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Lacey M Eden, Janelle LB Macintosh, Karlen E Luthy, Renea L Beckstrand College of Nursing, Brigham Young University, Provo, UT, USA Abstract: Pain experienced in childhood can lead to long-term and psychologically detrimental effects. Unfortunately, the most common pain experienced in childhood is caused by vaccinations and may lead to non-adherence to the recommended vaccination schedule. As a result, it is the health care provider's responsibility to take measures to reduce vaccination pain; however, there are a plethora of pain relieving interventions during immunizations and it is unclear which interventions are most cost efficient, timely, and effective. Studies have been conducted to investigate the efficacy of different pain management interventions during vaccinations. This review evaluates various pain relieving interventions and provide health care providers age appropriate guidance on pain relieving interventions during vaccinations. Employment of these strategies may successfully reduce vaccination-associated pain in infants, children, and adolescents, and may improve compliance with the vaccination schedule. Keywords: immunization, intervention, effective, compliance

Background: Twenty percent of Americans live in rural areas where most of their health care is provided in critical-access hospitals (CAHs). It is unknown how frequently obstacle and helpful behavior items occur in end-of-life (EOL) care in CAHs., Objectives: The aims of this study were to determine the frequency of occurrence scores of obstacle and helpful behavior items in providing EOL care in CAHs and to also determine which obstacles and helpful behaviors have the greatest or least impact on EOL care based on the magnitude scores., Methods: A questionnaire was sent to nurses working in 39 CAHs in the United States. Nurse participants were asked to rate obstacle and helpful behavior items by size and frequency of occurrence. Data were analyzed to quantify the impact of obstacle and helpful behavior items on EOL care in CAHs by multiplying the mean size by the mean frequency of items to determine mean magnitude scores., Results: Items with the highest and lowest frequency were determined. In addition, obstacle and helpful behavior item magnitude scores were calculated. Seven of the top 10 obstacles were related to patients' families. Seven of the top 10 helpful behaviors involved nurses ensuring families had positive experiences., Conclusion: Nurses in CAHs perceived issues around patient family members as significant obstacles to EOL care. Nurses work to ensure that families have positive experiences. Visiting hour issues seemed to be irrelevant. The use of technology, such as telehealth, seemed to provide little benefit in EOL care in CAHs., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Critical care nurses working in urban settings have reported obstacles in caring for dying patients. However, the perceptions of such obstacles by nurses working in critical access hospitals (CAHs), which are located in rural areas, are unknown., Objective: To study stories and experiences related to obstacles in providing end-of-life care reported by CAH nurses., Methods: This exploratory, cross-sectional study presents the qualitative stories and experiences of nurses working in CAHs as reported on a questionnaire. Quantitative data have been previously reported., Results: Sixty-four CAH nurses provided 95 categorizable responses. Two major categories emerged: (1) family, physician, and ancillary staff issues and (2) nursing, environment, protocol, and miscellaneous issues. Issues with family behaviors were families' insistence on futile care, intrafamily disagreement about do-not-resuscitate and do-not-intubate orders, issues with out-of-town family members, and family members' desire to hasten the patient's death. Issues with physician behaviors were providing false hope, dishonest communication, continuation of futile treatments, and not ordering pain medications. Nursing-related issues were not having enough time to provide end-of-life care, already knowing the patient or family, and compassion for the dying patient and the family., Conclusion: Family issues and physician behaviors are common obstacles in rural nurses' provision of end-of-life care. Education of family members on end-of-life care is challenging because it is most families' first experience with intensive care unit terminology and technology. Further research on end-of-life care in CAHs is needed., (©2023 American Association of Critical-Care Nurses.)

School nurses frequently interact with school-age children and their parents/guardians regarding vaccinations. As a trusted source of information, the school nurse is in a unique position to share vaccine information with parents/guardians and school-age children that may dispel myths and, consequently, improve vaccination rates. Nevertheless, some parents/guardians are still reluctant to vaccinate their school-age children against Human Papilloma Virus (HPV) for a variety of reasons. Common barriers to HPV vaccination include a lack of understanding of the vaccine's purpose, concerns regarding the vaccine's safety, and insufficient recommendation from healthcare workers. However, school nurses have many duties in addition to ensuring vaccine compliance. School nurses may have difficulty remaining up-to-date on evidence-based answers to parents'/guardians' questions about HPV vaccine. Therefore, the purpose of this article is to provide school nurses with a quick reference question and answer guide to parents'/guardians' common HPV-related vaccination questions.

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., (©2022 American Association of Critical-Care Nurses.)

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., (Copyright © 2021 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Abstract: Nurse practitioners have the skills needed to make meaningful policy change to improve health care. In 2017, the authors championed a bill, House Bill 308 Substitution 2 (HB 308 Sub 2), which passed in the Utah Legislature. This health policy article details the process of successful passage of HB 308 Sub 2 and guides advanced practice registered nurses (APRNs) in enacting legislation. The steps detailed to enact legislation are based on Longest's policy framework (2006). The acronym CHANGE was developed and stands for collecting data, hinge, associations, negotiate, gather, and expect to be the expert. Intricacies of lawmaking are also explained including timing of legislation, the three readings, and lobbying. The CHANGE acronym outlines the following: Collecting data to legitimize the problem and proposed solution. The Hinge refers to the specifics of the proposed solution. Associations involve garnering support from key stakeholders early and often in the legislative process. Negotiate refers to finding a bill sponsor that is trustworthy, negotiates well, and has political capital. Gather public support is a critical step to increase legislatures' constituent communication requesting support for the bill. Expect to be the expert refers to understanding arguments for and against the bill and crafting power statements. Passing of HB 308 Sub 2, through the work of APRNs, provides a step-by-step guide to successful passing of legislation. This guide will empower APRNs across the nation with the knowledge to enact and pass policies to improve health care in our nation., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2020 American Association of Nurse Practitioners.)

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: Antibiotic stewardship (ABS) is a set of strategies to optimize antimicrobial use while reducing antibiotic resistance, improving patient outcomes, and decreasing unnecessary costs. Nurse practitioners (NPs) play an essential role in health care education and represent a valuable potential resource for ABS efforts., Purpose: The purpose of this study was to describe the knowledge, attitudes, and perceptions of NPs toward ABS., Methods: A convenience sample of NPs attending the American Association of Nurse Practitioners annual conference was given a modified descriptive survey. Descriptive statistics were used to assess normality., Results: A total of 194 NPs completed the questionnaire (88% female; 70% master's degree). Factors affecting the decisions of antibiotic prescriptions included patient condition (79%) and patient cost (58%). Nurse practitioners based their antibiotic decisions on the antibiogram (63%) in their setting, whereas 56% indicated they start with broad spectrum and tailor antibiotic choices after cultures are received. Nurse practitioners understood that inappropriate antibiotic use causes resistance (97%), harms the patient (97%), and optimum antibiotic use will reduce resistance (94%). Participants also recognized that strong knowledge of antibiotics was important (94%) and felt confident in using antibiotics (86%). However, 94% agreed that antibiotics are overused nationally, and only 62% thought antibiotics were overused in their setting., Implications for Practice: Nurse practitioners recognize that knowledge about antibiotics is important to their career and would like more education about antibiotics and feedback about their antibiotic choices. Finding effective ways to provide this education could change practice and improve antibiotic use., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2020 American Association of Nurse Practitioners.)

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., (© 2020 American Association of Critical-Care Nurses.)

Background: Adults who suffer with severe and persistent mental illness (SPMI) rarely access medical care to receive preventive vaccines. Aims: To increase the rate of vaccines among the SPMI population in an outpatient community mental health center (CMHC). Methods: A review of the literature identified a gap between the general population and SPMI clients in receiving preventive vaccinations. An initial mixed-method convenience survey of SPMI clients ( n = 392) provided information on current vaccination status, demographics, beliefs, and interest in receiving vaccines. A vaccination program was developed to address identified barriers and increase vaccination rates. Postintervention data were collected through a mixed-method convenience survey of SPMI clients ( n = 60) who participated in immunizations clinics to evaluate client satisfaction. A partnership between the health department and CMHC was developed to deliver vaccines in a nontraditional site. Vaccines administered included annual influenza; hepatitis A; hepatitis B; herpes zoster; measles, mumps, and rubella; pneumococcal; and tetanus, diphtheria, and pertussis (Tdap). Results: More than 1,000 vaccines were administered in the first 8 months, with a significant increase in vaccination rates over baseline for individual vaccines ranging from 18.75% to 83%. Postintervention survey results found a 95% satisfaction rate. Conclusions: Implementation of a vaccination program in a nontraditional site that facilitates access for SPMI clients can promote an overwhelming increase in the vaccination rates for this underserved population. Results suggest that the integration of mental health and CMHC services can have a profound positive effect on SPMI population health.

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.

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.

Background: Immunizations are one of the most important health interventions of the 20th century, yet people in many areas of the world do not receive adequate immunizations. Approximately 3 million people worldwide die every year from vaccine-preventable diseases; about half of these deaths are young children and infants. Global travel is more common; diseases that were once localized now can be found in communities around the world., Problem: Multiple barriers to immunizations have been identified. Healthcare access, cost, and perceptions of safety and trust in healthcare are factors that have depressed global immunization rates., Interventions: Several global organizations have focused on addressing these barriers as part of their efforts to increase immunization rates. The Bill and Melinda Gates Foundation, The World Health Organization, and the United Nations Children's Emergency Fund each have a part of their organization that is concentrated on immunizations., Clinical Implications: Maternal child nurses worldwide can assist in increasing immunization rates. Nurses can participate in outreach programs to ease the burden of patients and families in accessing immunizations. Nurses can work with local and global organizations to make immunizations more affordable. Nurses can improve trust and knowledge about immunizations in their local communities. Nurses are a powerful influence in the struggle to increase immunization rates, which is a vital aspect of global health promotion and disease prevention.

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 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., (©2016 American Association of Nurse Practitioners.)

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., (Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

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.

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., (© 2016 The Author(s).)

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., (Copyright © 2016 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

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., (© The Author(s) 2015.)

Purpose: School employees are in direct contact with children in confined areas, a setting in which communicable infection can quickly spread. Therefore, it is important for school employees to be fully vaccinated. The purpose of this study is to ascertain the current vaccination status and perceptions of school employees in an urban school district., Data Sources: The study employed a nonexperimental mixed-method design. School employee participants (N = 1400) completed a questionnaire to evaluate vaccination status, availability of vaccination records, and vaccination awareness. Participants were randomly selected from 85 schools within one urban school district., Conclusions: Two common perceptions about vaccines emerged from the questionnaire: (a) vaccines are only for children and (b) vaccinations received during childhood are still effective. School employees are unaware of their own vaccination status and the recommended vaccination schedule for adults. Additionally, accessibility to immunization records for adults is frequently inadequate., Implications for Practice: Healthcare providers (HCPs), including nurse practitioners (NPs), are the first line of defense to ensure adults are adequately vaccinated. When vaccinations are tracked and recommended by HCPs, vaccination uptake is improved. NPs who discuss recommended vaccinations with adult patients are instrumental in improving vaccination rates among school employees., (©2015 American Association of Nurse Practitioners.)

Purpose: To determine whether a high rate of postpartum depression (PPD), previously found in immigrant Hispanic women at a community clinic, would also be found in a community sample., Data Sources: Sixty women from local community settings were given the PPDS-S instrument and the General Acculturation Index to screen for PPD symptoms. Data were then compared with previously published community clinic data., Conclusion: Sixty percent of the immigrant Hispanic women showed significant PPD. The only statistically significant positive predictive factor for increased PPD symptoms was having a previous history of depression. In addition, 54% had an elevated symptom content profile score for suicidal thinking., Implications for Practice: Health practitioners should be aware of a potentially high rate of PPD in this population, especially in light of previously studied increased rates of suicide attempts in Latinas. If a prior history of depression is predictive of PPD, it is possible that many of the mothers in our sample suffered from depression prior to the postpartum period, but were not appropriately diagnosed or treated. Recommendations for outreach and further research are discussed. In particular, further research regarding the prenatal prevalence of depression in immigrant Hispanic women is recommended in order to further understand the high incidence of PPD., (©2013 American Association of Nurse Practitioners.)

Background: There continues to be a need for increases in adult vaccination rates, especially among those working in environments which may easily become communicable disease outbreak centers, such as school employees in the school environment. The purpose of this study was to evaluate why rural Utah school employees were non-compliant with the influenza and measles, mumps, and rubella (MMR) vaccines, as well as to identify their views on mandatory vaccination policies., Methods: A questionnaire was distributed to all school employees in a rural Utah school district. Data analysis included frequencies and measures of central tendency and dispersion for quantitative items and theme identification for qualitative items., Results: Only 51% of school employees were adequately vaccinated for influenza. Reasons for noncompliance with the influenza vaccine included inconvenience, lack of perceived need, and questionable vaccine efficacy. There were 39.3% school employees who had not received an MMR during adulthood, which was commonly attributed to lack of knowledge regarding the need for this vaccine. Almost half (45.7%) of school employees believed a mandatory vaccination policy should be instituted, although 24.2% of school employees were opposed to mandatory adult vaccination policies. Reasons for opposing vaccination mandates included violation of personal choice, lack of perceived vaccination safety and efficacy, lack of perceived need for adult vaccines, and vaccine cost., Conclusions: Suboptimal vaccination rates of school employees may negatively affect the health and well-being of individuals in the school environment. School employees report a variety of beliefs regarding the influenza and MMR vaccines. While over half of school employees support mandatory vaccination policies for adults working in the school environment, those opposing such a policy report concerns regarding violation of personal choice. Public health officials and school administrators should coordinate efforts to increase vaccination rates among adults in the school environment., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: Heart disease is the leading cause of death in the United States. HMG-CoA reductase inhibitors, or statins, are medications at the forefront of the battle against cardiovascular disease. Despite their effectiveness, patient compliance with statins has lagged because of medication cost and adverse effects, namely myopathy. Myopathy is the most common side effect of statin use. The purpose of this review is to report plasma levels of CoQ10 in patients taking statins and then to determine the benefit of Coenzyme Q10 (CoQ10) supplementation on statin-related myopathy as evidenced by symptomatic improvement and increase in serum levels of CoQ10., Data Sources: CINAHL, Medline, Health Source: Nursing/Academic Edition, and Cochrane Library., Conclusions: Evidence from this review suggests that studies showed a significant relationship between statin intake and decreased serum levels of CoQ10. A few studies showed a benefit in symptoms of myalgia or improvement of serum levels of CoQ10 with supplementation. One study showed no benefit of CoQ10 supplementation when taken with statins. There were no risks of supplementation reported in any of the studies., Implications for Practice: CoQ10 supplementation might benefit those patients suffering from statin-induced myopathy as evidenced by the results of these studies. Supplementation of CoQ10 at a dose of between 30 and 200 mg daily has shown to have beneficial effects on statin myopathy with no noted side effects. Further research is necessary., (©2013 The Author(s) ©2013 American Association of Nurse Practitioners.)

Purpose: To identify common causes of parental anxiety regarding childhood vaccinations among parents who vaccinate. Another purpose was to seek recommendations for healthcare providers to help parents overcome their anxiety when their children are immunized., Data Sources: Four 1-h focus groups were conducted, each consisting of 8-10 parents. Each focus group discussion was conducted by a moderator and an assistant moderator. The moderator facilitated discussion while the assistant moderator took notes. Each session was recorded on video. The data were transcribed and analyzed for themes., Conclusions: Parents identifying themselves as being compliant with childhood vaccination requirements reported anxiety that can be divided into five major themes: parental anxiety prior to vaccination, parental anxiety during the vaccination, parental anxiety after the vaccination, parental suggestions for healthcare providers, and informational issues., Implications for Practice: Making minor changes in office policies may help alleviate some parental anxiety regarding vaccinations. Providers should also create lists of credible sources about vaccination information. Because the cause of vaccine-related parental anxiety varies, targeted education is necessary to relieve common causes of vaccine anxiety, even among parents who vaccinate., (©2013 The Author(s) ©2013 American Association of Nurse Practitioners.)

Introduction: 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., Methods: 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., Results: 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., Discussion: 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., (Copyright © 2013 National Association of Pediatric Nurse Practitioners. Published by Mosby, Inc. All rights reserved.)

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.

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.

Purpose: To provide an overview of normal and abnormal temper tantrum behavior as well as give recommendations nurse practitioners (NPs) can use in counseling families., Data Sources: Articles were identified from the following databases: CINAHL, HEALTH SOURCE: Nursing/Academic edition, Medline, Social Work Abstracts, Social Science Abstracts, Psych INFO, Psychology and Behavioral Science Collection. Textbook references were also identified using Stat!Ref., Conclusions: Temper tantrums are one of the most common behavior problems in children. Although most children will have tantrums, with NPs' support and guidance in primary care encounters, most children will not require further intervention., Implications for Practice: NPs caring for children will need to identify normal and abnormal tantrum behavior as well as rule out other causes of tantrums in order to help parents handle the tantrum behavior. To obtain CE credit for this activity, go to http://www.aanp.org and click on the CE Center. Locate the listing for this article and complete the post-test. Follow the instructions to print your CE certificate., (©2012 The Author(s) Journal compilation ©2012 American Academy of Nurse Practitioners.)

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., (Copyright © 2012 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Introduction: More than 123 million ED visits are reported annually. Many patients who arrive for care to help extend their lives instead die while in the emergency department. Emergency departments were designed to save lives rather than to provide optimal end-of-life (EOL) care. Emergency nurses care for these dying patients and their families. The purpose of this study was to determine what suggestions emergency nurses have for improving EOL care., Methods: Emergency nurses were asked which aspects of EOL care they would like to see changed to improve how patients die in emergency departments. Of the 1000 nurses surveyed, 230 provided a total of 295 suggestions for improving EOL care. Content analysis was used to identify categories of qualitative responses. Responses were coded individually by research team members and then compared with ED EOL literature. Clusters of data were formulated to form themes with sufficient data returned to reach saturation., Results: Five major themes and four minor themes were identified. The major themes were increasing the amount of time ED nurses have to care for dying patients, allowing family presence during resuscitation, providing comfortable patient rooms, providing privacy, and providing family grief rooms., Conclusion: Large numbers of patients seek care in emergency departments. Emergency nurses are often called on to care for dying patients and their families in this highly technical environment, which was designed to save lives. Emergency nurses witness the obstacles surrounding EOL care in emergency departments, and their recommendations for improving EOL care should be implemented when possible., (Copyright © 2012 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Introduction: Of the 119.2 million visits to the emergency department in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In 2 national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses and to determine how much input emergency nurses have on the design of their emergency department., Methods: A 25-item questionnaire regarding ED design as it affects EOL care was sent to a national, geographically dispersed, random sample of 500 members of ENA. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis., Results: Two mailings yielded 198 usable responses. Nurses did not report that ED design was as large an obstacle to EOL care as previous studies had suggested. Nurses reported that the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested ED designs., Discussion: Overall, nurses reported some dissatisfaction with ED design and believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department., (Copyright © 2012 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Purpose/objectives: To determine the impact of obstacles and supportive behaviors in end-of-life (EOL) care as perceived by hospital-based oncology nurses., Design: A 69-item mailed survey., Setting: National random sample., Sample: 1,005 nurse members of the Oncology Nursing Society who had provided EOL care for patients with cancer., Methods: Three mailings yielded 380 usable responses from 912 eligible respondents, resulting in a 42% return rate., Main Research Variables: Size and frequency of EOL care obstacles and supportive behaviors for patients with cancer in a hospital setting., Findings: Results of this research demonstrate the need for more EOL education and help in forming teams of nurses, social and palliative care workers, and physicians to support high-quality care. Another finding was the need for other nurses at a facility to give the nurse caring for the dying patient more time to support the patient and family., Conclusions: Dealing with the family is vital in providing optimal EOL care to patients dying from cancer. By carefully listening to the experience, concerns, and recommendations of hospital-based oncology nurses, compassionate EOL care can be provided to these patients and their families., Implications for Nursing: Oncology nurses are dedicated to providing the best EOL care to their patients and patients' families. This study helped to identify research-based obstacles and supportive behaviors regarding the provision of high-quality EOL care.

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.

State immunization laws necessitate compliance for students enrolling in a public or private school system. In support of state laws, school nurses expend hours to achieve immunization compliance with school-age children. For the purpose of creating a more efficient system, researchers implemented an educational and incentive program in local elementary schools to increase tetanus, diphtheria, and acellular pertussis (Tdap) booster compliance rates. Students were instructed in regard to their immune systems, immunizations, and where to obtain immunizations. In addition, compliant students were entered into a drawing for an iPod Shuffle or a RipStick. In 2009, the compliance rate expanded from 4% to 57% during a 4-week intervention program. Notably, the Tdap immunization compliance rate in the previous year (2008) was 54%. Researchers concluded that the intervention did not improve compliance rates significantly.

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.

Introduction: One reason for lower immunization rates is that some parents hesitate to have their children immunized. A hesitancy questionnaire was developed to identify reasons parents hesitate in having their children immunized., Methods: The hesitancy questionnaire was distributed from local pediatric and family practice offices and from the area's county health department. To be eligible, participants needed to be present in the clinic with a child needing a minimum of one immunization that was at least 6 months overdue., Results: When questioned why their child was overdue for immunizations, the most common response was that participants were confused about the immunization schedule and not sure when to return. Of the participants who reported having concerns regarding immunizations, the child's pain/crying/anxiety was the most commonly occurring answer. When asked where they receive the majority of childhood immunization information, participants frequently identified their health care provider as the main source of information., Discussion: Health care providers may be missing opportunities to educate hesitant parents about immunizations. Parents may not have ample opportunities to discuss their immunization concerns in detail with their health care provider during regularly scheduled clinic visits. It is important for health care providers to suggest ways parents can cope with their child's pain/crying/anxiety when receiving immunizations.

Nurses are encountering an increasing number of ethical dilemmas in clinical practice. Ethics courses for baccalaureate nursing students provide the opportunity for the development of critical thinking skills in order to deal with these effectively. The purpose of this descriptive qualitative study was to describe ethical reasoning in 70 baccalaureate nursing students enrolled in a nursing ethics course. Reflective clinical journals were analyzed as appropriate for qualitative inquiry. The overriding theme emerging from the data was 'in the process of becoming', which includes: practicing as a professional, lacking the confidence as a student nurse to take an ethical stand, advocating for patients, being just in the provision of care, identifying the spiritual dimensions of nursing practice, confronting the 'real world' of health care, making a commitment to practice with integrity, and caring enough to care. The development of critical thinking and ethical reasoning within the framework of knowing and connecting is essential in nursing education.

The purpose of this article is to explain the concepts of Writing Across the Curriculum, Writing in the Disciplines, and Writing to Learn, and to describe the incorporation of advanced writing into a baccalaureate nursing program and provide suggestions for accessing resources and promoting success. The goals of incorporating Writing Across the Curriculum, Writing in the Disciplines, and Writing to Learn concepts into nursing curriculum are to assist nursing students to achieve competence in clinically relevant writing assignments; to demonstrate critical thinking and communication skills, both oral and written; to execute useful literature searches; to read and understand research reports; and to encourage the incorporation of evidence into clinical practice. With a strong and established writing foundation, nursing students will be more successful in written and oral communication during their nursing program and throughout their nursing career.