A Maternal and Child's Nurses Quest Towards Excellence

8/8/2019 A Maternal and Child's Nurses Quest Towards Excellence

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Self Enrichment: A Maternal

& Child Nurses QuestTowards Excellence

DR. MARIA TERESITA SY-SINDAProfessor & Dean

College of Nursing & Allied Health Sciences

Silliman University, Philippines

28th Founding Anniversary & 27th Annual Convention

Maternal Child Nurse Association of the Philippines

July 18, 2008 Great Eastern Hotel, Quezon City


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Compared with many other highlytechnical endeavors, health care

activities despite many advances are

inexact procedure based uponincomplete knowledge and are

performed in a rapidly changing world

on an increasing aging population.


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Uncertainty is large and

error margins are small.

Health care professionalsand their patients both

possess medical

knowledge as one surgeonrecently noted:

We look for medicine to be

an orderly field of

knowledge and

procedure.

But it is NOT!


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IT IS:

an imperfect science,

an enterprise of constantly changing

knowledge,

uncertain information Fallible individuals

lives on the line

There is a science in what we do, Yes.


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However it is also a habit, intuition

and sometimes plain old guessing.

The gap between what we know and

what we aim for persists and thisgap complicates everything we do

(Gawande, 2002).


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In this time & age, health

care professionals areexpected to evaluate the

care they provide and

show evidence that care is

not only clinically

effective but also cost

effective and satisfying to

the patients.


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In light of these challenges, the

term best practice has emergedas a descriptor of clinical

practice that result to the best

outcomes as well as theprocess used to select these

clinical practices.


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Best practice is often

associated with

benchmarking whichinvolves identifying

the most successful

institutions, using

their approach,

replicating andrefining their

methods


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Perlith, Jakubowski & Busse

(2001) describe best practice asan approach organizational

process, improvement that

involves using research findingsto change organizational

policies, to improve the delivery

of health care


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Santos (2002) describes best practice

guidelines as evidence based

statements that assist practitioners

and patients in making decisions in

specific health care situations.


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Sigma Theta Tau International

define evidence - basedpractice as the integrating the

best evidence available,

nursing expertise, & the value

& preferences of individuals,

families, & communities whomwe serve.


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This assumes that optimal nursing

care is provided when Nurses and

health care decision makers haveaccess to a synthesis of the latest

research, a consensus of expert

opinion, & are thus able to

exercise their judgment as they

plan & provide care that takes intoaccount cultural and personal

values & preferences.


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Both best practice & evidence

based practice though with

slight differences in their

definitions have one goal:

To provide optimal patient care thatis based on reliable evidence with

the goal of enhancing practice &

in turn improving patient orsystem outcomes.


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Contemporary health care

consumers are

knowledgeable &

demanding.

They expect the mostcurrent; effective and

efficient interventions.


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In our quest to promote excellence

for our patients, we are challenged

to stay abreast of new

developments in health care even

within the limits of our own areas

of specialization.


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Similarly with the growth of health

care knowledge, health care costsincrease and patients

satisfaction, takes on greater

importance.Administration expects health care

providers to satisfy their

customers and do it in the mostclinically effective & cost

effective manner.


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Control of health care cost

was one of the initialdrivers of the best practice

movement (Larafee, 2004)


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In todays health care

environment, Nurses areincreasingly accepted as

essential members & often as

leaders of theinterdisciplinary health care

team.


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To effectively participate & lead a health

care team, Nurses must have

knowledge of the most effective andreliable evidence based approaches to

care.

And as Nurses, increase their expertisein critiquing research, they are

expected to apply the evidence of their

findings to selecting optimal

interventions for their patients.


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During the late 1990s Sigma Theta

Tau International conducted a

strategic planning process to

establish future directions for the

organization.

They found out that the most

frequently cited request from

practicing Nurses was a desire forsupport systems & resources to help

them implement evidenced based

practices.


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The feedback was consistent across

Nursing specialties and across Nursingroles & positions.

For e.g. Obstetrics & Neonatology,Malon, Albrech & Thomas, et. al. (2003)

have for their research, the title ortheme, Implementing evidence based practice: Reducing risk for lowbirth weight through pregnancy

smoking cessation. The type of report is to describe

implementation process for evidence -based protocol.


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In womens health, Mason (2002)

had the research title,Who says its best practice.

The type of report is discussion of

changes in prescribing hormone

replacement therapy.


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Craig & Smyth (2002) asserted that best

practice begins by asking good

questions.

Nurses must be empowered to ask

critical questions in the spirit of looking

at opportunities to improve Nursingpractice & patient outcomes.

In any specialty or role, nurses can

regard their work as a continual seriesof questions & decisions.


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For e.g. in the area of Maternal &Child Health, we can askthese questions:

1. What particular healtheducation methods candecrease the incidence of

teenage pregnancy in thePhilippines?

2. What demographic factorsrelate to incidence of fetal

death?3. What obstacles are in the

way for women to accessreproductive healthservices?


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In general, qualitative, descriptive

quasi experimental studies are

much more common methods of

inquiry in Nursing research ratherthan randomized clinical trials

(RCTs) or Meta analysis.


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Optimal professional

practice can occur whenpractitioners take all kinds of

sources of knowledge into

account in the clinical situation

& make use of then wisely for

their specific goals.


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In practice settings, much of the work

of successful encounter rests on how

practitioners actually utilize theknowledge produced through hypothetico

deductive processes.

This include how they take the extant

knowledge of books & research papers &

use it in the different modes of applicationthey select for patient care situations.


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General observations of policies aimed

to increase patients, involvement in

their health care, of moves to increase

physical activity in societies, & other

strategies to increase community

participation in health lifestyles, callsinto questions many of the passive

treatments & interactions in health care

that are labor intensive, of high cost and

tending to create patient dependency


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A dilemma for the practicingnurse is the time, access &

expertise needed to search &

analyze the research literatureto answer clinical questions.


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In the light of the challenges of

providing best practices,Nurses must consider some

alternative support

mechanisms when searching

for the best evidence to

support their practice.


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The following strategies are:

Keep abreast of the evidence

subscribe to professionaljournals & read widely.

Use and encourage the use of

multiple sources of evidence. Use evidence not only to support

clinical interventions but also for

teaching strategies.

Find established sources of

evidence in your specialty.

Dont reinvent the wheel.


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Other ways to support best practices are:

1. Garner administrative support, it is needed to

access resources, provide support personneland sanction necessary changes in policies

and procedures.

2. Collaborate with a Research Mentor Advance

Practice Nurses, Nurse researchers orNursing faculty are examples of Nurses who

may provide consultation & collaboration to

support the process of searching, reviewing &

critiquing research literature and data basesto answer clinical questions & identify best

practices.


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3. Search already reviewed orsummarized research

For e.g. Some journals such as

Evidence Based Nursing andWorldviews on Evidence Based

Nursing specifically focus on

providing summaries, critiques, &practice implications of existing

research studies.


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4. Access Resources from professional

Organizations

Professional Nursing Organizationsalso provide a wealth of resources to

support evidence based practices.

For e.g. the Association WomensHealth Obstetrics Neonatology Nursing

(AWHONN) provides multiyear projects

focusing on the management of womenin the second stage labor, urinary

continence for women, Neonatal skin

care, & cyclic pelvic pain & discomfort

management.


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They also fund a project on

guidelines for care in topics

such as Breastfeeding support,

regional Analgesia/Anesthesiain labor, promotion of

emotional well being during

mid-life and cardiovascularhealth for women.


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5. Benchmark with high performing teams,units and institutions.

Although evidence based practicesare being discussed and pursued byNurses around the world, there areobstacles that inhibit the movement.

These are:

a. Accessibility of research findings

b. Anticipated outcomes of using

research (concerns about discomfortwith change)

c. Support from others & lack oforganizational support.


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Yet challenges continue. Organizationalcultures may not support the Nurse whoseeks and uses research to change long

standing practices rooted in traditionsrather than science.

In addition, a stronger connection needs to

be established between researchers &academicians studying evidence basednursing & best practices & staff Nurses whomust translate those findings into the art of

nursing practice over the science.Both are critical in making sure that patients

received the highest quality of care

possible.


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Some studies which are evidence basedthat Maternal Child nurse specialists can

apply to practice are the following:A study to examine Nurses knowledge,attitude and practice in positioning healthynewborns for sleep in the hospital setting

revealed that Nurses no longer placeinfants on the prone position for sleep, butalmost 75% of those answering the surveyused either the side lying position or amixture of side & back positioning eventhough 96% of the Nurses said that theywere aware of the guideline recommendingback to sleep


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The clinical implications would be that

Nurses are the role models for new parents

regarding newborn sleep position, & are in aunique position to influence parents

decisions about how to put their infants to

sleep at home.

Because Nurses continue to worry about

aspiration when newborns are placed on

their backs, it is clear that more education is

needed for hospital nurses about newbornsleep position. Practice is difficult to change

as evidenced by this study.


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Strategies need to be developed

to help change the knowledge,attitude and behavior of

hospital newborn nursery

nurses in relation to theguideline.


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Another study to provide evidence

based practice is a descriptive and

replicate study of Nursing ambient soundlevels associated with nursery equipment

and care activities in a Level III Neonatal

Intensive CareU

nit (NICU

).

Measurements were obtained

using sound level meter andevaluated in the light of

previous findings.


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Suggested clinical implications include:

1. Awareness of ambient sound level and

ongoing control is an important aspectof neonatal care.

2. Certain sound levels in incubators arehigh, including opening/closingporthole and plastic porthole sleeves,using the incubator hood as worksurface (writing, tapping, & closingincubator cabinet) Incubator hoodsshould not be used as work surface


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3. Be aware that noise caused by IV &cardiopulmonary alarms & ventriculartubing bubbling is high. Prompt responseto alarms & removal of fluid from tubing is

warranted.4. Nurses should be aware that dropping the

head of the incubator mattress was theloudest sound measured.

Levers should be used to gently raise orlower the mattress.


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5. Assessment of sound levels

associated with specific care

activities may help the care providermodify infant exposure to loud

sounds.

6. Equipment selection should includeevaluation of sound levels criteria.


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A study on the controversy of neonatal

exposure to plasticizers in the NICU was

explored by Pak, Victoria et. al in 2007.

Critically ill infants in the NICU undergo

medical procedures & treatments that

require extensive use of medicaldevices. As a result these infants maybe

exposed to di (2 ethyhaxy) phthalate

(DEHP) levels much higher than

exposure of the general population.


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DEHP is a major component in the

manufacturing of polyvinyl chloride

devices commonly used in the health caresetting such as blood bags, IV tubing,

ventilator, enteral and parenteral

feedings, O2

& suction equipment.

Because maintaining a DEHP free NICU

environment requires teamwork, Nurses

should begin discussing with their co

workers & managers the researchevidence cumulative exposure & adverse

effects that result from infant exposure to

DEHP.


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Identify alternative devices & equipment

that are DEHP free

Advocate that the purchasing

department of the hospital consider

purchasing only DEHP free equipment &

supplies. More human studies are needed to

explore health outcomes in infants

exposed to DEHP

& to look forrelationships between exposure &

subsequent outcomes.


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Further studies are

needed to

demonstrative efficacyof alternative materials

in the manufacturing

of medical devices. The authors of the

study believe that a

conservative approachto their use involving a

reduction of exposure

to infants is warranted.


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In recent nursing literature,

mothers of newborns have been

shown to associate satisfaction in

breastfeeding with behaviors of

their infants related to state

organization.

This suggests a positive

relationship between newborn

behavioral state management &

breastfeeding success.


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Because Nurses are critical to its

success, they must constantly refine

their practice of passing on the art andscience of breastfeeding of mothers.

A strong Nursing role model is that of a

facilitation around with the knowledgeabout newborn states, the Nurse can

explain how the newborn organize

themselves in preparation forbreastfeeding and how the mother can

help the newborn.


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150 new mothers completed the PDSS andan interview with a Nurse

psychotherapist. Date analysis focused on exploring the

profiles of women who were diagnosed

with PPD as well as those who were not. Results revealed that the group with PPD

averaged scores twice as high as those in

the non depressed group and describedmore profound emotional responses tothe maternal role transition.


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PPD should be conceptualized as

occurring in a continuum with symptoms

worsening overtime for some women.Nurses working across all health care

settings can use the PDSS to identify

women with PPD.

All health care provides who are in

contact with postpartum women should

be open to discussing those womens

emotional needs, & should assess womenon an ongoing basis. They can help

identify women who require treatment for

this curable illness.


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Spaulding, Deborah et al in 2007 asked

the question How does postpartum

Depression affect breastfeeding? The purpose of the study is to examine

patterns of exclusive bottle feeding

among a sample of women identified at 2 4 weeks postpartum with positive PPD

symptoms.

The sample include 122 women who were

part of a larger study. Data were collected

during the three postpartum home visits.


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Results revealed that the severity of

depression was not related to

breastfeeding.

Older Maternal age, living with a

partner and high income were

positively related to breastfeeding.

Compared to a random sample the

level of exclusive breastfeeding was

significantly lower in the sample thanthe level of combination feeding.


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Nurses should be involved in

screening all prenatal &

postpartum women forPPD

Symptoms particularly whenthey present breastfeeding

difficulties & refer to treatment

when appropriate.


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Weinhard, Orpha 2007 wrote an

article in theDevelopment of the Perinatal

Concerns Program: Care of

Mothers after Diagnosis ofFetal infant anomalies.


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Development of this program required

collaboration of several services,

coordination of protocols, andestablishment of a clear lines of

communication.

It was born after a particularly difficultcase in labor and delivery that alerted a

staff nurse to the fact that coordination

of care for this patient could have

resulted in enhanced ability of all the

staff to meet this womans physical and

emotional needs.


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The development of thisprogram demonstratesthat a motivated staffnurse, with effectiveleadership skills can

make major changes inan institution which

can make a difference

in the care ofgrieving patients.


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Conclusion:

The successful development of

the Perinatal Concerns program

was dependent on the ability of the

staff nurse at this institution to

move forward to solve a difficult

problem.

This staff nurse acted as anempowered leader in order to

accomplish this task.

A ff ti d


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An effective, empowered

leader must possess

specific characteristicsincluding

(1) Effective communication

skills,

(2) Integrity, and

(3) Vision.


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Effective communicationskills include

the ability to expressthoughts and be

understood, the ability tomotivate people, the skill

to listen clearly andunderstand sharedthoughts, and the

capability to effectivelycommunicate messagesas a leader.


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In addition, an effective communicator

will also have other qualities such as

enthusiasm, empathy, self-regulation,wisdom, and the ability to empower.

Integrity means being honest and

forthcoming, and is motivated by

intention (Dye, 2003).

Vision means having the ability to see

beyond the moment, to know where you

want to be, and how to get there (Dye).


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I like to end this talkwith the definition of a

Nurse by the theorist

Virginia Hendersonwhich spells excellence in

the Nurse

THE NURSE


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THE NURSE

The NURSE is the Consciousness of the

UnconsciousnessThe NURSE is the Sight of the Newly Blind

The NURSE is the Leg of the amputee

The NURSE is the Confidence of the New

Mother

The Nurse is the LOVE OF LIFE of theSuicidal

The NURSE is the Mouthpiece of those who

cannot Speak

We can only be this Nurse if we diligently


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We can only be this Nurse if we diligently

seek for current knowledge to guide our

practice that should result in:Positive Client Outcome at the least Cost.


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REFERENCES:

1 Higgs Joy Richardson Barbara & Dahlgram Madeleine Developing Practice


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1. Higgs, Joy, Richardson, Barbara & Dahlgram, Madeleine. Developing PracticeKnowledge ForProfessionals. Butterworth & Heinmann 2004 edition.

2. Keeping Patients Safe: Transforming the Work Environment of Nurses.National Academy of Sciences. 2004 edition.

3. Huston Carol. Professional Issues in Nursing Challenges & Opportunities.Lippincott, Williams & Wilkins 2006 Edition.

4. Bullock, Linda et. al Are Nurses Acting as Role Models for the Provider ofSIDS? Journal of Maternal & Child Nursing, May June 2004.

5. Thomas, Karen et al. How the NICU Environment to a Preterm Infant Journalof Maternal Child Nursing. Vol. 12 July/August 2007

6. Park, Victor & McCauly, Linda. Controversy: Neonatal Exposure toPlasticizers In the NICU. Journal of Maternal Child Nursing. Vol. 12July/August 2007

7. Karl, Dona. Using Principles of Newborn Behavioral State Organization toFacilitate Breastfeeding. Journal of Maternal Child Nursing. Vol 29 ________Oct 2005

8. Clemmence, Donna et. al. Postpartum Depression Journal of Maternal Child Nursing. Vol. 29 May June 2004

9. Spaulderg, Deborah & Horowitz, June Andrews. How does PostpartumDepression Affect Breastfeeding? Journal Maternal Child Nursing. Vol. 12January Feb. 2007

10. Weinhold, Orpha. Development of the Perinatal Concerns Program: Care ofMother after Diagnosis of Fetal Infant Anomalies Journal of Maternal ChildNursing. January/Feb. 2007

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A Maternal and Child's Nurses Quest Towards Excellence

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