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Introduction Even with the benefits of vaccinations, some parents refuse vaccinations because of the influence of vaccine opponents. The purpose of this article is to identify common vaccine concerns on public forums and address these concerns with scientific evidence, thereby offering pediatric nurse practitioners (PNPs) information on how to respond. Method Six electronic databases were searched to identify parental concerns regarding vaccines and provide evidence-based responses to each concern. Results Some parents are concerned that health care providers do not obtain written informed consent before vaccinating their children. Another common concern is that pharmaceutical companies are solely motivated by financial profits when manufacturing vaccines. Parents also share concerns about vaccine manufacturers’ exemption from liability for those who suffer a vaccine-related injury. Discussion PNPs are responsible for addressing parents’ concerns regarding vaccines and providing the public with correct information. PNPs are in a prime position to influence parental vaccine decision-making positively.

BACKGROUND Critical care nurses (CCNs) frequently provide end of life (EOL) care in intensive care units (ICUs). Obstacles to EOL care in ICUs exist and have been previously published along with reports from CCNs. Further data exploring obstacles faced during ICU EOL care may increase awareness of common EOL obstacles. Research focusing on obstacles related to physician behaviors and nursing issues (and others) may provide improvement of care. OBJECTIVE The aim of this study was to gather first-hand data from CCNs regarding obstacles related to EOL care. METHODS A random, geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from an item asking CCNs to tell us of the obstacles they experience providing EOL care to dying patients were analyzed. RESULTS There were 104 participants who provided 146 responses to this item reflecting EOL obstacles. These obstacles were divided into 11 themes; 6 physician-related obstacles and 5 nursing- and other related obstacles. Major EOL ICU barrier themes were inadequate physician communication, physicians giving false hope, poor nurse staffing, and inadequate EOL care education for nurses. DISCUSSION AND CONCLUSION Poor physician communication was the main obstacle noted by CCNs during ICU EOL care, followed by physicians giving false hope. Heavy patient workloads with inadequate staffing were also a major barrier in CCNs providing EOL care.

Background Critical access hospitals were created to bring health care to rural populations. These hospitals lack equipment and resources, but the nurses who work there still provide end-of-life care to critically ill and dying patients. Objective To determine how nurses in critical access hospitals perceive the size of obstacles and helpful behaviors for the provision of end-of-life care. Methods Questionnaires were sent to a cross-sectional, nationally representative sample of nurses working in 39 critical access hospitals. The nurses were asked to score obstacle and helpful behavior items on a scale of from 0 (not an obstacle or not a help, respectively) to 5 (extremely large obstacle or extremely large help, respectively). The items were then ranked from highest to lowest according to their mean scores. Results Seven of the top 10 obstacles were directly related to family behaviors and attitudes, such as families not understanding what lifesaving measures entail and internal family disagreements about life support. Helpful behaviors ranked in the top 10 included interventions that were controlled by nurses and items that affected the nurses’ having adequate time to deliver end-of-life care. Obstacles and helpful behavior items unique to critical access hospitals, such as a lack of resources and the nurse knowing the patient or the patient’s family, ranked below the top 10 items. Conclusion Obstacles and helpful behaviors for providing end-of-life care remain consistent. Nurses in critical access hospitals are accustomed to working without the typical resources found in urban hospitals and thus did not perceive resource deficits to be among the greatest obstacles to providing end-of-life care. Family behaviors and attitudes remain the most dominant obstacle noted by nurses.

Background and objective: Despite the importance of vaccination in disease prevention some people choose to remain unvaccinated. Nurses are influential in the choice to vaccinate. Considering the possibility of poor public understanding of vaccines and need for continued improvement in vaccination rates, it is essential for nurses to be knowledgeable and adept at addressing vaccine concerns, especially since the COVID-19 pandemic. Vaccination education formally begins in nursing school. The objective of this study was to identify nursing students’ vaccine understanding by exploring information learned from formal online vaccine education specifically the Nursing Initiative Promoting Immunization Training Modules (NIP-IT).Methods: Nursing students enrolled in a Community Health Nursing course were required to complete three online, self-study, modules entitled Vaccine Preventable Diseases, Vaccine Concerns, and Nursing Roles. The nursing students who completed these modules responded, in writing, to an open-ended prompt asking them to identify what new piece of information they learned. Responses gathered from 244 nursing students between September of 2016 and April of 2018 were categorized and grouped according to theme using a first and second cycle coding process. Responses containing more than one idea were considered separate responses and categorized accordingly totaling 273 responses.Results: Nursing student responses revealed five major themes regarding new information learned from the online modules: (1) barriers to vaccination; (2) components of vaccines; (3) the influence of nurses; (4) vaccine-preventable diseases; and (5) community immunity.Conclusions: Formal vaccine education is a critical component of a comprehensive nursing program. The nursing students in this study described information they learned when completing the NIP-IT modules, thus it was inferred the nursing students did not have a full understanding of vaccine concepts prior to viewing the modules. Formal nursing school vaccine education is essential in developing nurses capable of navigating vaccine issues and promoting health and preventing disease through vaccination advocacy.

Approximately 2.5 million neonates died worldwide in 2018. Over one quarter of neonatal deaths are caused by birth asphyxia. Helping Babies Breathe (HBB) was created to teach basic neonatal resuscitation steps in limited-resource settings. Fifteen Fijian faculty members attended a master teacher class. Nine undergraduate nursing students from the western United States assisted in teaching two HBB classes for Fijian nursing students. Fijian faculty and student knowledge increased significantly posteducation. Educational settings provide ideal locations for future nurses to learn and practice evidence-based neonatal resuscitation skills. Implementing HBB in an academic setting, though novel, may ensure educators are familiar with current guidelines.

Genetic test results have important implications for close family members. Indeterminate negative results are the most common outcome of BRCA1/2 mutation testing. Little is known about family members’ understanding of indeterminate negative BRCA1/2 test results. The purpose of this mixed-methods study was to investigate how daughters and sisters received and understood genetic test results as shared by their mothers or sisters. Participants included 81 women aged 40–74 with mothers or sisters previously diagnosed with breast cancer and who received indeterminate negative BRCA1/2 test results. Participants had never been diagnosed with breast cancer nor received their own genetic testing or counseling. This Institutional Review Board-approved study utilized semi-structured interviews and surveys. Descriptive coding with theme development was used during qualitative analysis. Participants reported low amounts of information shared with them. Most women described test results as negative and incorrectly interpreted the test to mean there was no genetic component to the pattern of cancer in their families. Only seven of 81 women accurately described test results consistent with the meaning of an indeterminate negative. Our findings demonstrate that indeterminate negative genetic test results are not well understood by family members. Lack of understanding may lead to an inability to effectively communicate results to primary care providers and missed opportunities for prevention, screening, and further genetic testing. Future research should evaluate acceptability and feasibility of providing family members letters they can share with their own primary care providers.

Introduction: Target doses of guideline-directed medical therapy (GDMT) reduce morbidity and mortality, and yet, are challenging to achieve in patients with heart failure and reduced ejection fraction (HFrEF). Long-term, relationship-based approaches are not well described. Methods: We implemented a person-centered approach in a nurse-managed multidisciplinary heart failure clinic. We used repeated measures analysis to prospectively evaluate patient satisfaction, appointment attendance, dose optimization of GDMT for renin-angiotensin inhibitors, beta-blockers (BB), mineralocorticoid antagonists (MRA), and anticoagulation, and ICD placement and cardiac rehab participation at 12 months. GDMT was scored 0-6, with one point for each guideline-indicated therapy. Composite scores were compared using ANOVA at baseline, 6-months, and 12-months. Results: Participants (n=102) were age 68 (± 14.95) years on average, predominantly white (95.1%), male (62.75%), and high school graduates (88.24%). At 12-months, the proportion of patients on ≥50% of target doses improved: renin-antiotensin inhibitors from 27% to 41%, beta-blockers from 46% to 64%, and MRA from 35% to 65%. Cardiac rehab attendance improved from 25% to 84%. Patient satisfaction with care improved; four (3.9%) patients did not attend scheduled follow-up in the 12-month period. Though overall composite scores of GDMT improved (F=51.74, p Conclusion: A persistent patient-provider relationship and person-centered approach to HF management may improve GDMT.

Background Critical care nurses routinely care for dying patients. Research on obstacles in providing end-of-life care has been conducted for more than 20 years, but change in such obstacles over time has not been examined. Objective To determine whether the magnitude scores of obstacles and helpful behaviors regarding end-of-life care have changed over time. Methods In this cross-sectional survey study, questionnaires were sent to 2000 randomly selected members of the American Association of Critical-Care Nurses. Obstacle and helpful behavior items were analyzed using mean magnitude scores. Current data were compared with data gathered in 1999. Results Of the 2000 questionnaires mailed, 509 usable responses were received. Six obstacle magnitude scores increased significantly over time, of which 4 were related to family issues (not accepting the poor prognosis, intrafamily fighting, overriding the patient’s end-of-life wishes, and not understanding the meaning of the term lifesaving measures). Two were related to nurse issues. Seven obstacles decreased in magnitude, including poor design of units, overly restrictive visiting hours, and physicians avoiding conversations with families. Four helpful behavior magnitude scores increased significantly over time, including physician agreement on patient care and family access to the patient. Three helpful behavior items decreased in magnitude, including intensive care unit design. Conclusions The same end-of-life care obstacles that were reported in 1999 are still present. Obstacles related to family behaviors increased significantly, whereas obstacles related to intensive care unit environment or physician behaviors decreased significantly. These results indicate a need for better end-of-life education for families and health care providers.

Background Neonatal deaths (infants less than 28 days old) account for two thirds (66.7%) of all infant deaths with most occurring in an ICU setting. NICU nurses are frequently involved in end-of-life (EOL) care and face unique obstacles. Objective The objective of this study was to obtain NICU nurses’ suggestions for improving obstacles in EOL care in NICUs. Methods Suggestions were obtained through mailed survey research in qualitative study design. Returned surveys yielded 121 nurse respondents who gave a total of 138 suggestions. Results A total of 10 cohesive themes were identified: (1) environmental design issues, (2) improved communication between healthcare teams, (3) ending futile care earlier, (4) realistic and honest physician communications to families, (5) providing a “good death,” (6) improved nurse staffing, (7) need for EOL education, (8) earlier entry into hospice/palliative care, (9) availability of ancillary staff, and (10) allowing parents more time to prepare for death. Conclusions Despite the variety of obstacles encountered in providing EOL care to dying infants and their families, NICU nurses can influence environmental factors, help improve communication, and use self-assessment tools to identify current EOL care practices.

BACKGROUND Nurses are an integral part of the healthcare team. Parents rely on nurses for information regarding the plan of care for their child. Medically stable infants under supervision in a newborn intensive care unit (NICU) can and should be immunized. PURPOSE The purpose of this study was to explore attitudes and knowledge in NICU nurses regarding 2-month immunizations. METHODS Participants were attendees of the National Association of Neonatal Nurses (NAAN) 33rd Annual Conference. Participants responded to a survey that focused on knowledge and attitudes regarding 2-month immunizations. FINDINGS/RESULTS A total of 188 nurses attending the NAAN conference completed the survey. Most nurses had positive attitudes regarding immunizations. A majority (n = 117, 62.5%) of NICU nurses knew that immunizations should be given to medically stable infants in a NICU. However, as few as 27% of participants were able to identify recommended 2-month immunizations. Almost two-thirds of participants (n = 115, 61.1%) did not know current guidelines regarding minimum age at the time of administration of immunizations, although NPs were more likely to know current guidelines. Nurse practitioners were more comfortable talking family about immunizations and were more likely to view that the illnesses prevented by vaccines as serious. IMPLICATIONS FOR PRACTICE NICU nurses would benefit from continued education focused on Centers for Disease Control and Prevention (CDC) guidelines for 2-month immunizations. Additionally, as a primary source of information for parents, NICU nurses should be encouraged to practice teaching parents and family about immunizations. This practice could reinforce nurse knowledge. IMPLICATIONS FOR RESEARCH Further research regarding the effect of education, simulation, and yearly reinforcement of CDC guidelines could further enlighten our knowledge on this topic.

Background Major obstacles exist in the care of patients at the end of life: lack of time, poor or inadequate communication, and lack of knowledge in providing care. Three possible nursing roles in care decision-making were investigated: Information Broker, Supporter, and Advocate. The purpose of this study was to examine obstacles faced by oncology nurses in providing end-of-life (EOL) care and to examine roles of nurses in providing care. Methods A descriptive, cross-sectional, correlational design was applied. The study was conducted at two major University Hospitals of Oncology in Lithuania that have a combined total of 2365 beds. The study sample consisted of 239 oncology registered nurses. Data collection tool included a questionnaire about assessment of obstacles and supportive behaviors, nursing roles, and socio-demographic characteristics. Results The two items perceived by respondents as the most intense obstacles to providing EOL care were The nurse’s opinion on immediate patient care is not welcome, valued or discussed and. Family has no access to psychological help after being informed about the patient’s diagnosis. The majority of respondents self-assigned the role of Supporter. Conclusions Major obstacles in providing care included the nurse’s opinion that immediate patient care was not valued, lack of nursing knowledge on how to treat the patient’s grieving family, and physicians who avoided conversations with the patient and family members about diagnoses and prospects. In EOL care nurses most frequently acted as Supporters and less frequently as Advocates.

Introduction Rural emergency nurses face unique obstacles to providing quality end-of-life (EOL) care. Stories provided by emergency nurses embody their most difficult EOL care obstacles. Methods A questionnaire was sent to 53 rural hospitals. Respondents were asked to share stories that epitomized the obstacles faced while providing EOL care in the rural emergency setting. Results The lack of an ideal death (eg, the nurse personally knows the patient, issues with family members, and unknown patient wishes) was the top obstacle. Other reported obstacles were insufficient ED staff and power struggles between nurses and physicians. Discussion Rural emergency nurses often provide EOL care to friends and family members, whereas their urban counterparts are likely to transfer care to nurses with no relation to the dying patient. Not only does caring for patients whom the nurse knows or is related to cause great distress to rural emergency nurses, but this unfortunately common situation also may prevent patients from receiving the highest quality EOL care.

BACKGROUND All major hospital facilities in the state of Utah have employee vaccination policies. However, the presence of healthcare worker vaccination policies in outpatient oncology clinics was unknown. OBJECTIVES The objectives of this article are to identify oncology outpatient employee vaccination policies in Utah and to identify what consequences, if any, are present for unvaccinated employees. METHODS This was a cross-sectional, descriptive study design in which clinic managers from outpatient oncology clinics were asked, via questionnaire, to describe the clinic's employee vaccination policy and the consequences for refusing the policy. FINDINGS Most vaccination policies applied to employees primarily assigned to work in the direct patient care area. Most commonly, influenza and hepatitis B vaccines were required as part of the vaccination policy. Most managers offered free vaccinations to employees, but most managers also allowed employees to refuse to follow the vaccination policy for medical, religious, or personal reasons.

The purpose of this study was to explore public school employee perceptions regarding vaccinations. Employees from 1 urban school district in Utah responded to the School Employees' Perception of Immunizations Questionnaire. Lack of perceived efficacy was the most common explanation for lack of seasonal influenza vaccine. Being unsure of need was the most common reason participants were unvaccinated for measles, mumps, and rubella. The most common reason for rejecting a mandatory vaccine policy was a perceived violation of personal freedoms. Nurse practitioners can positively influence the health of public school employees by ensuring they are properly vaccinated.

Vaccines are an important disease prevention strategy among individuals of all age groups. Despite the success of vaccinations in preventing communicable diseases, adults, in particular, often have sub-optimal vaccination rates. Consequently, some vaccine-preventable diseases, such as pertussis, are still on the rise in the United States despite the availability of the Tdap vaccine. As most adults can be found in the workplace, occupational and environmental health nurses are in a unique position to encourage employers to promote adequate Tdap vaccination among their employees. As specific resources regarding Tdap vaccination are lacking, the Pertussis Prevention Toolkit was developed to help occupational health nurses promote Tdap vaccination in the workplace.

BACKGROUND Critical care nurses (CCNs) frequently provide end-of-life (EOL) care for critically ill patients. Critical care nurses may face many obstacles while trying to provide quality EOL care. Some research focusing on obstacles CCNs face while trying to provide quality EOL care has been published; however, research focusing on family behavior obstacles is limited. Research focusing on family behavior as an EOL care obstacle may provide additional insight and improvement in care. OBJECTIVES We wanted to gather firsthand experiences of CCNs regarding working with families of dying patients. We then wanted to determine the predominant obstacle themes noted when CCNs share these rich experiences in EOL care. METHODS A random geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from a qualitative question on the questionnaire were analyzed. RESULTS Sixty-seven EOL obstacle experiences surrounding issues with families' behavior were analyzed for this study. Experiences were categorized into 8 themes. Top 3 common obstacle experiences included families in denial, families going against patient wishes and advanced directives, and families directing care that negatively impacted patients. CONCLUSIONS In overcoming EOL obstacles, it may be beneficial to have proactive family meetings to align treatment goals and to involve palliative care earlier in the ICU stay.

School nurses work in a unique environment with key opportunities to address parental concerns and questions regarding their child’s health. A common concern for parents during school enrollment is childhood vaccination safety and efficacy. As public health leaders, school nurses are well respected among parents, therefore school nurses are in a prime position to educate parents and promote childhood vaccinations while also dispelling common vaccination myths. The purpose of this integrative literature review is to synthesize evidence-based answers to common parental questions regarding childhood vaccinations.

Introduction Although death is common in emergency departments, there is limited research regarding ED design as an obstacle to end-of-life care. This study identifies emergency nurses' recommendations regarding ways designs have negative or positive impact on care for dying patients and their families. Methods A 25-item questionnaire was sent to a national random sample of 500 emergency nurses. Inclusion criteria were nurses who could read English, worked in emergency departments, and had cared for at least 1 patient at the end of life (EOL). Responses were individually reviewed and coded. Results Major obstacles included (1) issues related to limited space, (2) poor department layout and design, and (3) lack of privacy. Despite emergency departments being a challenging place to provide EOL care, positive ED design characteristics had impact on EOL care. Discussion Emergency nurses understand the need for family presence during resuscitation, for secure body stowage areas, and for more resuscitation rooms so that families have time to grieve before being removed because of the immediate needs of a second trauma patient. Nurses can evaluate existing facilities to identify areas in which potential change and remodeling could improve care, increase patient privacy, or further utilize space. Understanding ED design's impact on EOL care is crucial. Modifications to ED layout and design may be challenging; however, improvements to space, layout, and privacy need to be considered when planning new emergency departments or remodeling existing departments. Further research is required to determine the impact of ED design on EOL care.

Although a common psychological disorder, pharmacologic treatment of attention-deficit hyperactivity disorder can be a costly endeavor. Among 4- to 5-year olds, methylphenidate is a safe, efficacious, and cost-effective option for short-, intermediate-, and long-acting medication options. Short-acting methylphenidate, intermediate-acting methylphenidate extended release and sustained release, and long-acting methylphenidate are the most efficacious and cost-effective medications. The selection of nonstimulant medications should be based on recommended guidelines rather than primarily on cost. For children incapable of swallowing pills, the most efficacious and cost-effective treatments are short-acting dextroamphetamine liquid and long-acting methylphenidate capsules that can be opened and sprinkled over food.

BACKGROUND Clients in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are required to complete education modules quarterly to maintain eligibility. The purposes of this project were to: (1) create a whooping cough vaccination education module for WIC clients; (2) evaluate baseline perceptions of WIC clients on the whooping cough vaccine and disease; and (3) evaluate whooping cough knowledge following completion of the module. PROBLEM A decline in vaccination rates among infants and children using WIC services was reported by a local WIC program director who requested whooping cough vaccination education materials. This quality improvement project included development of a whooping cough education module and evaluation of learning. METHODS Learning was evaluated using a pre- and posttest design. Client feedback was solicited via open-ended questions. Quantitative analysis was performed on visual analog-type questions with paired t-tests and a Cohen's d. Content analysis was conducted on open-ended items. INTERVENTIONS The module was designed by a team of vaccination experts and included general definitions, signs and symptoms during the three stages of disease, recommendations to prevent whooping cough, and vaccination recommendations. Learning of users of the module was then evaluated. RESULTS After using the module, clients indicated they were significantly more likely to vaccinate themselves and their child against whooping cough, and to recommend the vaccination to their family members. The greatest concern of participants about whooping cough was how it affected infants. Participants reported they learned new information on disease seriousness, recognition of symptoms, and treatment options but still requested additional information on the whooping cough disease and vaccine. CONCLUSIONS A whooping cough education module is an effective strategy to improve whooping cough knowledge and promote the whooping cough vaccine.

BACKGROUND Critical-care nurses (CCNs) provide end-of-life (EOL) care on a daily basis as 1 in 5 patients dies while in intensive care units. Critical-care nurses overcome many obstacles to perform quality EOL care for dying patients. OBJECTIVES The purposes of this study were to collect CCNs' current suggestions for improving EOL care and determine if EOL care obstacles have changed by comparing results to data gathered in 1998. METHODS A 72-item questionnaire regarding EOL care perceptions was mailed to a national, geographically dispersed, random sample of 2000 members of the American Association of Critical-Care Nurses. One of 3 qualitative questions asked CCNs for suggestions to improve EOL care. Comparative obstacle size (quantitative) data were previously published. RESULTS Of the 509 returned questionnaires, 322 (63.3%) had 385 written suggestions for improving EOL care. Major themes identified were ensuring characteristics of a good death, improving physician communication with patients and families, adjusting nurse-to-patient ratios to 1:1, recognizing and avoiding futile care, increasing EOL education, physicians who are present and "on the same page," not allowing families to override patients' wishes, and the need for more support staff. When compared with data gathered 17 years previously, major themes remained the same but in a few cases changed in order and possible causation. CONCLUSION Critical-care nurses' suggestions were similar to those recommendations from 17 years ago. Although the order of importance changed minimally, the number of similar themes indicated that obstacles to providing EOL care to dying intensive care unit patients continue to exist over time.

The pain and anxiety associated with vaccination is a significant reason why parents are reluctant to have their children vaccinated. Distraction methods and vapocoolant sprays may be use to modify the parent's perceptions of their child's pain and anxiety, thus encouraging parents to return for the child's next vaccination.A convenience sample of 68 parents with children ranging in age from 2 to 12 years was selected. The parents and the child were randomly assigned to three groups: a control group, a DVD distraction group, or a vapocoolant spray group. After the child was vaccinated, parents evaluated the child's pain and anxiety.No significant difference in the parents' perception of their child's pain or anxiety was found between the two treatment groups compared with the control group. Some parents expressed the desire to be able to choose the type of distraction method their child received rather than having them randomly assigned to a group.Although quantitative results were not statistically significant in this pilot study, parents commented that the DVD distraction method seemed helpful before and/or after vaccination, but not during vaccination, and parents appreciated the distraction. Parents, however, would prefer to choose the intervention rather than being randomly assigned to a group. The effectiveness of interventions with regard to parental perceptions of pain or anxiety warrants further study.

As key members of the school environment, it is important for school employees to be vaccinated. Employees are in direct contact with children in close quarters for long periods of time and such an environment can easily serve as an outbreak center for vaccine-preventable communicable diseases such as measles. Despite the fact that most school employees believe vaccines are safe and effective and many school employees report they are up-to-date with their vaccines, a closer examination reveals discrepancy between belief and behavior. This research study evaluates the vaccination status, awareness, and perceptions of school employees located in a large rural school district in Utah. As a vaccine advocate, the school nurse can be influential in providing adult vaccination education for school employees, thus increasing awareness of the importance of adult vaccines and knowing one’s vaccination status. Additionally, school nurses might need to meet with school district policy makers to promote vaccine mandates for school employees and to assist in the creation of containment plans in the event of a measles outbreak at school.

Schools are where vaccine-preventable diseases can spread. Vaccination of school children has been studied; however, data are lacking on the vaccination status, perceptions, and barriers to vaccination for school employees. We surveyed school employees’ vaccination perceptions, awareness of current vaccination status, and potential barriers to vaccinations. Adult vaccination knowledge is lacking in the school employee population. School employees were unaware of their vaccination status for diseases such as measles and pertussis. Most subjects believed vaccinations were safe and effective, although they believed vaccinations were more important for children than adults. Many believed vaccine mandates should exist for school employees. Knowledge gaps regarding adult vaccines can be positively influenced by school nurses. Gaps may be especially important to bridge regarding adults working in the school setting, an environment ideal for the spreading of communicable diseases.

Background Nurses working in intensive care units (ICUs) frequently care for patients and their families at the end of life (EOL). Providing high-quality EOL care is important for both patients and families, yet ICU nurses face many obstacles that hinder EOL care. Researchers have identified various ICU nurse-perceived obstacles, but no studies have been found addressing the progress that has been made for the last 17 years. Objective The aims of this study were to determine the most common and current obstacles in EOL care as perceived by ICU nurses and then to evaluate whether meaningful changes have occurred since data were first gathered in 1998. Methods A quantitative-qualitative mixed methods design was used. A random, geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Results Five obstacle items increased in mean score and rank as compared with 1999 data including (1) family not understanding what the phrase "lifesaving measures" really means, (2) providing lifesaving measures at families' requests despite patient's advance directive listing no such care, (3) family not accepting patient's poor prognosis, (4) family members fighting about the use of life support, and (5) not enough time to provide EOL care because the nurse is consumed with lifesaving measures attempting to save the patient's life. Five obstacle items decreased in mean score and rank compared with 1999 data including (1) physicians differing in opinion about care of the patient, (2) family and friends who continually call the nurse rather than calling the designated family member, (3) physicians who are evasive and avoid families, (4) nurses having to deal with angry families, and (5) nurses not knowing their patient's wishes regarding continuing with tests and treatments. Conclusions Obstacles in EOL care, as perceived by critical care nurses, still exist. Family-related obstacles have increased over time. Obstacles related to families may not be easily overcome as each family, dealing with a dying family member in an ICU, likely has not previously experienced a similar situation. On the basis of the current top 5 obstacles, recommendations for possible areas of focus include (1) improved health literacy assessment of families followed by earlier directed, appropriate, and specific EOL information; (2) improved physician/team communication; and (3) ensuring patients' wishes are followed as written. In general, patient- and family-centered care using clear and open EOL communication regarding wishes and desires between patients and families, their physicians, and nurses will help decrease common obstacles, thus improving the quality of EOL care provided to dying patients and families.

Background: Children are required by law to receive vaccinations to enter school. States and territories offer exemptions for parents who refuse to vaccinate their children. Types of exemptions vary by state or territory, as does the exemption filing process. The purpose of this research was to identify the various education-related processes implemented by states and territories which allow parents to exempt children from vaccinations. Methods: A questionnaire was distributed to immunization program managers in the 50 United States, District of Columbia, the United States Indian Health Service, and eight United States territories. Managers reported vaccination requirements for their jurisdiction (collectively referred to as "state"). Education-related questions identified which states required parents to: 1) read and sign a vaccination risk/benefit statement prior to exemption; 2) complete mandatory vaccine education before obtaining vaccination exemption; 3) complete education within a certain time period before school admission. Additionally, states were asked how parental vaccine education was regulated. Results: A parent-signed risk/benefit statement was required by 25 states for religious exemptions, 12 states for personal exemptions, 10 states for medical exemptions, and 1 state for temporary medical exemptions. Thirteen states required mandatory parental vaccine education prior to obtaining an exemption. For states that mandated parental vaccine education prior to exemption, the education was most commonly regulated by statute, verses administrative rule or school policy. Conclusions: Vaccine education requirements and the process for providing this education to parents seeking immunization exemptions vary greatly between the states. More research is needed to fully understand the impact of the education requirement on exemption rates. Familiarity with and effectiveness of various state vaccine education requirements may aid policymakers who are considering enacting mandatory vaccine education in their state.

Aim The aim of this study was to assess the validity and reliability of the Korean version of a questionnaire assessing facilitators/barriers in end-of-life care that was originally developed for nurses in the USA. Methods Back-translation was undertaken to produce the Korean version. A principal component analysis with varimax rotation and Cronbach's alpha was used to test factorial validity and reliability, respectively. Results The analysis examined data from 383 nurses in a tertiary hospital in Korea. For end-of-life care facilitators, five factors accounted for 59% of the total variance. The factors were labeled “family preparedness”, “support for nurses”, “nurse–patient relationship”, “transition after death”, and “decision-making”. Six factors, explaining 59% of the variance, were extracted for end-of-life care barriers. These factors were “misunderstanding patient's will”, “preoccupied nursing workload”, “lack of institutional support”, “dealing with family's maladaptive coping”, “visiting hours”, and “communication about patient's status with family members”. Cronbach's alpha was 0.89 for the 23 facilitator items and 0.90 for the 24 barrier items. Conclusion Overall, the findings demonstrate that the questionnaire has measurement properties in a sample of Korean nurses. Further studies are needed with different populations to reflect end-of-life care in various clinical settings.

Objective To identify patients with specific ED discharge diagnoses reporting symptoms associated with a mild traumatic brain injury (MTBI), compare frequency/severity of MTBI symptoms by discharge diagnosis, investigate head injury education provided at ED discharge, and learn about changes made by MTBI patients after injury. Methods The Post Concussion Symptom Scale, a demographic questionnaire, and open-ended questions about the impact the injury had on patients' lives were completed by 52 ED patients, at least 2 weeks after injury, discharged with concussion/closed head injury, head laceration, motor vehicle crash (MVC), or whiplash/cervical strain diagnoses. Results Between 1 and 23 MTBI symptoms were reported by 84.6% of the participants. Headache and fatigue were the most common; female patients had almost twice as many symptoms on average as male patients. Of MVC patients, 83.3% reported moderate severity scores for all 4 Post Concussion Symptom Scale categories, and these represented the highest overall severity scores. Concussion/closed head injury diagnosis patients received the most head injury education. The majority of patients were more cautious afterinjury. Conclusion Most participants reported having MTBI symptoms. Although MVC participants reported the most severe MTBI symptoms, they had the least head injury education. Emergency nurses need to be aware patients may have an MTBI regardless of their presenting symptoms or injury severity.

Nurse practitioners should constantly compare a medication's potential effect with its associated cost, thus identifying the most cost-effective treatment plan. Such an approach is warranted for both pediatric and adult patients. Prescribing medications for children who are uninsured or underinsured can be especially challenging, particularly for those patients diagnosed with a chronic health condition requiring routine treatment and follow-up. Asthma can be such a chronic illness for which the cost associated with treatment may become a barrier to compliance with the treatment plan. Cost-effective treatment options for asthma in the pediatric patient are presented.

Introduction: Caring for dying patients is part of working in a rural emergency department. Rural emergency nurses are prepared to provide life-saving treatments but find there are barriers or obstacles to providing end-of-life (EOL) care. This study was completed to discover the size, frequency, and magnitude of obstacles in providing EOL care in rural emergency departments as perceived by rural emergency nurses. Methods: A 57-item questionnaire was sent to 52 rural hospitals in Idaho, Wyoming, Utah, Nevada, and Alaska. Respondents were asked to rate items on size and frequency of perceived obstacles to providing EOL care in rural emergency departments. Results were compared with results from 2 previous emergency nurses' studies to determine if rural nurses had different obstacles to providing EOL care. Results: The top 3 perceived obstacles by rural emergency nurses were: (1) family and friends who continually call the nurse for an update on the patient's condition rather than calling the designated family member; (2) knowing the patient or family members personally; and (3) the poor design of emergency departments that does not allow for privacy of dying patients or grieving family members. The results of this study differed from the other 2 previous studies of emergency nurses' perceptions of EOL care. Discussion: Nurses in rural emergency settings often work in an environment without many support personnel. Answering numerous phone calls removes the nurse from the bedside of the dying patient and is seen as a large and frequent obstacle. Personally knowing either the patient or members of the family is a common obstacle to providing EOL care in rural communities. Rural nurses often describe their patients as family members or friends. Caring for a dying friend or family member can be intensely rewarding but also can be very distressing. Conclusion: Rural emergency nurses live and work on the frontier. Little EOL research has been conducted using the perceptions of rural emergency nurses possibly because of the difficulty in accurately accessing this special population of nurses. Rural emergency nurses report experiencing both similar and different obstacles compared with their counterparts working in predominately non-rural emergency departments. By understanding the obstacles faced by emergency nurses in the rural setting, changes can be implemented to help decrease the largest obstacles to EOL care, which will improve care of the dying patient in rural emergency departments. Further research is needed in the area of rural emergency nursing and in EOL care for rural patients.

School nurses, as vaccination advocates, need to be aware of parents’ common concerns regarding vaccines, so the nurse can develop strategies to communicate with parents. The purpose of this cross-sectional, descriptive study was to identify common reasons parents in Utah seek exempting rather than vaccinating their children. Data were collected from a convenience sample of 801 parents responding to a 16-item questionnaire about why they exempted their children from receiving vaccinations. The most commonly reported reason for seeking a personal exemption included vaccines conflicting with philosophical beliefs. Parents exempting from one vaccine most commonly exempted the hepatitis series. Most parents communicated their vaccine concerns with their health care provider prior to seeking exemption. The majority of exempting parents did not use the Internet when researching vaccines even though they had Internet access. Considering the common vaccine-related perceptions of parents may be helpful when developing strategies to overcome these barriers to vaccination.

Vitamin D deficiency is prevalent across all geographic areas, age groups, and seasons and is increasing in incidence. Vitamin D receptors have been found to be present in almost every body cell and tissue. Clinical research has alluded to a preventive effect of vitamin D supplementation on cardiovascular disorders such as myocardial infarction, hypertension, and dyslipidemia. Furthermore, a low serum vitamin D level has been associated with an increased risk for cardiovascular disease. This article examines the association between serum vitamin D levels and cardiovascular disease mortality and risk.

Purpose: To determine the prevalence of postpartum depression (PPD) among Hispanic immigrant women seeking healthcare services at a community health clinic. Data sources: Of the 116 Hispanic immigrant women recruited, 96 comprised the final sample. Using the Beck PDSS-Spanish version, participants were screened for symptoms of PPD. Conclusions: The prevalence of significant symptoms of PPD was 54.2% for the entire sample. Nearly 66% of women who screened positive for symptoms of PPD scored above the listed cutoff score for suicidal thoughts. Women were divided into four postpartum age groups from 2 to 48 weeks; rates of symptoms of PPD ranged from 50% to 60.9% among the groups. There were no statistically significant demographic predictors for PPD. Implications for practice: Given that a large number of Hispanic women do not return for postpartum appointments, along with the high rates of PPD symptoms, it is strongly recommended that healthcare providers implement universal screening for all Hispanic women in pregnancy and across the first postpartum year to ensure prompt diagnosis and culturally appropriate treatment. Further research is needed to assess the cultural components of PPD and to determine if the prevalence is consistent in other community settings.

School nurses are on the front lines of educational efforts to promote childhood vaccinations. However, some parents still choose to exempt their children from receiving vaccinations for personal reasons. Studying the beliefs of parents who exempt vaccinations allows health care workers, including school nurses, to better understand parental concerns which may, in turn, help prepare school nurses for effective communication with these parents. The objective of the study was to explore personal beliefs of parents living in Utah, who exempted their children from receiving vaccinations. A cross-sectional, descriptive design was implemented. Data were collected from a convenience sample of 287 parents responding to an open-ended question about why they exempted their children from receiving at least one vaccination. The qualitative data included parental comments, concerns, or suggestions regarding childhood vaccinations. Five categories were identified regarding reasons for personal exemptions: parental perceptions, health care systems issues, chronic disease concerns, immune system concerns, adverse reaction concerns and other reasons not classified. The number of parents refusing childhood vaccinations remains relatively low; however, despite public health efforts, the percentage increases each year.

FARNES C., BECKSTRAND R.L. & CALLISTER L.C. (2011) Help-seeking behaviours in childbearing women in Ghana, West Africa. International Nursing Review58, 491–497 Aim: The purpose of this ethnographic study was to examine the health-seeking behaviours of Ghanaian childbearing women. Background: The Ashanti consider pregnancy to be a vulnerable time when risk increases that women may be affected by witchcraft and develop sunsumyare. Preparation for positive birth outcomes include biomedical, ethnomedical and faith-based interventions. Design: A sample of 42 childbearing Ghanaian women participated in audiotaped interviews. Transcribed interviews were coded and categorized into themes. Findings and discussion: The overriding theme was health seeking to ensure positive pregnancy outcomes. Subthemes included accessing multiple sources of care simultaneously, feeling vulnerable to spiritual illness, seeking spiritual protection and disclosing multiple sources of care. Conclusion: Childbearing is an essential part of the gender identity of Ashanti women. Witchcraft mentality provides a way for a woman to manage her life challenges. Implications for practice: Cultural beliefs and practices have profound effects on health-seeking behaviours. It is becoming increasingly important that healthcare providers perform cultural and spiritual assessments and inquire about complementary sources of health care.

Objectives To describe perceptions of immigrant Hispanic women experiencing symptoms of postpartum depression (PPD) and to identify barriers to seeking mental health services. Design Qualitative descriptive. Setting Community health clinic. Participants Twenty immigrant Hispanic women scoring positive for symptoms of PPD receiving health care at a community health clinic who declined mental health services participated in audiotaped interviews held in their homes. Methods Following Institutional Review Board approval and informed consent, interviews were conducted with study participants. Transcribed data were analyzed as appropriate for qualitative inquiry. Results Some of the women did not recognize and/or denied their symptoms attributing their sadness to financial concerns, family relationships, and/or work stressors. Study participants articulately described their symptoms and identified personal barriers including beliefs about emotional health, the perceived stigma of mental illness, hesitancy to seek treatment for symptoms of PPD, and cultural beliefs about motherhood and the role of women. Social barriers included inadequate social support, immigration status, and limited English proficiency. Health care delivery barriers included financial and time constraints and lack of child care and transportation. Conclusion Limited social networks and barriers to health care should be addressed to foster positive outcomes. Mental health services should be embedded with primary health care or obstetric care clinics to facilitate access. Personal and professional support can make a significant contribution to the reduction of symptoms of PPD.

Magnesium is an essential mineral necessary for optimal cellular health and well-being. Many adults in the United States fail to get recommended amounts of magnesium from their diets. Even so, symptoms of magnesium deficiency are rarely seen; however, maintaining normal body stores could be preventative against common diseases.

BackgroundEach year 55 000 children die in the United States, and most of these deaths occur in hospitals. The barriers and supportive behaviors in providing end-of-life care to children should be determined.ObjectiveTo determine pediatric intensive care unit nurses’ perceptions of sizes, frequencies, and magnitudes of selected obstacles and helpful behaviors in providing end-of-life care to children.MethodA national sample of 1047 pediatric intensive care unit nurses who were members of the American Association of Critical-Care Nurses were surveyed. A 76-item questionnaire adapted from 3 similar surveys with critical care, emergency, and oncology nurses was mailed to possible participants. Nurses who did not respond to the first mailing were sent a second mailing. Nurses were asked to rate the size and frequency of listed obstacles and supportive behaviors in caring for children at the end of life.ResultsA total of 474 usable questionnaires were received from 985 eligible respondents (return rate, 48%). The 2 items with the highest perceived obstacle magnitude scores for size and frequency means were language barriers and parental discomfort in withholding and/or withdrawing mechanical ventilation. The highest supportive behavior item was allowing time alone with the child when he or she has died.ConclusionsPediatric intensive care unit nurses play a vital role in caring for dying children and the children’s families. Overcoming language and communication barriers with children’s families and between interdisciplinary team members could greatly improve the end-of-life experience for dying children.

Purpose: To determine if increased dietary or supplemental intake of fiber slows or prevents inflammation as evidenced by high-sensitivity C-reactive protein (hs-CRP) values. Data sources: CINAHL, Medline, Health Source, Nursing/Academic Edition, and the Cochrane Library. Conclusions: Evidence from this review suggested significant associations between fiber consumption and decreased risk for cardiovascular (CV) disease as evidenced by a decrease in hs-CRP levels. Six of the seven articles reviewed showed statistically significant decreases in hs-CRP levels as dietary fiber was increased. Implications for practice: Fiber in the diet may play a strong role in CV health as evidenced by six clinical trials completed using amount of fiber intake in relation to inflammation, particularly hs-CRP levels. Patients need to be educated to adhere to a high fiber diet, either by dietary or supplemental means, using the recommended 25–30 g of fiber per day.

Objectives: To determine why parents in a Utah community hesitated in immunizing their children. Design and Sample: Cross-sectional descriptive study. Data were collected from a convenience sample of 86 parents of under-immunized children in the county health department and local pediatric and family practice offices. Measures: Participants were asked to complete an immunization hesitancy survey including questions regarding why parents hesitated to immunize their children, parental concerns regarding immunizations, and what advice they would give to a friend or family member who had concerns about childhood vaccines. Parents could also write in any other comment, concern, or suggestion they had regarding childhood immunizations. Results: 2 major themes were identified: concerns regarding immunization safety and lack of perceived need. The most commonly reported concerns regarding immunization safety included autism, immune system overload, and other adverse reactions. Many parents did not recognize the need for childhood immunizations, especially multiple immunizations given simultaneously on a strict timeline. Conclusions: The manner in which immunization information is shared with hesitant parents can be particularly important. There is a need for health care providers to assess and increase parental knowledge regarding immunizations.

BACKGROUND AND PURPOSE The purpose of this study was to collect information regarding healthcare worker (HCW) vaccination policies in Utah family practice clinics. METHODS The study was conducted in Utah family practice clinics in the most densely populated counties in the state and was a cross-sectional descriptive design. Data were collected from 91 family practice clinic managers. Descriptive statistics were performed, as well as a content analysis for open-ended items. CONCLUSIONS HCWs are employed in environments where infectious diseases can be easily spread from person to person, thus, vaccinations can be instrumental in protecting the health of HCWs and patients alike. In Utah, 56.8% of family practice clinics had either no vaccination policy for HCWs or had a policy with no consequences for noncompliance. Utah family practice clinics need to implement changes to create and maintain HCW vaccination policies. IMPLICATIONS FOR PRACTICE Nurse practitioners can be leaders and change agents by working with their county and state health departments to create state-wide policies that mirror the position statements from the American Nurses Association and the American Association of Nurse Practitioners.

Introduction Many patient visits to emergency departments result in the patient dying or being pronounced dead on arrival. The numbers of deaths in emergency departments are likely to increase as a significant portion of the U.S. population ages. Consequently, emergency nurses face many obstacles to providing quality end-of-life (EOL) care when death occurs. The purpose of this study was to identify suggestions that emergency nurses have to improve EOL care, specifically in rural emergency departments. Methods A 57-item questionnaire was sent to 53 rural hospitals in 4 states in the Intermountain West, plus Alaska. One item asked nurses to identify the one aspect of EOL care they would change for dying patients in rural emergency departments. Each qualitative response was individually reviewed by a research team and then coded into a theme. Results Four major themes and three minor themes were identified. The major themes were providing greater privacy during EOL care for patients and family members, increasing availability of support services, additional staffing, and improved staff and community education. Discussion Providing adequate privacy for patients and family members was a major obstacle to providing EOL care in the emergency department, largely because of poor department design, especially in rural emergency departments where space is limited. Lack of support services and adequate staffing were also obstacles to providing quality EOL care in rural emergency departments. Consequently, rural nurses are commonly pulled away from EOL care to perform ancillary duties because additional support personnel are lacking. Providing EOL care in rural emergency departments is a challenging task given the limited staffing and resources, and thus it is imperative that nurses' suggestions for improvement of EOL care be acknowledged. Because of the current lack of research in rural EOL care, additional research is needed.

Introduction Pediatric health care settings are high-risk environments for spreading communicable and vaccine-preventable diseases from health care workers to susceptible patients. Method All managers of pediatric clinics operating in the state of Utah were included. Participants were invited to complete a two-page questionnaire regarding their clinic vaccination policies. Results Half ( n = 23) of Utah pediatric outpatient clinic managers recommend employee vaccinations, although employee refusal was allowed without consequence. Of all adult vaccines, influenza was most often included by managers as part of the employee vaccination policy. Some managers required unvaccinated employees to wear masks in the event of illness, but many had no additional requirements for unvaccinated and ill employees. Discussion Vaccination of health care workers is an effective approach to reduce disease transmission. Mandatory vaccination policies can significantly improve vaccination rates among health care workers.

Purpose: Conduct an integrative literature review to evaluate the safety and effectiveness of live-virus vaccines, namely, the measles, mumps, rubella, and varicella vaccines, in children who are immune compromised by exogenous medication either posttransplant or while undergoing maintenance chemotherapy for leukemia. Data sources: Medline, MedlinePlus, EBSCO, PubMed, MD Consult, CINAHL, Clinical Pharmacology, ERIC, Biomedical Reference Collection-Basic, Health Source-Consumer Edition, Health Source-Nursing/Academic Edition, Ovid, CANCERLIT, and the Cochrane Library Online. Conclusions: Because measles infection has a low incidence rate in the United States, it may be advisable not to vaccinate children who are immunocompromised and risk side effects of the vaccine. In contrast to measles infection, varicella has a higher incidence rate and poses a more imminent threat to those who are immunocompromised. Children who are immunosuppressed can receive the varicella vaccination; however, they should have regular titers drawn to confirm adequate protection against the disease and should receive boosters as deemed appropriate. Implications for practice: The number of solid organ transplant recipients is steadily increasing with more than 600,000 solid organ transplantations worldwide since the first renal transplant in 1954. The steadily increasing numbers of pediatric patients surviving transplantation, coupled with increased life expectancy, accelerate the need for nurse practitioners to understand the management of these delicate patients following release from the transplant unit.

• Background Providing appropriate end-of-life care has become a primary concern of nurses and the public. The highly technological critical care environment may not facilitate such care. • Objective To collect suggestions from critical care nurses for improving end-of-life care in intensive care units. • Methods A geographically dispersed, random sample of 1409 members of the American Association of Critical-Care Nurses was sent a 72-item survey on perceptions of end-of life care. The survey included a request for suggestions on ways to improve end-of life care. • Results Of the 861 critical care nurses who responded to the survey, 485 offered 530 suggestions for improving end-of-life care. Providing a “good death” was the major theme; specific suggestions included ways to help ensure death with dignity and peace. Barriers to providing good deaths included nursing time constraints, staffing patterns, communication challenges, and treatment decisions that were based on physicians’ rather than patients’ needs. Suggestions for providing a good death included facilitating dying with dignity; not allowing patients to be alone while dying; managing patients’ pain and discomfort; knowing, and then following, patients’ wishes for end-of-life care; promoting earlier cessation of treatment or not initiating aggressive treatment at all; and communicating effectively as a health-care team. Educational initiatives for professionals and the public were also suggested. • Conclusions Implementation of specific suggestions provided by experienced critical care nurses might increase the quality of end-of-life care, facilitating a good death for intensive care patients.

• Background Critical care nurses care for dying patients daily. The process of dying in an intensive care unit is complicated, and research on specific obstacles that impede delivery of end-of-life care and/or supportive behaviors that help in delivery of end-of-life care is limited. • Objective To measure critical care nurses’ perceptions of the intensity and frequency of occurrence of (1) obstacles to providing end-of-life care and (2) supportive behaviors that help in providing end-of-life care in the intensive care unit. • Methods An experimental, posttest-only, control-group design was used. A national, geographically dispersed, random sample of members of the American Association of Critical-Care Nurses was surveyed. • Results The response rate was 61.3%, 864 usable responses from 1409 eligible respondents. The highest scoring obstacles were frequent telephone calls from patients’ family members for information, patients’ families who did not understand the term lifesaving measures, and physicians disagreeing about the direction of a dying patient’s care. The highest scoring supportive behaviors were allowing patients’ family members adequate time alone with patients after death, providing peaceful and dignified bedside scenes after death, and teaching patients’ families how to act around a dying patient. • Conclusions The biggest obstacles to appropriate end-of-life care in the intensive care unit are behaviors of patients’ families that remove nurses from caring for patients, behaviors that prolong patients’ suffering or cause patients pain, and physicians’ disagreement about the plan of care.

To provide an overview of the prothrombin 20210A mutation, its effects on the incidence of venous thromboembolism (VTE) in users of oral contraceptive therapy (OCT), and screening recommendations for the primary care practice setting.Several databases, including MEDLINE, EMBASE, BIOSIS, Cochrane Library, and SciSearch, were searched for articles published between 1996 and 2003. An integrative review of studies addressing prothrombin 20210A was done using available case-series and case-control studies. No randomized controlled trials on prothrombin 20210A were available in the literature from the years searched.Prothrombin 20210A increases the risk of developing a VTE for those who carry the genetic mutation. The presence of either concomitant circumstantial factors (e.g., surgery or immobilization) or a combination of genetic factors (e.g., factor V Leiden and prothrombin 20210A) raises the frequency of VTEs to an even greater extent. The risk increases exponentially in users of OCT. Screening guidelines for the use of OCT in prothrombin 20210A carriers remain unclear due to the paucity of empirical evidence related to the topic.Practitioners caring for a prothrombin 20210A carrier should maintain a high degree of suspicion with even vague signs or symptoms of a possible VTE. Practitioners should consider completing a full diagnostic workup for VTE on that patient, particularly if that patient is taking OCT. Until evidence becomes available as to the best anticoagulation practice after an initial or recurrent VTE in a prothrombin 20210A carrier, standard treatment guidelines for anticoagulation should be followed.