Practices following the death of a loved one reported by adults from 14 countries or cultural/ethnic group

Aims

The purpose of this study was to examine the reported ritual practices (dealing with the deceased's remains, wake, funeral, burial and celebration) of White non-Hispanic, Black non-Hispanic and Hispanic/Latino adults in their country of origin or ethnic or cultural group in the United States following the death of a loved one.

Design

This descriptive study is a secondary analysis from a longitudinal mixed-methods study that examined parents' health and functioning following the death of a child.

Methods

Adult parents whose child died in neonatal intensive care units or paediatric intensive care units were recruited from four hospitals and from death records. Data were collected from 61 adult parents at 7 and 13 months postinfant/child death using semi-structured interviews about the child's death. Only those parents who responded to questions about usual death practices in their country of origin or cultural group were included in the data analysis.

Results

Thirty-two adults from 14 countries reported practices in their country or cultural group after a loved one's death including keeping the front door closed, walking funeral processions with a band playing, the deceased in a car accompanied by family and friends, fireworks, making home altars for deceased spirits with food and water for adults, toys and candy for children and no TV or radio for sometime.

Relevance to clinical practice

For community health nurses, understanding these practices is important in being sensitive and appropriate around the death. Asking the family about specific practices they hope to carry out and noting this in the family's record will help alert providers to the family's wishes at this challenging time.

What Children Wished They Had/Had Not Done and Their Coping in the First Thirteen Months after Their Sibling's Neonatal/Pediatric Intensive Care Unit/Emergency Department Death

Background: Research on what children wished they had done differently after their sibling's death has not been reported. Objective: Examine what children wished they had/had not done, and their coping after a sibling's neonatal/pediatric intensive care unit/emergency department (NICU/PICU/ED) death. Design: Qualitative data are part of a longitudinal mixed methods study of 6- to 18-year-olds interviewed at 2, 4, 6, and 13 months after a sibling's death. Setting/Subjects: Ninety-five school-aged children and 37 adolescents (58% female; 30% Hispanic, 50% black, 20% white). Measurements: Children responded to three open-ended questions: Thinking about your sibling's death, are there things you wish you (1) had done? (2) had not done? (3) What do you do to deal with your sibling's death? Conventional content analysis procedures were used. Results: Children wished they had spent more time, talked and played more with their sibling, saved their sibling, taken care of their sibling more, and been able to see their sibling grow up. They wished they had not been mean/yelled at their sibling, complained/argued with mother about their sibling, and kept their feelings inside. Children coped by talking with family, friends, and the deceased; playing, reading, watching TV; avoiding thoughts about and remembering their sibling; crying, keeping calm, praying; living for their sibling. Resuming their usual activities, trying to be happy, and laughing also helped children cope. Conclusions: Children commented more about what they wish they had done (n = 317) and less about what they wish they had not done (n = 107). Children talked to others and tried resuming usual activities to cope.

Parent and child perceptions of the child's health at 2, 4, 6, and 13 months after sibling intensive care or emergency department death

BACKGROUND

Approximately 50,000 US infants and children die annually, leaving surviving children and families with long-lasting effects. In most studies, children's health is rated by parents, but not the children.

PURPOSE

To compare the surviving children's self-rated health with parents' ratings at 2, 4, 6, and 13 months after sibling neonatal intensive care unit/pediatric intensive care unit/emergency department death death and identify the related factors.

METHODS

Children and their parents rated the child's health "now," "now compared with others your age," and "now versus before" the sibling's death.

SAMPLE

One hundred thirty-two children (58% girls, 72% school-aged, and 50% Black non-Hispanic), 70 mothers, and 26 fathers from 71 bereaved families.

CONCLUSIONS

Children self-rated their health: "now" as lower than their mothers at 4, 6, and 13 months and their fathers at 2, 4, and 13 months; "now compared with others your age" as lower than their mothers at each time point and fathers at 4, 6, and 13 months; and "now versus before" their sibling's death as higher than their mothers at 4, 6, and 13 months and fathers at 6 months. Ratings did not differ by age, gender, or race/ethnicity. At 6 months, children self-rated their health "now" as higher than their fathers in families with one to two surviving children but lower than their fathers in families with three to eight surviving children.

IMPLICATIONS FOR PRACTICE

Parents often perceive their children as healthier than children perceive themselves after sibling death, especially in larger families. Talking with children separately can identify the children at risk for emotional and physical illnesses earlier, providing more timely and appropriate interventions and referrals.

Children's fears 2-13 months after sibling NICU/PICU/emergency department death

BACKGROUND AND PURPOSE

Sibling loss can heighten children's fears. Approximately two million children in the United States experience the death of a sibling each year, leaving 25% of them in need of clinical intervention and more than 50% with significant behavioral problems. Fear, guilt, anxiety, and even distance from parents are some of the reactions that children feel after experiencing the loss of a sibling. The purpose of this study was to describe children's fears 2-13 months after their sibling's death. Fears were examined by children's age, gender, race/ethnicity, and time.

METHODS

Children completed two open-ended questions about fears and five fear items on the Spence Children's Anxiety Scale. The sample consisted of 132 children.

RESULTS

Children's top fears across age, gender, and race/ethnicity were daily situations (such as darkness, high places, and violent situations), bugs, animals, and medical examinations. Girls had more total fears than boys. These included fears of bugs and situations with parents and siblings. Boys and Hispanic children had more fears of daily situations. Black children had more fears of animals, whereas White children had more fears of bugs and medical examinations.

IMPLICATIONS FOR PRACTICE

Children identify many fears after sibling death, including but not limited to fantasy creatures, common daily situations, bugs, animals, and medical examinations likely related to their sibling's death. Identifying children's fears early can help nurse practitioners assist families in better understanding and responding to children's behavior after sibling death.

Black, White, and Hispanic Children's Health and Function 2-13 Months After Sibling Intensive Care Unit Death

OBJECTIVE

To describe children's anxiety, depression, behaviors, and school performance at 2-13 months after sibling neonatal/pediatric intensive care unit (NICU/PICU) or emergency department (ED) death and compare these outcomes by child age, sex, race/ethnicity, whether the child saw their sibling in the NICU/PICU/ED, and attended the sibling's funeral.

STUDY DESIGN

Children in 71 families were recruited for this longitudinal study from 4 children's hospitals and 14 other Florida hospitals. Children rated anxiety (Spence Children's Anxiety Scale) and depression (Children's Depression Inventory); parents rated child behaviors (Child Behavior Checklist) and reported school performance (detentions, suspensions, requested parent-teacher meetings) at 2, 4, 6, and 13 months post-sibling death. Analyses included repeated measures-ANOVA, t-tests, and 1-way ANOVA.

RESULTS

In total, 132 children and 96 parents participated. More children were female (58%), black (50%), and school-age (72%). Of the children, 43% had elevated anxiety and 6% had elevated depression over 13 months post-sibling death. Child-rated anxiety was higher for girls and black vs white children. Child-rated anxiety and depression were lower if they saw their sibling in the NICU/PICU/ED before and/or after the death, and/or attended the funeral. Teens were more withdrawn than school-age children at all time points. Children who did not see their deceased sibling in the NICU/PICU/ED after death had more requests for parent-teacher conferences.

CONCLUSIONS

Children's anxiety was more common than depression, especially in girls and black children. Children who saw their siblings in the NICU/PICU/ED before/after death and/or attended funeral services had lower anxiety and depression over the first 13 months after sibling death.

Acute Illnesses, Use of Health Services, and Changes in Medication Among Parents After Infant or Child Death

BACKGROUND

The death of an infant or child has been described as the most stressful life event, but few reports exist on the effects on parents' physical health in the year after the death.

OBJECTIVE

To examine acute illnesses, use of health services, and medication changes among parents from 3 racial/ethnic groups 1 to 13 months after the death of an infant or child in the neonatal intensive care unit or pediatric intensive care unit.

METHODS

In a longitudinal study, 96 parents (41% black, 32% Hispanic, 27% white) of deceased infants or children were recruited from 4 children's hospitals and death records. Parents reported demographic information, acute illnesses, health services used, and medication changes 1 to 13 months after the death. Descriptive statistics and 1-way analysis of variance were used to analyze the data.

RESULTS

Seventy mothers (age, mean [SD], 35.9 [7.13] years) and 26 fathers (age, 39.0 [7.37] years) participated; 56% of mothers and 42% of fathers had preexisting health problems before the death. Morbidity was greatest in the first 6 months, was relatively quiescent in months 7 through 10, and increased in months 11 through 13. Mothers reported 363 acute illnesses, 16 hospitalizations, and 124 medication changes. Morbidity rates and medication changes for fathers followed similar patterns but with lower frequency.

CONCLUSION

After the death of an infant or child, interventions for parents, especially parents with chronic health problems, are best targeted on illness prevention and mental health in months 1 to 6 and 11 to 13 following the death.

Comparison of mothers and grandmothers physical and mental health and functioning within 6 months after child NICU/PICU death

Background

Losing a child is devastating for parents and grandparents. Family and friends generally focus on comforting and supporting the bereaved parents, unintentionally ignoring the bereaved grandparents. Grandmothers and grandfathers often struggle with wanting to help their adult children (deceased child’s parents) without usurping the parents’ responsibilities and decisions regarding the deceased child. Research on mothers’ and grandmothers’ health at about the same time after the same child’s death in the neonatal or pediatric intensive care unit is lacking. The aim of this study was to compare mothers and grandmothers on physical health, mental health, and functioning in the first 1–6 months after the same child’s death in a neonatal or pediatric intensive care unit.

Methods

This cross-sectional secondary analysis compared 32 mothers with 32 grandmothers of the same 32 deceased children (newborn-6 years). Grandmothers were recruited through these 32 mothers. Most grandmothers and mothers were Hispanic (25%, 34%) or Black (44%, 41%), respectively. Mothers and grandmothers separately completed questions about their Physical Health, Mental Health [depression (Beck Depression Inventory), Post-Traumatic Stress Disorder (PTSD, Impact of Events-R), grief (Hogan Grief Reaction Checklist)], and Functioning (social support [MSPSS] and Employment) since the child’s/grandchild’s death. Paired t-tests and Chi Square tests were used to compare grandmothers with mothers of the same deceased infant/child on their private and separate responses to study measures.

Results

Mothers had significantly more acute illnesses than grandmothers. More mothers (63%) than grandmothers (37%) were categorized as clinically depressed. More mothers (69%) than grandmothers (44%) had clinical PTSD. Mothers reported significantly higher levels of despair and detachment than grandmothers. Only 4 mothers and 2 grandmothers were in therapy at the time of interview. Grandmothers and mothers rated their ability to concentrate on their work and their level of social support similarly.

Conclusions

Mothers had more acute illnesses, more severe depression, and a higher level of grief than grandmothers. However, few received therapy despite their high levels of depressive and PTSD symptoms.

Surviving Siblings' Illnesses, Treatments/Health Services over 13 Months after a Sibling's Death

Two million children experience sibling death annually and have problems that require clinical intervention although few receive such help. Effects on surviving siblings' mental health has been well documented, however their physical health has not. This study described surviving siblings' illnesses, treatments/health services at 2, 4, 6, and 13 months post-sibling death. The 132 children (76 girls, 56 boys, M 10.6 years, SD 3.43); 30% Hispanic, 51% Black, 26% White were recruited via hospital ICUs and published obituaries. Using a longitudinal design, parents reported types and numbers of surviving siblings' illnesses, treatments/health services, and dates post-sibling death. Most of the 207 illnesses and 674 treatments/health services occurred in the first 6 months post-sibling death. While girls had more illnesses (131) than boys (76) and Hispanic children had more illnesses than White or Black children, these differences were not statistically significant. Girls accounted for 66% of the treatments/health services and boys 34%. There was no significant difference in treatments/health service use by gender of the children (F = 1.00, p = .32). Hispanic children had significantly more treatments/health service use than Black children (F = 6.81, p = .002). Sibling death affects surviving siblings' physical health. Study data document the importance of monitoring the health, treatments and health service use of surviving siblings especially in the first 6 months after a sibling death, regardless of the child' s gender. On average, Hispanic children had greater health service use, which may warrant greater attention.

Use of spiritual coping strategies by gender, race/ethnicity, and religion at 1 and 3 months after infant's/child's intensive care unit death

BACKGROUND AND PURPOSE

In the United States, 57,000 children (newborn to 18 years) die annually. Bereaved parents may rely on religious or spiritual beliefs in their grief. The study's purpose was to examine differences in parents' use of spiritual and religious coping practices by gender, race/ethnicity, and religion at 1 and 3 months after infant/ICU death.

METHODS

The sample consisted of 165 bereaved parents, 78% minority. The Spiritual Coping Strategies Scale was used to measure religious and spiritual coping practices, separately. One-way ANOVAs indicated that Black non-Hispanic mothers used significantly more religious coping practices at 3 months than White non-Hispanic mothers. Protestant and Catholic parents used more religious coping practices than the "no" and "other" religion groups at 1 and 3 months. Within the 30 mother-father dyads (paired t-tests), mothers reported significantly greater use of religious coping practices at 1 and 3 months and spiritual coping practices at 3 months than fathers.

CONCLUSION

Religious coping practices were most commonly used by Black mothers and Protestant and Catholic parents. Within dyads, mothers used more spiritual and religious coping practices than fathers.

IMPLICATIONS FOR PRACTICE

These findings are beneficial for healthcare personnel in providing support to bereaved parents of diverse races/ethnicities and religions.

Adolescents' Experiences 7 and 13 Months Following the Death of a Brother or Sister

This qualitative study used semi-structured interviews to describe adolescents' responses at 7 and 13 months to siblings' NICU/PICU/ED death. At 7 months, adolescents were asked about events around the sibling's death; at 7 and 13 months, about concerns/fears, feelings, and life changes. Seventeen adolescents participated (13-18 years; M=15); 65% Black, 24% Hispanic, 11% White. Themes included death circumstances, burial events, thinking about the deceased sibling, fears, and life changes. Adolescents reported shock and disbelief that the sibling died; 80% knew the reason for the death; many had difficulty getting through burials; all thought about the sibling. From 7 - 13 months fears increased including losing someone and thoughts of dying. Adolescents reported more changes in family life and greater life changes in them (more considerate, mature) by 13 months; some felt friends abandoned them after the sibling's death. Girls had more fears and changes in family life and themselves. Adolescent's responses to sibling death may not be visually apparent. One recommendation from this study is to ask adolescents how they are doing separately from parents since adolescents may hide feelings to protect their parents, especially their mothers. Older adolescents (14-18 years) and girls may have more difficulty after sibling death.

School Aged Children's Experiences 7 and 13 Months Following a Sibling's Death

This study described 6-year to 12-year-old children's responses 7 and 13 months after siblings' NICU/PICU/ED death. Using semi-structured interviews, at 7 months, children were asked about events around their sibling's death. At both 7 and 13 months, children were asked about their thoughts and feelings about the deceased, concerns or fears, and life changes since the death. Thirty one children (58% female), recruited from four South Florida hospitals and Florida obituaries, participated. Children's mean age was 8.4 years; 64.5% were Black, 22.5% Hispanic, 13% White. Interviews were analyzed using conventional content analysis. Resulting themes: circumstances of the death, burial events, thinking about and talking to the deceased sibling, fears, and life changes. Most children knew their sibling's cause of death, attended funeral/memorials, thought about and talked to their deceased sibling, reported changes in family and themselves over the 13 months. Fears (something happening to themselves, parents, other siblings-death, cancer, being snatched away) decreased from 7 to 13 months especially in 7-year to 9-year-olds. Seven-year to 9-year-olds reported the greatest change in themselves from 7 to 13 months. More Black children and girls thought about the deceased and reported more changes in themselves over the 13 months. School aged children thought about and talked with their deceased sibling, reported changes in themselves and their family and their fears decreased over the first 13 months after their sibling's death.

Psychometric Properties of Newly Translated Spanish Life Events Inventory and Daily Hassles Scale

BACKGROUND AND PURPOSE

Measuring stress in Hispanic Americans, the fastest growing U.S. minority, is problematic. The Life Events Inventory (LEI) and the Daily Hassles Scale (DHS), widely used stress instruments, are not available in Spanish.

PURPOSE

To test the psychometric properties of the translated Spanish versions of the LEI and DHS.

METHODS

A convenience sample of 63 Hispanic women completed both instruments in Spanish and English 2 weeks apart.

RESULTS

Internal consistency reliability and stability were strong for both instruments (.85-.97). Reliability and validity evidence for the translated Spanish versions were strong and similar to the English version.

CONCLUSIONS

Psychometric findings suggest that the newly translated Spanish versions are good representations of the English versions and that these newly translated instruments are ready for use.

Parents' Acute Illnesses, Hospitalizations, and Medication Changes During the Difficult First Year After Infant or Child NICU/PICU Death

BACKGROUND AND OBJECTIVES

Infant/child death is described as a most stressful life event; however, there are few reports of effects on parent physical health during the first year after the death. The study's purpose is to examine the patterns of parent acute illnesses, hospitalizations, and medication changes over 1 to 13 months after neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) infant/child death in 3 racial/ethnic groups.

METHODS

Secondary analyses were conducted with longitudinal data on parent health and functioning 1 to 13 months after infant/child NICU/PICU death. Parents (176 mothers, 73 fathers; 44% Hispanic, 35% black non-Hispanic, and 21% white non-Hispanic) of deceased infants/children were recruited from 4 children's hospitals and state death records. Inclusion criteria-parents understood English or Spanish and had a deceased neonate/child ≤ 18. Exclusion criteria -deceased newborn from multiple gestation pregnancy, child in foster care, child's injury due to suspected abuse, or parent death in illness/injury event. Parents reported numbers and types of acute illnesses, hospitalizations, and medication changes 1 to 13 months postdeath.

RESULTS

Parents' acute illnesses, hospitalizations, and medication changes were greatest between months 1 and 6, with relative quiescence in months 7 to 10, and an increase in months 11 to 13. Mothers (aged 32 ± 7.8 years) reported 300 acute illnesses (primarily colds/flu, headaches, anxiety/depression, and infections) and 89 hospitalizations (primarily infections, chest pain, and gastrointestinal problems). Fathers (aged 37 ± 8.8 years) reported 104 acute illnesses (colds/flu and headaches) and 9 hospitalizations.

CONCLUSION

After infant/child NICU/PICU death, mothers had greater morbidity than fathers, with no significant differences by race/ethnicity. Parents' health needs to be monitored in months 1 to 6 and months 11 to 13, and interventions targeted to parents in these months.

Comparing mothers' postpartum concerns in two clinical trials 18 years apart

BACKGROUND AND PURPOSE

To determine if U.S. women's postpartum concerns have changed over time.

METHODS

Mothers' postpartum concerns were compared in two clinical trials: 1997 (high-risk pregnancy) and 2015 (first-time mothers). Advanced practice nurses (APNs) provided care through 8 weeks postpartum and recorded interactions in clinical logs. Content analysis of logs was used for identifying concerns.

RESULTS

Ninety-five percent of 58 1997 mothers were African American; 64% of 62 2015 mothers were Hispanic. The number of infant concerns (129 vs. 144) was similar to four of the top five infant concerns; infant feeding was the top concern for both groups. The 1997 mothers were concerned with body changes, birth control, breastfeeding, maternal health problems, and had more concerns about their health (142 vs. 43); the 2015 mothers were concerned with not having help, fatigue, finding things hard. Both groups had postpartum pain concerns and problems accessing mother/infant governmental programs.

CONCLUSIONS

Mothers' concerns regarding infant care were essentially the same over the two time periods with infant feeding as the top concern. Maternal concerns in common were postpartum pain and needing help accessing government programs. Women who had high-risk pregnancies had more health concerns.

IMPLICATIONS FOR PRACTICE

Results provide guidance for helping minority mothers in the postpartum period.

Parent & Child Perceptions of Child Health after Sibling Death

BACKGROUND

Understanding children's health after a sibling's death and what factors may affect it is important for treatment and clinical care. This study compared children's and their parents' perceptions of children's health and identified relationships of children's age, gender, race/ethnicity, anxiety, and depression and sibling's cause of death to these perceptions at 2 and 4 months after sibling death.

METHODS

64 children and 48 parents rated the child's health "now" and "now vs before" the sibling's death in an ICU or ER or at home shortly after withdrawal of life-prolonging technology. Children completed the Child Depression Inventory and Spence Children's Anxiety Scale. Sibling cause of death was collected from hospital records.

RESULTS

At 2 and 4 months, 45% to 54% of mothers' and 53% to 84% of fathers' ratings of their child's health "now" were higher than their children's ratings. Child health ratings were lower for: children with greater depression; fathers whose children reported greater anxiety; mothers whose child died of a chronic condition. Children's ratings of their health "now vs before" their sibling's death did not differ significantly from mothers' or fathers' ratings at 2 or 4 months. Black fathers were more likely to rate the child's health better "now vs before" the death; there were no significant differences by child gender and cause of death in child's health "now vs before" the death.

CONCLUSIONS

Children's responses to a sibling's death may not be visually apparent or become known by asking parents. Parents often perceive their children as healthier than children perceive themselves at 2 and 4 months after sibling death, so talking with children separately is important. Children's perceptions of their health may be influenced by depression, fathers' perceptions by children's anxiety, and mother's perceptions by the cause of sibling death.

Parent Grief 1-13 Months After Death in Neonatal and Pediatric Intensive Care Units

OBJECTIVE

Describe changes in mothers' and fathers' grief from 1 to 13 months after infant/child neonatal/pediatric intensive care unit death and identify factors related to their grief.

METHODS

Mothers (n = 130) and fathers (n = 52) of 140 children (newborn-18 years) completed the Hogan Grief Reaction Checklist at 1, 3, 6, and 13 months post-death.

RESULTS

Grief decreased from 3 to 13 months for mothers and from 3 to 6 months for fathers. Grief was more intense for: mothers of deceased adolescents and mothers whose child was declared brain dead.

CONCLUSION

Mothers' and fathers' grief intensity may not coincide, resulting in different needs during the 13 months after infant/child death.

Cause of Death of Infants and Children in the Intensive Care Unit: Parents' Recall vs Chart Review

BACKGROUND

More than 55 000 children die annually in the United States, most in neonatal and pediatric intensive care units. Because of the stress and emotional turmoil of the deaths, the children's parents have difficulty comprehending information.

OBJECTIVES

To compare parents' reports and hospital chart data on cause of death and examine agreement on cause of death according to parents' sex, race, participation in end-of-life decisions, and discussion with physicians; deceased child's age; unit of care (neonatal or pediatric); and hospital and intensive care unit lengths of stay.

METHODS

A descriptive, correlational design was used with a structured interview of parents 1 month after the death and review of hospital chart data. Parents whose children died in intensive care were recruited from 4 South Florida hospitals and from Florida Department of Health death records.

RESULTS

Among 230 parents, 54% of mothers and 40% of fathers agreed with the chart cause of death. Agreement did not differ significantly for mothers or fathers by race/ethnicity, participation in end-of-life decisions, discussions with physicians, or mean length of hospital stay. Agreement was better for mothers when the stay in the intensive care unit was the shortest. Fathers' agreement with chart data was best when the deceased was an infant and death was in the pediatric intensive care unit.

CONCLUSIONS

Death of a child is a time of high stress when parents' concentration, hearing, and information processing are diminished. Many parents have misconceptions about the cause of the death 1 month after the death.

Parent Spirituality, Grief, and Mental Health at 1 and 3 Months After Their Infant's/Child's Death in an Intensive Care Unit

The death of an infant/child is one of the most devastating experiences for parents and immediately throws them into crisis. Research on the use of spiritual/religious coping strategies is limited, especially with Black and Hispanic parents after a neonatal (NICU) or pediatric intensive care unit (PICU) death.

PURPOSE

The purpose of this longitudinal study was to test the relationships between spiritual/religious coping strategies and grief, mental health (depression and post-traumatic stress disorder) and personal growth for mothers and fathers at 1 (T1) and 3 (T2) months after the infant's/child's death in the NICU/PICU, with and without control for race/ethnicity and religion.

RESULTS

Bereaved parents' greater use of spiritual activities was associated with lower symptoms of grief, mental health (depression and post-traumatic stress), but not post-traumatic stress in fathers. Use of religious activities was significantly related to greater personal growth for mothers, but not fathers.

CONCLUSION

Spiritual strategies and activities helped parents cope with their grief and helped bereaved mothers maintain their mental health and experience personal growth.

Health and Functioning in Grandparents After a Young Grandchild's Death

This cross-sectional study examined the physical and mental health, grief and role functioning of 136 grandparents in the first year after death of their young grandchild (newborn through 6 years). Grandparents were 36-77 years old; 73% female; 24% Hispanic, 38% Black/African American, and 38% White. Mean age of the 115 deceased grandchildren was 12.8 months (SD = 20.71) with 37% <1 month old; 65% were male, 77% died in the hospital. Grandparents were recruited through state death records and interviewed by telephone. Grandparents experienced: clinical depression (31%), PTSD (35%); illnesses (28%), hospitalizations, new chronic health conditions (mental disorders, hypertension, angina, cancer), and medication changes. Grandparents who provided care for the deceased grandchild had more intense symptoms of grief, depression and PTSD and more trouble focusing at their jobs. Severity of depressive and/or PTSD symptoms were more likely to be at clinically important levels for grandparents who had provided childcare for the deceased grandchild than for non-caregiving grandparents. Black grandparents had more severe symptoms of PTSD and thought more about their deceased grandchild on the job than White grandparents. The interaction effect of race/ethnicity and provision of child care was significant for PTSD and Blame and Anger. Hispanic grandparents who provided some child care for their deceased grandchild had less severe PTSD symptoms than caregiving Black and White grandparents. Caregiving Hispanic grandparents also experienced less Blame and Anger than White caregiving grandparents.

Infant and child deaths: Parent concerns about subsequent pregnancies

PURPOSE

Examine parents' concerns about subsequent pregnancies after experiencing an infant or child death (newborn to 18 years).

DATA SOURCES

Thirty-nine semistructured parent (white, black, Hispanic) interviews 7 and 13 months post infant/child death conducted in English and/or Spanish, audio-recorded, transcribed, and content analyzed. Mothers' mean age was 31.8 years, fathers' was 39 years; 11 parents were white, 16 black, and 12 Hispanic.

CONCLUSIONS

Themes common at 7 and 13 months: wanting more children; fear, anxiety, scared; praying to God/God's will; thinking about/keeping the infant's/child's memory and at 7 months importance of becoming pregnant for family members; and at 13 months happy about a new baby. Parents who lost a child in neonatal intensive care unit (NICU) commented more than those who lost a child in pediatric intensive care unit (PICU). Black and Hispanic parents commented more on praying to God and subsequent pregnancies being God's will than white parents.

IMPLICATIONS FOR PRACTICE

Loss of an infant/child is a significant stressor on parents with documented negative physical and mental health outcomes. Assessing parents' subsequent pregnancy plans, recognizing the legitimacy of their fears about another pregnancy, discussing a plan should they encounter problems, and carefully monitoring the health of all parents who lost an infant/child is an essential practitioner role.

Physical activity and stress in adult Hispanics

PURPOSE

Physical inactivity and obesity are major U.S. health concerns. Hispanics have higher rates of obesity and lower incidence of meeting physical activity (PA) recommendations, however most studies on PA focus on non-Hispanic Whites. This study examined type and amount of physical activities, and their relationship to age, BMI, employment, and stress in adult female Hispanics.

DATA SOURCES

Sixty-three female Hispanics (mean age 34 years, SD = 10.5) were recruited in the Miami community. By BMI, of 47 women reporting both weight and height, 8.5% were underweight, 38.3% were normal weight, 27.2% were overweight, and 26.0% were obese. Women completed two instruments measuring PA and two measuring stress.

CONCLUSIONS

Attitudes toward PA were positive; greatest concerns were job security and finances not exercise. Leisure walking (14.3%) was the most common type of PA followed by activities watching TV (32.8%) and using video games (32.8%). Women with greater stress had higher BMIs and were less physically active (p < .05).

IMPLICATIONS FOR PRACTICE

In this sample, exercise was not a main priority although 53% were overweight/obese. Stress related to employment and finances was a major concern. Interventions on stress reduction and incorporating exercise within their daily lives are important strategies.

Parent health and functioning 13 months after infant or child NICU/PICU death

BACKGROUND

After a child's death, parents may experience depression, posttraumatic stress disorder (PTSD), and increased risk for cancers, diabetes, psychiatric hospitalization, and suicide. Racial/ethnic differences are unknown. This longitudinal study investigated health and functioning of Hispanic, black, and white parents through 13 months after NICU/PICU death.

METHODS

Parents (176 mothers, 73 fathers) of 188 deceased infants/children were recruited from 4 NICUs, 4 PICUs, and state death certificates 2 to 3 weeks after death. Deaths occurred after limiting treatment/withdrawing life support (57%), unsuccessful resuscitation (32%), or brain death (11%). Data on parent physical health (hospitalizations, chronic illness), mental health (depression, PTSD, alcohol use), and functioning (partner status, employment) were collected in the home at 1, 3, 6, and 13 months after death.

RESULTS

Mean age for mothers was 32 ± 8, fathers 37 ± 9; 79% were Hispanic or black. Thirteen months after infant/child death, 72% of parents remained partnered, 2 mothers had newly diagnosed cancer, alcohol consumption was below problem drinking levels, parents had 98 hospitalizations (29% stress related) and 132 newly diagnosed chronic health conditions, 35% of mothers and 24% of fathers had clinical depression, and 35% of mothers and 30% of fathers had clinical PTSD. At 6 months after infant/child death, 1 mother attempted suicide. Week 1 after infant/child death, 9% of mothers and 32% of fathers returned to employment; 7 parents took no time off. More Hispanic and black mothers than white mothers had moderate/severe depression at 6 months after infant/child death and PTSD at every time point.

CONCLUSIONS

Parents, especially minority mothers, have negative physical and mental health outcomes during the first year after NICU/PICU death.

Preschool children with head injury: comparing injury severity measures and clinical care

The purpose of this study was to compare child, hospital course, and discharge characteristics by admitting unit, injury type, head Abbreviated Injury Scale (AIS), and Glasgow Coma Scale (GCS), and test congruence of AIS and GCS categories. Chart data were collected from seven hospitals on 183 preschool children with head injury (90 admitted to PICU, 93 to general care unit). Injury events included falls (n = 89, 49%), hit by car (n = 35, 19%), motor vehicle crashes (n = 26, 14%), bicycle crashes (n = 12, 7%), and blunt traumas (n = 21, 11%). Most children (68%) had head injuries only, 20% had other fractures, 5% had organ damage, and 7% had all three. Injury severity was measured by head AIS and GCS scores. Treatments and procedures included tubes/lines, blood/blood products, and medications. Children with head injuries only had fewer hospital days, less severe head injuries, and near normal GCS scores. They were less likely to have tubes/lines and medications. Children were discharged with medications (61%) and medical equipment (14%). Five children were discharged to long-term care facilities, and five were discharged to rehabilitation facilities. Concordance of head AIS and GCS categories occurred for only 50 (28%) children. Although the GCS is the gold standard for identifying changes in neurological status, it was not as helpful in representing hospital care. Head AIS injury categories clustered children in more homogeneous groups and better represented hospital care. Head AIS categories are better indicators of injury severity and care provided than GCS. Head injury AIS score may be an important addition to GCS for guiding care.

Parents' report of child's response to sibling's death in a neonatal or pediatric intensive care unit

BACKGROUND

Research on sibling death in a pediatric/neonatal intensive care unit is limited, despite many qualitative differences from deaths at home or in hospitals' general care areas and has overlooked cultural differences.

OBJECTIVES

To describe parents' reports of children's responses to a sibling's death in a neonatal or pediatric intensive care unit via qualitative interviews at 7 months after the death. Methods English-speaking (n = 19) and Spanish-speaking (n = 8) parents of 24 deceased infants/children described responses of their 44 surviving children: 10 preschool, 19 school-age, and 15 adolescent. Parents' race/ethnicity was 48% black, 37% Hispanic, 15% white. Ten siblings died in the neonatal unit and 14 in the pediatric intensive care unit. Semistructured interviews in parents' homes were audio recorded, transcribed verbatim, and analyzed with content analysis.

RESULTS

Six themes about surviving children emerged. Changed behaviors were reported by parents of school-age children and adolescents. Not understand what was going on was reported primarily by parents of preschoolers. Numbers of comments in the 4 remaining themes are as follows: maintaining a connection (n = 9), not having enough time with their siblings before death and/or to say goodbye (n = 6), believing the sibling is in a good place (n = 6), not believing the sibling would die (n = 4). Comments about girls and boys were similar. White parents made few comments about their children compared with black and Hispanic parents. The pattern of comments differed by whether the sibling died in the neonatal or the pediatric intensive care unit.

CONCLUSIONS

Children's responses following a sibling's death vary with the child's sex, parents' race/ethnicity, and the unit where the sibling died. Children, regardless of age, recognized their parents' grief and tried to comfort them.

The impact of interprofessional collaboration on the effectiveness, significance, and future of advanced practice registered nurses

Interprofessional collaboration was essential for the conduct of research that demonstrated the effectiveness and significance of advanced practice registered nurses (APRNs) in providing care, in reducing health care costs, and in developing innovative models of care for the nation's citizens. If the 2010 Affordable Care Act is to be implemented, APRNs, with their expertise and numbers, are essential to its implementation. Continued interdisciplinary collaboration is needed to expand the scope of APRN state practice regulations, to change reimbursement for APRN services, and to mute opposition to these changes by medical organizations.

Outcomes of an asthma program: Healthy Children, Healthy Homes

PURPOSE

To test the effects of the Healthy Children Healthy Homes program on community perception of susceptibility and severity of asthma, knowledge of common household asthma triggers, misconceptions about asthma, and reported behaviors to control asthma triggers.

DESIGN

Quasi experimental study with pre-post survey conducted in English and Spanish.

LOCATION

Catholic elementary school community in northern Miami, Florida. SELECTION AND SAMPLE: Convenience sample of 15 Asthma Amigo participants, and pre-post survey sample of 100 parents, teachers, and school staff.

INTERVENTION

Program consists of two 90-minute educational sessions with Asthma Amigos, 8-week diffusion of asthma information in the community, educational sessions with 276 school children (grades 1 to 8), and an asthma fair.

FINDINGS

Compared to pre-intervention, post-intervention data indicated significantly greater perceived asthma susceptibility and knowledge about common household triggers and fewer asthma misconceptions.

CONCLUSIONS

Healthy Children Healthy Homes program can be a valuable tool in asthma prevention and management.

The experience of being an Asthma Amigo in a program to decrease asthma episodes in Hispanic children

Asthma is the most common chronic illness among Latino children in urban areas. It is especially problematic for schools serving low-income and minority populations. The purpose of this study was to describe the experience of being an Asthma Amigo, a community-based educator who delivered asthma education to a Hispanic community in a train-the-trainer educational model. Focus group process evaluation was used to assess participant experiences and program strengths and weaknesses. Findings suggested that being an Asthma Amigo helped in gaining entrée into the community and in spreading the message of asthma triggers and prevention.

Women with high-risk pregnancies, problems, and APN interventions

PURPOSE

To (a) describe women's prenatal and postpartum problems and advanced practice nurses (APN) interventions; and (b) determine if problems and APN interventions differed by women's medical diagnosis (diabetes, hypertension, preterm labor).

DESIGN AND METHODS

Content analysis of 85 interaction logs created by APNs during a randomized clinical trial in which half of physician-provided prenatal care was substituted with APN-provided prenatal care in the women's homes. Patients' problems and APN interventions were classified with the Omaha Classification System.

FINDINGS

A total of 212,835 health problems and 212,835 APN interventions were identified. The dominant antenatal problems were physiologic (59.2%) and health-related behaviors (33.3%); postpartum were physiologic (44.0%) and psychosocial problems (31.6%). Antenatally, women with diabetes had significantly more health-related behavior problems; women with preterm labor had more physiologic problems. APN surveillance interventions predominated antenatally (65.6%) and postpartum (66.0%), followed by health teaching, guidance, and counseling both antenatally (25.4%) and postpartum (28.1%). Women with chronic hypertension required significantly more case-management interventions.

CONCLUSIONS

The categories of women's problems were largely similar across medical diagnostic groups. Interventions to address women's problems ranged from assessing maternal and fetal physiologic states to teaching interpersonal relationships and self-care management to assisting with transportation and housing. Data show the range of APN knowledge and skills needed to improve maternal and infant outcomes and ultimately reduce healthcare costs in women with high-risk pregnancies.

Psychometric Properties of Spanish Versions of the FACES II and Dyadic Adjustment Scale

Although Hispanic Americans are one of the fastest growing ethnic populations in the United States, use and psychometric testing of Spanish versions of two instruments commonly used to measure quality of the couple’s relationship and family functioning, the Dyadic Adjustment Scale (DAS) and the FACES II, have not been reported. The purpose of this study was to test the psychometric properties of the newly translated Spanish version of these two instruments. In this bilingual sample of 78 adults, internal consistencies were acceptable (.72 to .77 for the FACES II; .67 to .93 for the DAS) and test-retest correlations were high (.80 to .88 FACES II; .79 to .87 DAS). Correlations between the Spanish and English versions were also high (.87 to .94 FACES II; .91 to .99 DAS). Psychometric findings support the reliability and validity of the Spanish versions of these newly translated measures.

Pediatric head trauma: parent, parent-child, and family functioning 2 weeks after hospital discharge

OBJECTIVE

To investigate effects of pediatric head trauma on parent mental health, parent-child relationship and family functioning 2 weeks after discharge.

METHODS

Ninety-seven mothers and 37 fathers of 106 preschool children hospitalized with head injury completed Mental Health Inventory (MHI), Parenting Stress Index, Family Adaptability and Cohesion Evaluation Scales II (FACES II) and Multidimensional Scale of Perceived Social Support (MSPSS) 2 weeks after discharge, and perceived injury severity, Parental Concerns Scale (PCS), Parental Stressors Scale: Pediatric Intensive Care Unit (PSS: PICU), and MHI 24-48 h after hospital admission.

RESULTS

Mental health after discharge was related to social support and baseline mental health. Mothers' parental distress was related to perceived injury severity and social support. Greater family cohesion was related to baseline mental health, social support, and being in a two-parent family for mothers, and to social support for fathers.

CONCLUSIONS

Parents' mental health and social support were important for parent mental health and family cohesion after discharge. Perceived injury severity and parent reactions to hospitalization also played a role.

Nurse Dose as a Concept

PURPOSE

To describe the concept of Nurse Dose.

METHODS

The concept of nurse dose has been identified from decades of clinical research as a concept essential in the delivery of safe and high quality health care. The components of nurse dose were conceptualized through review of the literature from nursing, medicine, and health services research.

FINDINGS

Nurse dose is conceptualized as having three equally essential components: dose, nurse, and host and host response. Dose in the macro view includes the number of nurses per patient or per population in cities, states, regions, or countries. Dose in a micro view includes the amount of nurse time and the number of contacts. The nurse component consists of the education, expertise, and experience of the nurse. Host is represented by an organization and its characteristics (culture, autonomy, practice control) in a macro view and by the patient and characteristics (beliefs, values, culture) in a micro view. Host response includes response to the autonomy and acceptability of the nurse.

CONCLUSIONS

Greater nurse dose has been associated with decreases in patient mortality, morbidity, and healthcare costs.

Cross-cultural beliefs, ceremonies, and rituals surrounding death of a loved one

The purpose of this qualitative study was to describe practices surrounding death of a loved one by European, Asian, Caribbean, Central American, and South American families living in the United States. A focus group with 14 masters nursing students from a wide variety of cultural and religious backgrounds was conducted to gain a better understanding of the beliefs, ceremonies, and rituals surrounding death. Many commonalties were found across cultures and religions. A pervasive theme was that beliefs about the soul of the deceased lead families to perform rituals and ceremonies that foster passage to God, the "light," or another life. The stronger their beliefs, the more dedicated the family is in completing the rituals and ceremonies in the way dictated by their religion or culture. Participants had difficulty separating the influence of culture and religion on these practices.

Parents' reactions at 24-48 hrs after a preschool child's head injury

OBJECTIVES

Our objectives were, first, to compare mothers' and fathers' early reactions (stressors, concerns) to the preschool child's head injury, their perceptions of the child's injury severity, and their social support and mental health; second, to compare families with a child in the pediatric intensive care unit (PICU) vs. general care unit (GCU) on these variables; and third, to describe the relationships between parents' early reactions and perceived and objective injury severity, their social support, and mental health.

DESIGN

Analysis of data collected in the hospital 24-48 hrs after the child's admission as part of a longitudinal study of parent and family functioning after a preschool child's head injury.

SETTING

Seven tertiary care centers: three free-standing children's hospitals and four comprehensive hospitals.

PARTICIPANTS

Participants were 182 mothers and 64 fathers of 183 preschool children (ages 3-6) hospitalized for head injury, half in a PICU.

INTERVENTIONS

Data collection.

MEASUREMENTS AND MAIN RESULTS

We measured parents' early reactions (stressors, concerns), influenced by parent mental health, social support, and objective and perceived injury severity. Mothers reported more stress than fathers regarding the child's behavior and emotions, communication with staff, and their parental role. Mothers in the PICU group reported more concern about the child's future and more stress regarding the child's appearance, sights and sounds of the unit, and procedures done to the child than mothers in the GCU group. Fathers in the PICU and GCU groups reported similar levels of stress and concern. Mothers' reactions were influenced by objective and perceived injury severity, social support, and psychological distress. Fathers' reactions were influenced by objective injury severity and psychological distress.

CONCLUSIONS

Although mother-father couples rated their child's injury severity similarly, mothers experienced more stress than fathers. Social support decreased the stress for mothers but not for fathers. The experience of pediatric head trauma was more stressful for mothers of children in the PICU than mothers of children in the GCU.

Child care use by low-income single mothers of preschoolers born preterm versus those of preschoolers born full term

This study describes prewelfare reform child care use by 64 primarily low-income single mothers (65.6% African American) with preschoolers (half born preterm). Forty percent used child care for more than 75% of their children's lives, 20% did when not employed. Preschool children born preterm were more likely to receive child care from nonrelatives throughout their lives than children born full term. Children with health problems used a greater number of child care arrangements. Findings suggest addressing child care issues with both employed and nonemployed mothers and adequacy of child care for children with special needs.

The cost of prematurity: hospital charges at birth and frequency of rehospitalizations and acute care visits over the first year of life: a comparison by gestational age and birth weight

The proportion of preterm and low-birth-weight infants has been growing steadily for two decades. Most of the more than US 10 billion dollars spent on neonatal care in the United States in 2003 was spent on the 12.3% of infants who were born preterm. Research has shown higher initial hospital costs and a higher rate of acute care visits and rehospitalization for preterm and low-birth-weight infants, but only a limited number of studies of the cost of prematurity that follow infants through the first year of life have been conducted. This study is a secondary analysis of data on a subset of infants drawn from a randomized clinical trial that examined health outcomes and health care costs in women with high-risk pregnancies and their infants. For the current study, a sample of 84 singleton infants was chosen. Forty-three infants (51%) were full term (37 weeks' gestation or more) and 41 (49%) were born preterm (less than 37 weeks' gestation). Fifty-five infants (65.5%) were born at normal birth weights (2,500 g or greater), 24 (28.5%) were born at low birth weights (1,501 to 2,499 g), and five (6%) were born at very low birth weights (less than 1,500 g). Data on the initial hospital charges and the rates of rehospitalization and acute care visits in the first year of life in relation to gestational age and birth weight were collected. The results clearly demonstrated that the charges for initial hospitalizations increased as birth weights and gestational ages decreased. Low-birth-weight infants were less likely to have unscheduled acute care visits than normal-birth-weight infants. Interventions to improve prenatal care targeted to women at high risk for delivering preterm or low-birth-weight infants would reduce health care costs and improve health outcomes of infants as well.

A Comparison of Maternal Attachment between American Adolescent and Adult Mothers of Preschoolers

American adolescent mothers have been viewed as less effective parents than adult mothers. The socioeconomic disadvantages of adolescent mothers should be taken into account. The objectives of this study were to compare maternal attachment between adolescent and adult mothers of preschoolers and to examine changes of adolescents' maternal attachment over time. A secondary analysis of data from a larger study of maternal employment and low birth weight infant outcomes were used. Data were collected through home visits using structured questionnaires at two different time points. Forty-three pairs of adolescent and adult mothers who could be matched on family structure, maternal race, and child's gestational status were compared on maternal attachment. The 7-item Attachment subscale of the Parenting Stress Index was used to measure maternal attachment. Results revealed that the adolescent mothers were not less attached to their preschoolers than the adults. This held true when important confounding factors were taken into account using multiple regression.

South Florida: a national microcosm of diversity and health disparities

South Florida is a microcosm of diversity that reflects a changing national population. The purpose of this paper is to examine some common health status indicators in the four counties that comprise South Florida. The researchers look at birthweight, neonatal and infant death rates, receipt of prenatal care, major causes of death, availability of health care facilities and services, and expenditures for health. Data indicate that, of the four counties, the most affluent has the worst health indicators, and the least affluent--with the highest proportion of minority residents--has some of the best health status indicators. The researchers provide implications for practitioners and future research.

Patient problems, advanced practice nurse (APN) interventions, time and contacts among five patient groups

PURPOSE

To describe patient problems and APN interventions in each of five clinical trials and to establish links among patient problems, APN interventions, APN time and number of contacts, patient outcomes, and health care costs.

DESIGN AND METHODS

Analysis of 333 interaction logs created by APNs during five randomized controlled trials: (a) very low birthweight infants (n = 39); (b) women with unplanned cesarean birth (n = 61), (c) high-risk pregnancy (n = 44), and (d) hysterectomy (n = 53); and (e) elders with cardiac medical and surgical diagnoses (n = 139). Logs containing recordings of all APN interactions with participants, APN time and type of patient contact were content analyzed with the smallest phrase or sentence representing a "unit." These units were then classified using the Omaha Classification System to determine patient problems and APN interventions. Groups were compared concerning total amount of APN time, number of contacts per patient, and mean length of time per APN contact. All studies were conducted in the United States.

FINDINGS

Groups with greater mean APN time and contacts per patient had greater improvements in patients' outcomes and greater health care cost savings. Of the 150,131 APN interventions, surveillance was the predominant APN function in all five patient groups. Health teaching, guidance, and counseling was the second most frequent category of APN intervention in four of the five groups. In all five groups, treatments and procedures accounted for < 1% of total APN interventions. Distribution of patient problems (N = 150,131) differed across groups reflecting the health care problems common to the group.

CONCLUSIONS

Dose of APN time and contacts makes a difference in improving patient outcomes and reducing health care costs. Skills needed by APNs in providing transitional care include well-developed skills in assessing, teaching, counseling, communicating, collaborating, knowing health behaviors, negotiating systems, and having condition-specific knowledge about different patient problems.

Institutional research responsibilities and needed infrastructure

PURPOSE

To describe research grantee institutions' responsibilities to the funding agencies, research participants, and investigators, and the infrastructure and resources necessary for successful completion of funded research projects.

ORGANIZING FRAMEWORK

Grants management includes investigator access to institutional and school infrastructure and resources, oversight and monitoring of the implementation of the research, and strategies to maximize research yield while stretching research dollars.

CONCLUSIONS

Grantee institutions are responsible for overseeing the conduct of research, protecting rights of research participants, safety of study personnel, monitoring conflict of interest, fiscal management, access to data, and disseminating study findings. Central and school departments that provide needed services are important infrastructure supports. In addition to research space and investigator time, senior research mentors and research administrators are the most valuable resources for research success.

Identification of sleep-disordered breathing in children: variation with event definition

STUDY OBJECTIVES

To determine the effect of varying approaches to the measurement of the respiratory disturbance index (RDI) on identification of sleep disordered breathing (SDB) in children.

DESIGN

Cross-sectional study of SDB in a well-characterized birth cohort (stratified for term and preterm birth) participating in longitudinal studies of cognition and behavior.

SETTING

Community-based; overnight studies conducted in participant's homes.

PARTICIPANTS

433 children, ages 8-11 years, un-referred for clinical assessment of SDB.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Participants underwent unattended overnight in-home recording of respiratory inductance plethysmography, pulse oximetry, body position, and heart rate. The relationships among RDIs derived from various definitions of apnea and hypopneas and thresholds for frequency of events were assessed. Median RDI varied by more than 20-fold for definitions using the more liberal criteria for event definition (all respiratory events; i.e., central or obstructive events and hypopneas with no requirement for associated desaturation) to the most conservative definition (using obstructive apneas only or obstructive apnea and hypopneas requiring a 5% associated desaturation). Prevalence estimates for SDB based on RDIs that included central apneas were 40% to 140% higher than those that excluded central apneas.

CONCLUSIONS

Different approaches for quantifying RDI contribute to substantial variability in identification and classification of SDB in children and will lead to discrepant estimates of its presence and severity.

High-risk pregnancy: postpartum rehospitalization

OBJECTIVE

Examine frequency, timing, and reasons for maternal postpartum rehospitalizations and acute care visits 1 year postpartum after a high-risk pregnancy.

STUDY DESIGN

Secondary analysis of data collected during a randomized clinical trial of advanced practice nurses gives transitional care for women with high-risk pregnancies. The 171 women were primarily African American, never married, Medicaid eligible, diagnosed with pregestational diabetes (20), gestational diabetes (23), either diagnosed (48) or at risk (44) for preterm labor, and chronic hypertension (36).

RESULTS

Of the total rehospitalizations (17%) and acute care visits (32%), over one third occurred in the first 8 weeks postpartum. Chronic hypertensives and gestational diabetics had the highest rate of rehospitalization and proportion of acute care visits. Six women were rehospitalized for subsequent pregnancies.

CONCLUSION

Women with high-risk pregnancies have continued high health care resource use over the first postpartum year demonstrating the need for more intensive patient education and follow-up to improve outcomes and reduce resource use.

Lessons learned from testing the quality cost model of Advanced Practice Nursing (APN) transitional care

PURPOSE

To describe the development, testing, modification, and results of the Quality Cost Model of Advanced Practice Nurses (APNs) Transitional Care on patient outcomes and health care costs in the United States over 22 years, and to delineate what has been learned for nursing education, practice, and further research.

ORGANIZING CONSTRUCT

The Quality Cost Model of APN Transitional Care.

METHODS

Review of published results of seven randomized clinical trials with very low birth-weight (VLBW) infants; women with unplanned cesarean births, high risk pregnancies, and hysterectomy surgery; elders with cardiac medical and surgical diagnoses and common diagnostic related groups (DRGs); and women with high risk pregnancies in which half of physician prenatal care was substituted with APN care. Ongoing work with the model is linking the process of APN care with the outcomes and costs of care.

FINDINGS

APN intervention has consistently resulted in improved patient outcomes and reduced health care costs across groups. Groups with APN providers were rehospitalized for less time at less cost, reflecting early detection and intervention. Optimal number and timing of postdischarge home visits and telephone contacts by the APNs and patterns of rehospitalizations and acute care visits varied by group.

CONCLUSIONS

To keep people well over time, APNs must have depth of knowledge and excellent clinical and interpersonal skills that are the hallmark of specialist practice, an in-depth understanding of systems and how to work within them, and sufficient patient contact to effect positive outcomes at low cost.

Evidence-based nursing practice: why is it important?

Evidence-based practice has gained momentum in nursing, and definitions vary widely. Research findings, knowledge from basic science, clinical knowledge, and expert opinion are all considered "evidence"; however, practices based on research findings are more likely to result in the desired patient outcomes across various settings and geographic locations. The impetus for evidence-based practice comes from payor and healthcare facility pressures for cost containment, greater availability of information, and greater consumer savvy about treatment and care options. Evidence-based practice demands changes in education of students, more practice-relevant research, and closer working relationships between clinicians and researchers. Evidence-based practice also provides opportunities for nursing care to be more individualized, more effective, streamlined, and dynamic, and to maximize effects of clinical judgment. When evidence is used to define best practices rather than to support existing practices, nursing care keeps pace with the latest technological advances and takes advantage of new knowledge developments.

A randomized trial of nurse specialist home care for women with high-risk pregnancies: outcomes and costs

OBJECTIVE

To examine prenatal, maternal, and infant outcomes and costs through 1 year after delivery using a model of prenatal care for women at high risk of delivering low-birth-weight infants in which half of the prenatal care was provided in women's homes by nurse specialists with master's degrees.

STUDY DESIGN

Randomized clinical trial.

PATIENTS AND METHODS

A sample of 173 women (and 194 infants) with high-risk pregnancies (gestational or pregestational diabetes mellitus, chronic hypertension, preterm labor, or high risk of preterm labor) were randomly assigned to the intervention group (85 women and 94 infants) or the control group (88 women and 100 infants). Control women received usual prenatal care. Intervention women received half of their prenatal care in their homes, with teaching, counseling, telephone outreach, daily telephone availability, and a postpartum home visit by nurse specialists with physician backup.

RESULTS

For the full sample, mean maternal age was 27 years; 85.5% of women were single mothers, 36.4% had less than a high school education, 93.6% were African American, and 93.6% had public health insurance, with no differences between groups on these variables. The intervention group had lower fetal/infant mortality vs the control group (2 vs 9), 11 fewer preterm infants, more twin pregnancies carried to term (77.7% vs 33.3%), fewer prenatal hospitalizations (41 vs 49), fewer infant rehospitalizations (18 vs 24), and a savings of more than 750 total hospital days and $2,496,145 [corrected].

CONCLUSION

This model of care provides a reasoned solution to improving pregnancy and infant outcomes while reducing healthcare costs.

Effects of maternal employment and prematurity on child outcomes in single parent families

BACKGROUND

Effects of maternal employment for preschool children vary based on specific characteristics of the mother's employment, the family's economic status, and the mother's attitudes about employment. However, there is limited research on a growing group of children at developmental risk-those born prematurely and living in a single-parent family.

OBJECTIVE

To examine the effects of maternal employment and prematurity on child cognition and behavior in single-parent families.

METHODS

Sixty preterm and 61 full-term preschool children were recruited through NICU admission records and birth records. Data were collected with the Kaufmann Assessment Battery for Children, Peabody Picture Vocabulary Test, Child Behavior Checklist, Parenting Stress Index, and the Life History Calendar.

RESULTS

Greater hours employed was related to higher achievement and mental processing scores only. Less discrepancy between actual and desired employment was related to higher achievement, mental processing, and language scores and lower behavior scores. Prematurity was not related to child cognitive and behavioral performance. Only the relationship between discrepancy and language remained after statistical control.

CONCLUSIONS

The concerns about negative effects of maternal employment on young children may be overstated, especially in low-income, single-mother families. These findings are especially important in the context of welfare reform.