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

BACKGROUND

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

METHODS

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

CONCLUSIONS

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

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

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

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

REVIEW REGISTRATION

Open Science Framework osf.io/2rek9.

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

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

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

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

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

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

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

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

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

OBJECTIVE

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

DESIGN

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

SAMPLE

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

PARTICIPANTS AND SETTING

Forty-seven public health nurses across BC.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021245240.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Social Organization of Neonatal Nurses' Feeding Work

PURPOSE

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

SAMPLE

Five primary informants; 18 secondary informants.

DESIGN

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

MAIN OUTCOME

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

RESULTS

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

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

OBJECTIVE

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

INCLUSION CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Non-pharmacological care for opioid withdrawal in newborns

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

Values are not enough: qualitative study identifying critical elements for prioritization of health equity in health systems

Background

Health system policies and programs that reduce health inequities and improve health outcomes are essential to address unjust social gradients in health. Prioritization of health equity is fundamental to addressing health inequities but challenging to enact in health systems. Strategies are needed to support effective prioritization of health equity.

Methods

Following provincial policy recommendations to apply a health equity lens in all public health programs, we examined health equity prioritization within British Columbia health authorities during early implementation. We conducted semi-structured qualitative interviews and focus groups with 55 senior executives, public health directors, regional directors, and medical health officers from six health authorities and the Ministry of Health. We used an inductive constant comparative approach to analysis guided by complexity theory to determine critical elements for prioritization.

Results

We identified seven critical elements necessary for two fundamental shifts within health systems. 1) Prioritization through informal organization includes creating a systems value for health equity and engaging health equity champions. 2) Prioritization through formal organization requires explicit naming of health equity as a priority, designating resources for health equity, requiring health equity in decision making, building capacity and competency, and coordinating a comprehensive approach across levels of the health system and government.

Conclusions

Although creating a shared value for health equity is essential, health equity - underpinned by social justice - needs to be embedded at the structural level to support effective prioritization. Prioritization within government and ministries is necessary to facilitate prioritization at other levels. All levels within health systems should be accountable for explicitly including health equity in strategic plans and goals. Dedicated resources are needed for health equity initiatives including adequate resourcing of public health infrastructure, training, and hiring of staff with equity expertise to develop competencies and system capacity.

What Is Missing from "Patient-Oriented Research?" A View from Public Health Systems and Services

Patient-oriented research (POR) aims to increase patient engagement in health research to improve health research and health services. In Canada, the Strategies for Patient-Oriented Research (SPOR) framework provides guidance for conducting POR. We critically review the SPOR framework through the lens of public health systems and services research. The SPOR framework is primarily focused on engaging individual patients in health research without attention to broader structural forces that shape health and participation in healthcare systems. Shifting from patient to public involvement and from patient to community engagement and being explicit about the range of health research that SPOR encompasses would enhance the framework and strengthen the potential of SPOR to improve health systems through health protection, promotion and prevention of disease and injury.

Characteristics of the collaborative learning unit practice education model for undergraduate nursing students: a scoping review protocol

What evidence on characteristics and processes of the collaborative learning unit practice education model for undergraduate nursing students is available?

Bibliometric and Textual Analysis of Historical Patterns in Maternal–Infant Health and Nursing Issues in The Canadian NurseJournal, 1905–2015

Study background

Journals are key learning mechanisms for nursing organizations. Analysis of publications provides opportunities to explore influences, priorities, and perspectives of nurses over time.

Purpose

To identify historical trends in maternal–infant health and nursing practice.

Methods

Historical bibliometric and content analysis of articles in The Canadian Nurse, 1905–2015. Six hundred sixty-eight lead publications in the journal were identified. Data were extracted on authorship, writing style, geographical distribution, and language, and content themes were determined.

Results

Five hundred twenty-five publications were written by nurses, and 272 came from the Ontario and Quebec. Nine key content areas were identified, including changing families, women’s bodies, prenatal care, birth care, postpartum care, when things go wrong, and keeping babies healthy. The number of maternal–infant publications in this national journal has been decreasing since the emergence of specialty journals.

Conclusion

Advances in perinatal nursing practice over the past 115 years in Canada reflect emerging scientific developments and evolving social values. These articles traced the medicalization and reclamation of pregnancy and childbirth, the shifting role of nurses in relation to other health and social care providers, and the impact of determinants of health on the well-being of mothers, infants, and families.

Neonatal abstinence syndrome in countries with no to low medical opioid consumption: a scoping review

AIM

To describe the current state of evidence on the care of neonates with neonatal abstinence syndrome in countries with low to virtually no medical opioid analgesic consumption.

BACKGROUND

While access to opioids for medical use improves globally, misuse grows as a health concern. One unintended consequence has been an increase in the incidence of neonatal abstinence syndrome. Because most evidence is generated in countries with adequate opioid analgesic consumption, a picture of evidence in lower opioid-consuming countries is not available.

DESIGN

A scoping review methodology was employed and augmented with principles of international development literature review. Electronic database searches (PubMed and CINAHL) located 1106 articles. Google was employed to access an additional 17 non-indexed articles. From the total of 1123 articles located, 27 articles from 15 countries were included.

RESULTS

Minimal evidence was produced in low to virtually no medical opioid-consuming countries. Sources were primarily review articles, descriptive, comparative or case reports. Seventy-one per cent of the articles identified at least one specific clinical practice related to the care of infants with neonatal abstinence syndrome.

CONCLUSIONS

As opioid analgesic use increases globally, a subsequent increase in neonatal abstinence syndrome is likely. It will be beneficial for providers and policymakers to be proactive in considering implications for neonatal and maternal populations and collaborate with providers who have been gaining experience in this area. A number of these countries are heroin-growing regions and already experiencing issues.

IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY

Policymakers may use these findings to support data collection and reporting, context and resource relevant guideline development, and advocacy for inclusion of the maternal-infant population in global opioid research priority setting. International collaboration for establishing gender and culturally appropriate practices globally is critical.

Rural Postpartum Women With Substance Use Disorders

The incidence of perinatal opioid use and neonatal withdrawal continues to rise rapidly in the face of the growing opioid addiction epidemic in the United States, with rural areas more severely affected. Despite decades of research and development of practice guidelines, maternal and neonatal outcomes have not improved substantially. This focused ethnography sought to understand the experience of accessing care necessary for substance use disorder recovery, pregnancy, and parenting. Personal accounts of 13 rural women, supplemented by participant observation and media artifacts, uncovered three domains with underlying themes: challenges of getting treatment and care (service availability, distance/geographic location, transportation, provider collaboration/coordination, physical and emotional safety), opportunities to bond (proximity, information), and importance of relationships (respect, empathy, familiarity, inclusion, interactions with care providers). Findings highlight the need for providers and policy makers to reduce barriers to treatment and care related to logistics, stigma, judgment, and lack of understanding of perinatal addiction.

Student and educator experiences of maternal-child simulation-based learning: a systematic review of qualitative evidence protocol

REVIEW QUESTION/OBJECTIVE

The overall aim of this systematic review is to identify the appropriateness and meaningfulness of maternal-child simulation-based learning for undergraduate or pre-registration nursing students in educational settings to inform curriculum decision-making.1. What are the experiences of nursing or health professional students participating in undergraduate or pre-licensure maternal-child simulation-based learning in educational settings?2. What are the experiences of educators participating in undergraduate or pre-licensure maternal-child simulation-based learning in educational settings?3. What teaching and learning practices in maternal-child simulation-based learning are considered appropriate and meaningful by students and educators?

BACKGROUND

Maternal-child care is one of the pillars of primary health care. Health promotion and illness/ injury prevention begin in the preconception period and continue through pregnancy, birth, the postpartum period and the childrearing years. Thus, lifelong wellness is promoted across the continuum of perinatal and pediatric care which influences family health and early child development. Registered nurses (RNs) are expected to have the knowledge and skills needed to provide evidence-based nursing with childbearing and child-rearing families to promote health and address health inequities in many settings, including inner city, rural, northern, indigenous and global communities. The Canadian Maternity Experiences survey and the Report by the Advisor on Healthy Children and Youth provide information on current shortages of perinatal and child health care providers and stress the importance of the role of nurses as providers of rural and remote care. From a global health perspective, continued concern with both perinatal and child health morbidities and mortalities highlight the importance of maintaining and strengthening the presence of maternal and child health learning opportunities within undergraduate nursing curriculum.Despite this importance, educators in many countries have acknowledged difficulties providing nursing students with maternal-child hospital learning experiencesdue to declining birth rates, women's changing expectations about childbirth (i.e. birth as an intimate experience), increased outpatient and community management of early childhood health conditions, and increased competition for clinical placements. Canadian nurse educators and practice leaders have also identified gaps in recent RN graduates' readiness to provide safe, competent and evidence-based care for childbearing and child-rearing families. Newly graduated RNs working in acute care hospitals and in rural/remote community practice settings report feeling unprepared for providing maternity, neonatal and early childhood care.Recent concerns about the clinical reasoning skills of new graduates and the link to poor patient outcomes (e.g. not recognizing deteriorating patients) have led to calls to reform nursing education. In the Carnegie report, Benner, Sutphen, Leonard and Day identified four essential themes needed in the thinking and approach to nursing education, including: (1) a shift in focus from covering decontextualized knowledge to "teaching for a sense of salience, situated cognition, and identifying action in particular clinical situations"; (2) better integration of classroom and clinical teaching; (3) more emphasis on clinical reasoning; and, (4) an emphasis on identity formation rather than socialization. Brown and Hartrick Doane propose that nurses need to draw on a range of knowledge that enhances the nurse's "sensitivity and ability to be responsive in particular moments of practice". Theoretical or decontextualized knowledge becomes a "pragmatic tool" used to improve nursing practice. Simulation has been identified as a promising pragmatic educational tool for practice learning that can be integrated with theoretical knowledge from nursing and other disciplines.Bland, Topping and Wood conducted a concept analysis and defined simulation in nursing education as:They also proposed that "simulated learning is a dynamic concept that deserves empirical evaluation not merely to determine its effects but to uncover its full potential as a learning strategy".Simulation usually involves student(s) providing nursing care to a simulated patient who might be a manikin or actor based on a standardized scenario. Following the experiential learning opportunity the scenario is debriefed and the clinical situation analyzed with opportunities for reflection on performance. In nursing education, simulation is usually used in a way that complements learning in practice settings. However simulation has also been used: to make up some clinical practice hours, to provide opportunities to practice and assess particular clinical skills, and for remedial learning when students encounter difficulties in practice settings. In addition simulation provides the opportunity to focus on quality and safety competencies (QSEN) that have been identified for nurses. New forms of simulation are being developed with multiple patients so that nursing students can learn to prioritize care needs and delegate care to other team members.Nurse educators have identified several advantages for learners using simulation, including: providing a safe environment to improve nursing competence, allowing learners to become more comfortable with receiving feedback about their clinical performance, providing consistent and comparable experiences for all students, and learning a mix of technical and non-technical skills including communication, teamwork and delegation. Within the Canadian context, students and instructors have reported positive learning experiences with simulation, particularly in understanding complex patient care scenarios, multidisciplinary team scenarios, team-based learning, and reflective debriefing. Furthermore, simulation technology has been proposed as a strategy for developing clinical reasoning skills, enhancing nurses' abilities to build upon previous knowledge and past experiences, and manage new or unfamiliar situations.Simulation has previously been integrated into nursing curricula in a "piecemeal" fashion that lacks an integrative pedagogy or theoretical approach. More recently a number of theoretical and pedagogical frameworks and best practice standards have been published. In April 2014 a preliminary search of literature (in CINAHL, Medline, Academic Search Complete and Web of Science) was conducted with guidance from our library specialist to test the search strategy and ensure that there would be enough qualitative findings to include in the systematic review. A preliminary scan of the abstracts from these searches demonstrated that many experiential case reports with qualitative findings were missed with the use of research limiters (including our search strategy specifically constructed to retrieve qualitative research) so the decision was made to err on the side of caution by searching more broadly and review a larger number of abstracts for inclusion in the study. However, a number of reports with qualitative findings were identified. For example, from a review of the abstracts from a CINAHL search dated April 17, qualitative research papers (including two dissertations), 12 evaluation study reports, six mixed methods studies and nine case reports with qualitative findings were identified. It is timely then to review qualitative studies to better understand the meaningfulness and appropriateness of integrating maternal-child simulation-based learning activities in undergraduate nursing education programs.A search of both the Cochrane Library of Systematic Reviews and the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports has been conducted. No systematic reviews of qualitative studies of maternal-child simulation-based learning for undergraduate or pre-registration nursing students in educational settings are evident in the literature. Although a systematic review of the meaningfulness and appropriateness of using human patient simulation manikins as a teaching and learning strategy in undergraduate nursing education had been planned and a protocol registered in October 2009, we learned from contacting the lead author that this systematic review was not completed. Currently little is known about how nursing students and/or educators have experienced maternal-child simulation or their understandings of the appropriateness and meaningfulness of particular simulation-based learning practices. Our proposed systematic review therefore fulfills all requirements for the PROSPERO database.

DEFINITIONS

For this review we will use the definition of "simulation-based learning experience" adopted by the International Nursing Association for Clinical Simulation and Learning (INACSL):We will include any use of simulation in an educational setting (with pre-registration or pre-licensure or undergraduate nursing or health professional students) with a focus relevant for maternal-child nursing.Maternal-child nursing has been variously defined in literature to include maternity care and pediatric nursing. For the purposes of this review, we will include perinatal, neonatal and pediatric contexts of care that focus on families with children under the age of five. We will exclude studies that focus on school age children, adolescents and/or youth.We have adapted an earlier definition of "appropriateness" as the "best conditions under which simulation can be integrated into undergraduate nursing education". In this review "meaningfulness" refers to the experiences and reflections of undergraduate nursing or health professional students and educators as presented in the studies reviewed.

Health Equity Talk: Understandings of Health Equity among Health Leaders

INTRODUCTION

Reducing health inequities is a stated goal of health systems worldwide. There is widespread commitment to health equity among public health leaders and calls for reorientation of health systems towards health equity. As part of the Equity Lens in Public Health (ELPH) program of research, public health decision makers and researchers in British Columbia collaborated to study the application of a health equity lens in a time of health system renewal. We drew on intersectionality, complexity and critical social justice theories to understand how participants construct health equity and apply a health equity lens as part of public health renewal.

METHODS

15 focus groups and 16 individual semi-structured qualitative interviews were conducted with 55 health system leaders. Data were analyzed using constant comparative analysis to explore how health equity was constructed in relation to understandings and actions.

RESULTS

Four main themes were identified in terms of how health care leaders construct health equity and actions to reduce health inequities: (1) population health, (2) determinants of health, and (3) accessibility and (4) challenges of health equity talk. The first three aspects of health equity talk reflect different understandings of health equity rooted in vulnerability (individual versus structural), determinants of health (material versus social determinants), and appropriate health system responses (targeted versus universal responses). Participants identified that talking about health equity in the health care system, either inside or outside of public health, is a 'challenging conversation' because health equity is understood in diverse ways and there is little guidance available to apply a health equity lens.

CONCLUSIONS

These findings reflect the importance of creating a shared understanding of health equity within public health systems, and providing guidance and clarity as to the meaning and application of a health equity lens. A health equity lens for public health should capture both the production and distribution of health inequities and link to social justice to inform action.

Student and educator experiences of maternal-child simulation-based learning: a systematic review of qualitative evidence

BACKGROUND

Although maternal-child care is a pillar of primary health care, there is a global shortage of maternal-child health care providers. Nurse educators experience difficulties providing undergraduate students with maternal-child learning experiences for a number of reasons. Simulation has the potential to complement learning in clinical and classroom settings. Although systematic reviews of simulation are available, no systematic reviews of qualitative evidence related to maternal-child simulation-based learning (SBL) for undergraduate nursing students and/or educators have been located.

OBJECTIVES

The aim of this systematic review was to identify the appropriateness and meaningfulness of maternal-child simulation-based learning for undergraduate nursing students and nursing educators in educational settings to inform curriculum decision-making. The review questions are: INCLUSION CRITERIA TYPES OF PARTICIPANTS: Pre-registration or pre-licensure or undergraduate nursing or health professional students and educators.

PHENOMENA OF INTEREST

Experiences of simulation in an educational setting with a focus relevant to maternal child nursing.

TYPES OF STUDIES

Qualitative research and educational evaluation using qualitative methods.

CONTEXT

North America, Europe, Australia and New Zealand.

SEARCH STRATEGY

A three-step search strategy identified published studies in the English language from 2000 until April 2016.

METHODOLOGICAL QUALITY

Identified studies that met the inclusion criteria were retrieved and critically appraised using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) by at least two independent reviewers. Overall the methodological quality of the included studies was low.

DATA EXTRACTION

Qualitative findings were extracted by two independent reviewers using JBI-QARI data extraction tools.

DATA SYNTHESIS

Findings were aggregated and categorized on the basis of similarity in meaning. Categories were subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings.

RESULTS

Twenty-two articles from 19 studies were included in the review. A total of 112 findings were extracted from the included articles. Findings were grouped into 15 categories created on the basis of similarity of meaning. Meta-synthesis of these categories generated three synthesized findings.Synthesized finding 1 Students experienced simulated learning experiences (SLE) as preparation that enhanced their confidence in practice. When simulation was being used for evaluation purposes many students experienced anxiety about the SLE.Synthesized finding 2 Pedagogical practices thought to be appropriate and meaningful included: realistic, relevant and engaging scenarios, a safe non-threatening learning environment, supportive guidance throughout the process, and integration with curriculum.Synthesized finding 3 Barriers and enablers to incorporating SLEs into maternal child education were identified including adequate resources, technological support and faculty development. Students and educators recognized that some things, such as relationship building, could not be simulated.

CONCLUSIONS

Students felt that simulation prepared them for practice through building their self-confidence related to frequently and infrequently seen maternal-child scenarios. Specific pedagogical elements support the meaningfulness of the simulation for student learning. The presence or absence of resources impacts the capacity of educators to integrate simulation activities throughout curricula.

A Grounded Theory of Mothering in the Early Years for Women Recovering From Substance Use

Women in recovery from addiction experience significant sociostructural barriers to reestablishing self, family, and home after having a baby. The aim of this grounded theory study was to describe pathways that women and their families followed and how transitions were experienced in the early years after receiving services through an integrated community-based maternity program. Eighteen women completed questionnaires and participated in a series of semistructured interviews over 2 years. The overall process women experienced was that of holding it together, which women did by restoring their sense of self during recovery, becoming a strong center for their family, and creating a sense of home no matter what the circumstances. Key elements supporting women in their transition to recovery and parenthood included longer term health, social, and recovery programs and services that addressed determinants of health (in particular, gender, housing, and income), and receiving support provided from strengths-based perspectives.

Adding to Our Practice Toolkit: Using the ACTS Script to Address Stigmatizing Peer Behaviors in the Context of Maternal Substance Use

Infants with neonatal abstinence syndrome (NAS) are a growing population in the NICU setting, and nurses report that caring for families can be challenging. Women who are pregnant and newly parenting who use drugs and alcohol typically face significant negative attitudes, judgment, and stigma within their communities and from providers when they access health care. When nurses witness biased behavior or communication from their peers, they may feel distressed and unprepared to address the situation. Using script guides or structured communication frameworks (e.g., SBAR) is one helpful strategy for rehearsing actions and responses. The ACTS script was developed specifically to address peer attitudes and stigma in relation to substance use during pregnancy.

Complicating the dominant morality discourse: mothers and fathers' constructions of substance use during pregnancy and early parenthood

Introduction

Consumption of substances is a highly controversial behaviour, with those who do so commonly viewed as deviants, even criminals, or else as out of control addicts. In other work we showed that the use of substances by women who are pregnant or have recently become parents was mainly viewed by health and social care providers as morally wrong. Problematic substance use was framed through the narrow lens of gendered responsibilisation, resulting in women being seen primarily as foetal incubators and primary caregivers of infants.

Methods

In this follow-up paper we examine descriptive and qualitative data from a convenience sample of biological mothers and fathers (N = 34) recruited as part of a larger mixed methods study of the development and early implementation of an integrated primary maternity care program. We present a description of the participants’ backgrounds, family circumstances, health status, and perception of drug-related stigma. This is succeeded by a thematic analysis of their personal views on substance use during both pregnancy and the transition to parenthood.

Results

Our results show that while many mothers and fathers hold abstinence as the ideal during pregnancy and early parenting, they simultaneously recognize the autonomy of women to judge substance use risk for themselves. Participants also call attention to social structural factors that increase/decrease harms associated with such substance use, and present an embodied knowledge of substance use based on their tacit knowledge of wellness and what causes harm.

Conclusions

While these two main discourses brought forward by parents concerning the ideal of abstinence and the autonomy of women are not always reconcilable and are partially a reflection of the dissonance between dominant moral codes regarding motherhood and the lived experiences of people who use substances, service providers who are attuned to these competing discourses are likely to be more effective in their delivery of health and social services for vulnerable families. More holistic and nuanced perspectives of health, substance use, and parenting may generate ethical decision-making practice frameworks that guide providers in meeting and supporting the efforts of mothers and fathers to achieve well-being within their own definitions of problematic substance use.

Reenvisioning success for programs supporting pregnant women with problematic substance use

Community-based, integrated, primary care maternity programs for pregnant women affected by problematic substance use are emerging as effective models for engaging women affected by multiple health and social issues. Although addictions services have historically been evaluated by individual achievement of abstinence, new definitions of program success are required as addiction comes to be viewed as a chronic illness. We conducted a mixed-methods study to follow the formative development stages of a community-based program, identifying key evaluation indicators and processes related to this program, program team members, and women and families served. As this program model develops, it is critical that providers, community partners, and health system leaders collaborate to frame definitions of success in ways helpful for guiding program development.

Tobacco and alcohol use in the context of adolescent pregnancy and postpartum: a scoping review of the literature

Adolescent girls are more likely than women of other ages to smoke tobacco or drink alcohol during pregnancy. The health impacts of smoking and drinking for girls and the interconnections between alcohol and tobacco use with adolescent pregnancy underscore the urgent need for integrated approaches to prevent and reduce alcohol and tobacco use among pregnant girls/young women. This article reports on the results of a scoping review of the literature focused on adolescents' use of tobacco and alcohol during pregnancy and postpartum. A search of CINAHL, Medline, Social Science Index and Web of Science identified 40 articles published in the two decades between 1990 and 2012 that met our inclusion criteria related to this age group, pregnancy/motherhood status, and use of both alcohol and tobacco. The review points to compelling gaps in our knowledge and our responsiveness to adolescents aged 19 and under who use alcohol and tobacco during pregnancy and the postpartum period. Research has been primarily descriptive, with separate, parallel streams of investigation to identify trends and predictors of alcohol and tobacco use, prior to, during and following pregnancy. There is a marked lack of effective interventions described in the literature that are designed to prevent or reduce alcohol and tobacco use during pregnancy among adolescent girls; and there are few examples of gender-informed prevention or treatment programmes for this population. Research is needed on interventions that attend to the context of adolescent girls' substance use as well as their preferences and developmental needs for support that encourage sustained behaviour change throughout pregnancy and the postpartum period and that effectively address the influence of partners and friends on use.

Supporting women with substance use issues: trauma-informed care as a foundation for practice in the NICU

Infants with neonatal abstinence syndrome and their mothers require extended support through health and social service systems. Practitioners are interested in exploring innovative approaches to caring for infants and mothers. There is now compelling evidence linking women's substance use to experiences of trauma and violence. A significant shift in the fields of addiction and mental health has been awareness of the impact of trauma and violence on infants and children, women, their families, and communities. In this article, the current state of knowledge of trauma-informed care is reviewed, in particular for application to practice within the NICU. Trauma survivors are at risk of being retraumatized because of health care providers' limited understanding of how to work effectively with them. Recognizing the impact of trauma and implementing evidence-based trauma-informed practices in the NICU holds promise for improving outcomes for women and their infants.

Providers' constructions of pregnant and early parenting women who use substances

The research literature indicates that problematic substance use as a form of health behaviour is poorly understood, being sometimes viewed as deviance, at other times as a disease, and most often as a combination of these states. The use of substances by women who are pregnant or new parents is often conceptualised within an individualised framework. Yet drinking alcohol and using other drugs during pregnancy and early parenthood cuts across social divisions and is shaped by socio-structural contexts including health care. There is a growing body of literature that critically examines public health interventions that are aimed at implementing harm reduction and health promotion techniques in service delivery to help pregnant and early parenting women who are identified as problem substance users. We examine qualitative data from representatives of a recent harm reduction intervention, focusing, in particular, on providers' individual conceptualisations of the problematic behaviour. Our results show that most study participants regard any substance use during pregnancy, birth and the postpartum period as fundamentally unacceptable. This framing of problematic substance use is accomplished via gendered responsibilisation of women as foetal incubators and primary caregivers of infants. We discuss our results in light of the current literature and suggest policy implications.

Quality improvement for neonatal nurses, part II: using a PDSA quality improvement cycle approach to implement an oral feeding progression guideline for premature infants

The development of clinical practice guidelines involving multiple health care providers presents a challenge in the neonatal intensive care unit (NICU). Implementation and evaluation of the guideline is as important as the development of the guideline itself. We explored the use of a quality improvement approach in the implementation of a feeding framework. A Plan-Do-Study-Act (PDSA) quality improvement cycle model was used to implement and evaluate a stepwise oral infant feeding guideline with emphasis on parent and care provider satisfaction. Three PDSA cycles were conducted, with each cycle resulting in modifications to use of the framework and development of knowledge translation and parent education techniques and tools. A PDSA cycle approach can be used effectively in guideline implementation and evaluation involving multidisciplinary health care professionals. This is Part II of a two-part series. Part I introduced the concept of quality improvement and tools for advancing practice changes.

Quality improvement for neonatal nurses, part I: a framework for advancing the quality and safety of care

Quality improvement (QI) and patient safety are becoming increasingly powerful drivers for health care planning and delivery. In this two-part series, the concept of QI will be introduced and implications for neonatal nursing care will be discussed. Part I reviews trends in the fields of QI and patient safety and introduces how neonatal practitioners are currently taking up QI and patient safety in their practice. Part II, to come, is titled "Using a Plan-Do-Study-Act Process to Introduce a Step-wise Framework for Establishing Oral Feeds in Premature Infants" will present the QI process "in action" by describing a QI project conducted in a Level III NICU on introducing and testing a new process for improving the transition from tube to oral feeding for preterm infants.