study that explored nurses' views on using research in practice. Quantitative methods of data collection and analysis were used and data were gathered using questionnaires. The findings suggest that nurses generally value research, but this does not necessarily mean that they base individual decisions on particular research findings, or that research is considered the most important form of evidence in direct practice. In addition, the resources that enable nurses to find, appraise and make decisions about using research, are not always readily available in practice settings. From this part of the study, it can be concluded that for research utilisation to increase, time, resources, role models and environments that support this ethos are needed, and that an emphasis on research should not eclipse other key forms of nursing knowledge such as patient views and experiences, and professional expertise in the promotion of evidence-based practice.

Clinical management of fever by nurses: doing what works

AIMS

The specific aims were to (1) define fever from the nurse's perspective; (2) describe fever management decision-making by nurses and (3) describe barriers to evidence-based practice across various settings.

BACKGROUND

Publication of practice guidelines, which address fever management, has not yielded improvements in nursing care. This may be related to differences in ways nurses define and approach fever.

METHOD

The collective case study approach was used to guide the process of data collection and analysis. Data were collected during 2006-7. Transcripts were coded using the constant comparative method until themes were identified. Cross-case comparison was conducted. The nursing process was used as an analytical filter for refinement and presentation of the findings.

FINDINGS

Nurses across settings defined fever as a (single) elevated temperature that exceeded some established protocol. Regardless of practice setting, interventions chosen by nurses were frequently based on trial and error or individual conventions -'what works'- rather than evidence-based practice. Some nurses' accounts indicated use of interventions that were clearly contraindicated by the literature. Participants working on dedicated neuroscience units articulated specific differences in patient care more than those working on mixed units.

CONCLUSIONS

By defining a set temperature for intervention, protocols may serve as a barrier to critical clinical judgment. We recommend that protocols be developed in an interdisciplinary manner to foster local adaptation of best practices. This could further best practice by encouraging individual nurses to think of protocols not as a recipe, but rather as a guide when individualizing patient care. There is value of specialty knowledge in narrowing the translational gap, offering institutions evidence for planning and structuring the organization of care.

Does specialist respiratory education make a difference to practice?

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) poses a huge burden to society. Continued professional development can be regarded as a requisite for implementing quality care. Within the literature the effectiveness of COPD care is evident, yet it is seldom attributed to the educational attainment of healthcare professionals. This study aimed to examine whether a nationally delivered COPD module is perceived to impact on clinical practice.

METHODS

As part of a mixed methods study (Cresswell et al., 2003), qualitative data were gathered post-intervention from 68 students utilising a semi-structured, self-completed questionnaire. Data were analysed using a themed content analysis and a quasi-statistical approach.

RESULTS

The major themes that emerged from the analysis were: changes in personal practice, evidence of changes implemented and changes in participants' personal views regarding disease management. These findings suggest that when students gain knowledge they use it to the benefit of patients.

DISCUSSION

Overall students reported an increase in knowledge and confidence regarding COPD management and an impact on practice was reported. The findings will add to a mounting body of evidence that supports the value of continuing professional learning and will aim to satisfy consumers of education of the efficacy of knowledge in terms of direct patient impact.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.

OBJECTIVES

To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.

SEARCH STRATEGY

For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.

MAIN RESULTS

We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.

Influences on parents’ fever management: beliefs, experiences and information sources

AIM

To identify parents' knowledge, beliefs, management and sources of information about fever management.

BACKGROUND

Despite numerous studies exploring parents' management of childhood fever; negative beliefs about fever and overuse of antipyretics and health services for mild fevers and self-limiting viral illnesses continue to be reported.

DESIGN

Qualitative design using semi-structured interviews and discussions.

METHOD

Fifteen metropolitan parents whose children were aged six months to five years, volunteered to participate in individual interviews or group discussions. Recruitment was through Playgroup Queensland's online newsletter and letters from two childcare centres to all parents. Verbatim and audio data were collected by an experienced moderator using a semi-structured interview guide.

DATA ANALYSIS

Two transcripts were independently analysed by two researchers; categories, sub-headings and codes were independently developed, crosschecked and found comparable. Remaining transcripts were analysed using developed categories and codes.

RESULTS

Fever, determined through behavioural changes, was perceived as 'good', a warning that something was wrong. High fever, reported as 38.0-39.1 degrees C, was considered harmful; it must be prevented or reduced irrespective of concerns about antipyretics. Positive febrile experiences reduced concern about fever. Negative experiences such as febrile convulsions, media reports of harm, not receiving a definitive diagnosis, inaccessibility to regular doctors and receiving conflicting information about fever management increased the concerns. Parents seek information about fever from multiple sources such as doctors, books and other parents.

CONCLUSIONS

Parents' experiences with and information sources about fever and fever management influenced their knowledge, beliefs and practices. Positive experiences reduce concerns, health service usage and sometimes antipyretic usage. Negative experiences increase concerns, monitoring and antipyretic and health service usage.

RELEVANCE TO CLINICAL PRACTICE

Health professionals need to update their fever management knowledge ensuring that it is based on the latest scientific knowledge. They must provide parents of young children with consistent, reliable information preferably before their first child's first febrile episode.