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The objective of this review was to determine whether electronic health (eHealth) educational interventions about infant procedural pain and pain management impact parental outcomes (eg, mental health, knowledge uptake), eHealth outcomes (eg, acceptance, use), and pain management outcomes (eg, parental involvement, infant pain response).Pain in infants is a common concern for parents. Routine postpartum care for infants in early life requires them to endure painful procedures, such as immunizations, yet infants often receive little to no pain management. Parents are an essential component of effective pain management, although they may not be aware of the roles they can have. Despite the increased number of eHealth resources available to educate parents about infant pain management, their impact has yet to be synthesized.This review considered studies that evaluated eHealth educational interventions targeted at parents during pregnancy and up to one year postpartum. Interventions included, but were not limited to, mobile applications, web-based applications, websites, videos, interactive training, hands-on direct simulation, short message service (SMS), and desktop applications. Primary outcomes included parental outcomes (eg, stress or anxiety, self-efficacy, knowledge, attitudes), eHealth outcomes (eg, acceptance, use), and pain management outcomes (eg, parental involvement, infant pain response). Experimental, quasi-experimental, and observational study designs were included.MEDLINE, CINAHL, PsycINFO, Embase, Scopus, Web of Science, and SciELO were searched for studies published in English up to June 14, 2021. Citation lists of relevant reviews and included studies were also searched for additional peer-reviewed articles. Two independent reviewers conducted critical appraisal, using standardized tools from JBI, and data extraction, using a data extraction form designed by the authors. Statistical pooling of quantitative data was not possible due to heterogeneity; thus, the findings were reported narratively.A total of 4163 unique studies were screened, with 11 studies ultimately included for synthesis. Five articles were randomized controlled trials, five articles were analytical cross-sectional studies, and one article was quasi-experimental. Studies reported on four unique eHealth educational interventions, all of which used video format and primarily targeted the postnatal period. The findings for all primary outcomes were mixed but suggested either improvements in outcomes or no impact. The certainty of evidence was determined as low or very low across primary outcomes for reasons related to imprecision, risk of bias, and indirectness.Although heterogeneity of findings limited quantitative synthesis of data, this review suggests that short and engaging educational videos have the potential to positively impact parents' knowledge, confidence, and desire to be involved in procedural pain management for their children. Most of the interventions presented in this review describe evidence-based information about procedural pain management strategies that are known to be effective for infant populations. Thus, it is reasonable to assume that infant pain response should be lower when parents appropriately apply the strategies. However, the findings of this review were not able to confirm this assumption. More research is needed to evaluate the impact of parent-targeted pain management education on infant pain response.PROSPERO CRD42020151569.

To explore the use of Indigenous philosophies and ways of knowing as a means to critique, understand and improve the care of Indigenous infants and families in the neonatal intensive care unit (NICU).The ability of health professionals to provide culturally safe and equitable care to Indigenous infants and their families can affect infant development and long-term health outcomes. Research suggests that family involvement in care benefits both the infant and their family, but there is limited research that addresses the experience of Indigenous families in the NICU and advances understanding of how nurses involve Indigenous families in their infants' care.A discursive, critical review will be presented to outline the assumptions of Indigenous philosophies and to explore how the consideration and implementation of Indigenous ways of knowing can improve the nursing care of Indigenous infants and their families in the NICU.First, our subjective positioning as Indigenous nurses and as health researchers is described. Second, our understanding of Indigenous philosophical frameworks and how these approaches fit in the context of the philosophy of science is defined. Third, the key elements of an Indigenous philosophical paradigm are described. Fourth, an application of Indigenous paradigms to supporting the care of Indigenous infants and families in the NICU context is made.An Indigenous philosophical approach to nursing is ideal for understanding and improving the experiences of Indigenous infants and families in the NICU. This approach allows nurses to critically analyse the history and legacy of colonialism and its impact on the health and wellbeing of Indigenous peoples. By prioritising the voices and concerns of Indigenous families in the clinical setting and in nursing research, nurses can better understand the experiences of these families in the NICU and use strengths-based approaches to facilitate family involvement in care.The application of Indigenous philosophies in the nursing context can be used to inform the care of Indigenous infants and families in the NICU. Potential benefits include improved therapeutic relationships between nurses and Indigenous families, and increased uptake of parent-led interventions in nursing practice, which may lead to improved health outcomes for Indigenous infants in the NICU and throughout their subsequent development.

BACKGROUND First Nations children and youth may have unique ways to convey their health needs that have not been recognized by health providers. This may contribute to the disparity between high rates of mental health and physical pain and the low rates of treatment for the conditions they experience. Evidence suggests a colonial history has resulted in poor experiences with the healthcare system, lack of trust with health providers and miscommunication between clinicians and patients. Contemporary ways using both Indigenous and Western knowledge is needed to bridge the gap in communicating pain. OBJECTIVE The aim of this qualitative study was to test the usability of the Kids Hurt App with First Nations youth and clinicians working with youth. METHODS Using a Two-eyed seeing approach, a kids hurt icon based app was developed using concepts from validated mood and pain assessment apps combined with community-based research that gathered First Nations youth perspectives on quality, intensity and location of pain and hurt. The kids hurt app contains 12 screens accessible on a handheld mobile phone or tablet device. RESULTS Three rounds of low fidelity testing and two rounds of high-fidelity testing were conducted with 19 First Nations youth to determine the usability of the Kids Hurt app. High-fidelity testing was also conducted with 15 clinicians after completing the youth sessions. Youth had constructive suggestions that were used to improve the app in subsequent rounds of version testing. There was one main discrepancy between youth and clinicians related to in visual preference for way to convey pain. Youth’s preference was maintained in the app. CONCLUSIONS All youth in all rounds of testing indicated they would use the Kids Hurt app if it was available to them in a health care setting with most clinicians noting the app would be useful in practice. CLINICALTRIAL N/A

Children with an autism spectrum disorder (autism) are vulnerable to negative experiences within the surgical setting. This qualitative study used Interpretive Description. Individual interviews were conducted with 8 parents of children with autism who had recently undergone surgery, and 15 healthcare providers (HCPs) with experience caring for children with autism. Participants were asked open-ended questions on the approaches used to support children with autism around the time of surgery and their effectiveness, how the surgical experience could be improved, and the barriers and facilitators to potential improvements. Results yielded three main themes within an overarching metaphor of a balancing act. The first theme, finding your footing through an uncertain journey, described individual factors (e.g. anticipatory anxiety) that set the foundation for surgery-related experiences. The second theme, relationships can help to keep everyone steady, highlighted how interpersonal dynamics (e.g. collaboration and empathy) influence the experience. Finally, the systems shape the experience theme captured the impact of systemic factors (e.g. the hospital environment) on the balancing act. These findings enriched our understanding of how individual, interpersonal, and systemic factors influence the surgical experiences of children with autism, families, and HCPs. Insights gained from this study can be used to inform future interventions. Lay abstract Children with an autism spectrum disorder (autism) often have negative experiences within the surgical setting. We conducted individual interviews with 8 parents of children with autism who had recently undergone surgery, and 15 healthcare providers (HCPs) with experience caring for children with autism. We asked open-ended questions on the approaches used to support children with autism around the time of surgery, how effective they were, suggestions for improvement, and the barriers and facilitators to improvement. Three main themes emerged within an overarching metaphor of a balancing act. The first theme, finding your footing through an uncertain journey, described individual factors (e.g. anticipatory anxiety) that set the foundation for experiences. The second theme, relationships can help to keep everyone steady, highlighted how personal interactions (e.g. collaboration and empathy) influence the experience. Finally, the systems shape the experience theme captured how systemic factors (e.g. the hospital environment) affected the balancing act. These findings enriched our understanding of the surgical experiences of children with autism, families, and HCPs by demonstrating the importance of individual characteristics, relationships, and systemic factors. Future interventions should consider this complexity and intervene not just with children, but also their parents, healthcare providers, and in policy to improve experiences.

Introduction Participatory research involving community engagement is considered the gold standard in Indigenous health research. However, it is sometimes unclear whether and how Indigenous communities are engaged in research that impacts them, and whether and how engagement is reported. Indigenous health research varies in its degree of community engagement from minimal involvement to being community-directed and led. Research led and directed by Indigenous communities can support reconciliation and reclamation in Canada and globally, however clearer reporting and understandings of community-led research is needed. This scoping review assesses (a) how and to what extent researchers are reporting community engagement in Indigenous health research in Atlantic Canada, and (b) what recommendations exist in the literature regarding participatory and community-led research. Methods Eleven databases were searched using keywords for Indigeneity, geographic regions, health, and Indigenous communities in Atlantic Canada between 2001-June 2020. Records were independently screened by two reviewers and were included if they were: peer-reviewed; written in English; health-related; and focused on Atlantic Canada. Data were extracted using a piloted data charting form, and a descriptive and thematic analysis was performed. 211 articles were retained for inclusion. Results Few empirical articles reported community engagement in all aspects of the research process. Most described incorporating community engagement at the project’s onset and/or during data collection; only a few articles explicitly identified as entirely community-directed or led. Results revealed a gap in reported capacity-building for both Indigenous communities and researchers, necessary for holistic community engagement. Also revealed was the need for funding bodies, ethics boards, and peer review processes to better facilitate participatory and community-led Indigenous health research. Conclusion As Indigenous communities continue reclaiming sovereignty over identities and territories, participatory research must involve substantive, agreed-upon involvement of Indigenous communities, with community-directed and led research as the ultimate goal.

The objective of this review is to determine if electronic health (eHealth) educational interventions for infant procedural pain and pain management impact parental outcomes (mental health outcomes, knowledge utilization outcomes, and parental involvement in care outcomes) and infant outcomes (morbidity outcomes, pain outcomes, health system outcomes).Pain in infants is a common concern for parents. Routine postpartum care for infants in early life requires them to endure painful procedures, yet infants often receive little to no pain management. While research has shown that parents can reduce their infant's pain during procedures by breastfeeding or skin-to-skin contact, parents may not be aware of their role in pain management. Despite the recent rapid increase in eHealth resources to educate parents about infant pain management, their impact has yet to be evaluated.This review will consider studies that include eHealth educational interventions targeted at parents during pregnancy and up to one year postpartum. All experimental study designs will be included. Primary outcomes will include: parental stress and anxiety, self-efficacy, knowledge, attitudes, eHealth intervention usage, acceptance of eHealth intervention, involvement in pain management, and infant pain response.PubMed, CINAHL, PsycINFO, Embase, Scopus, Web of Science, and SciELO will be searched for studies published in English. Critical appraisal and data extraction will be conducted by two independent reviewers using standardized tools. Quantitative data, where possible, will be pooled in statistical meta-analysis, or if statistical pooling is not possible, the findings will be reported narratively.

Pain and culture are complex and multifactorial phenomena. The concepts are difficult to define and measure since they intersect with the biological, psychological, and social realms. Considering the intrinsic multidimensionality of each phenomenon, we are only beginning to understand the myriad ways in which culture may influence pain. Consequently, (1) the study of the relationship between culture and pain has been fraught with methodological and theoretical challenges; and (2) there is little evidence to support specific guidelines on how to assess and treat pain of specific cultural groups. Therefore, researchers face challenges in conducting research on pain with indigenous populations.

Introduction Indigenous communities across Canada report that transformations in Indigenous health research are needed, where the benefits of research shift intentionally, collaboratively, and with transparency from the researchers directly to Indigenous communities and partners. Despite its challenges and potential for harm, research, if done ethically and with respect and partnership, can be a force for change and will strengthen the efficacy of data on Indigenous Peoples’ health and wellbeing. Purpose To characterize the nature, range, and extent of Indigenous health research in Atlantic Canada, and to identify gaps. Methods Eleven databases were searched using English-language keywords that signify Indigeneity, geographic regions, health, and Indigenous communities in Atlantic Canada between 2001 and May 2020. All references were reviewed independently by two reviewers. Of the 9056 articles identified, 211 articles were retained for inclusion. Data were extracted using a collaboratively developed data charting form. Results Indigenous health research in Atlantic Canada has increased over time, covering a diverse range of health topics. The main areas of research included climate change, child and youth health, and food and water security, with the majority of research deriving from Newfoundland and Labrador. Rates of reported community engagement remain relatively low and steady between 2001 and 2020, however there was an increase in researchers seeking Indigenous ethics approvals for such engagement. Conclusions This scoping review synthesizes 20 years of Indigenous health research in Atlantic Canada. The results indicate that although there are increases in Indigenous ethics approvals, there is more work needed to ensure that Indigenous Peoples lead, design, and benefit from research conducted in their homelands.

Etuaptmumk or Two-Eyed Seeing (E/TES) is foundational in ensuring that Indigenous ways of knowing are respected, honoured, and acknowledged in health research practices with Indigenous Peoples of Canada. This paper will outline new knowledge gleaned from the Canadian Institute of Health Research and Chronic Pain Network funded Aboriginal Children’s Hurt & Healing (ACHH) Initiative that embraces E/TES for respectful research. We share the ACHH exemplar to show how Indigenous community partners take the lead to address their health priorities by integrating cultural values of kinship and interconnectedness as essential components to enhance the process of community-led research. E/TES is conceptualised into eight essential considerations to know in conducting Indigenous health research shared from a L’nuwey (Mi’kmaw) perspective. L’nu knowledge underscores the importance of working from an Indigenous perspective or specifically from a L’nuwey perspective. L’nuwey perspectives are a strength of E/TES. The ACHH Initiative grew from one community and evolved into collective community knowledge about pain perspectives and the process of understanding community-led practices, health perspectives, and research protocols that can only be understood through the Two-Eyed Seeing approach.

Aim The purpose of this study was to evaluate the psychometric properties of the Korean-language versions of Pain Knowledge and Use (PKU-K), Collaboration and Satisfaction About Care Decisions (CSACD-K), and Environmental Complexity Scale (ECS-K). Methods A cross-sectional design was used with a convenience sample of 159 Korean nurses in seven neonatal intensive care units (NICUs). The data were collected by surveying the nurses with the PKU-K, CSACD-K, and ECS-K. Internal consistency reliability was assessed and Horn's parallel analysis, a confirmatory factor analysis, and a convergent construct validity test were conducted in order to evaluate the psychometric properties of the instruments. Results The PKU-K, CSACD-K, and ECS-K exhibited strong internal consistency reliability. Horn's parallel analysis showed four factor structures for the PKU-K, one for the CSACD-K, and three for the ECS-K. The confirmatory factor analysis showed a good model fit for the PKU-K and CSACD-K, but the ECS-K model showed a poor fit. Most factor loadings were statistically significant. The CSACD-K's convergent validity was supported by significant correlations for collegial nurse-physician relations with a validated instrument. Conclusion The findings support the reliability and validity of the PKU-K, CSACD-K, and ECS-K for measuring nurses' knowledge about neonatal pain care, nurse-physician collaboration, and the work environment in NICUs. However, the ECS-K needs further refinement before it is applied to Korean NICU nurses.

Aim The aim of this study is to explore advanced practice nurses’ perceptions of their leadership capabilities. Design A qualitative descriptive methodology informed by a well‐established leadership framework was used to explore advanced practice nurses’ perceptions of their leadership. Methods Purposive sampling of advanced practice nurses working in tertiary acute care facilities in Eastern Canada was employed. Data sources included face‐to‐face interviews and document analysis. Fourteen advanced practice nurses participated in two audio‐taped semi‐structured interviews from March 2013–January 2014. Data were transcribed and analysed using NVIVO 10 software and content analysis. Results Two main themes were identified: “Patient‐focused leadership” and “organization and system‐focused leadership”. These two themes are further described through leadership domains and capabilities that clearly articulate advanced practice nursing leadership and its contribution to improving the care environment for patients and families, nurses and other healthcare providers, organizations and the healthcare system.

Children with acute lymphoblastic leukemia experience pain from the disease, treatment, and procedures. Parents can be effective in managing their child’s pain, but little is systematically known about how they do this. Appreciative inquiry was used to frame the study within a strengths-based lens and interpretive descriptive methods were used to describe pain sources, parents’ pain care role, and key structures supporting parents pain care involvement. Eight paediatric oncology clinic nurses and 10 parents participated. Six key themes per group were identified. Parent themes included establishing therapeutic relationships, relearning how to care for my child, overcoming challenges and recognizing pain, learning parent specific strategies, empowering to take active pain care role, and maintaining relationships. Nurse themes included establishing therapeutic relationships, preparing parents to care for their child, facilitating pain assessment, teaching parents best pain care, empowering parents, and maintaining relationships. These findings can be used to guide clinical practice and future research.

To provide an updated synthesis of the current state of the evidence for the effectiveness of breast-feeding and expressed breast milk feeding in reducing procedural pain in preterm and full-term born infants. A systematic search of key electronic databases (PubMed, CINAHL, EMBASE) was completed. Of the 1032 abstracts screened, 21 were found eligible for inclusion. Fifteen studies reported on the use of breast-feeding or expressed breast milk in full-term infants and 6 reported on preterm infants. Direct breast-feeding was more effective than maternal holding, maternal skin-to-skin contact, topical anesthetics, and music therapy, and was as or more effective than sweet tasting solutions in full-term infants. Expressed breast milk was not consistently found to reduce pain response in full-term or preterm infants. Studies generally had moderate to high risk of bias. There is sufficient evidence to recommend direct breast-feeding for procedural pain management in full-term infants. Based on current evidence, expressed breast milk alone should not be considered an adequate intervention.

This study aimed to translate three English-language instruments-Pain Knowledge and Use (PKU), Collaboration and Satisfaction About Care Decisions (CSACD), and Environmental Complexity Scale (ECS)-into Korean and evaluate the equivalence of the instrument versions. Three Korean translators and two senior reviewers translated the instruments' 56 items using a committee approach. Eight Korean experts evaluated the cultural relevance of the translated instruments using a content validity index (CVI), and 12 Korean neonatal nurses were interviewed to assess their understanding of items. In an expert panel review, the item-CVI was less than 0.78 for 14 items. Based on cognitive interviews, four items were found to be unsuitable in Korea. Based on expert panel review and cognitive interviews, unsuitable items were modified or deleted. In another expert panel review, the scale-CVI was 1.00 for the final instruments. The findings support the validity of the Korean-language PKU, CSACD, and ECS for research application.

Background University students belonging to various ethnic groups have specific health needs that influence their self-rated health and health service use. Purpose To examine which determinants of health serve as key predictors of self-rated health and health service use in a sample of ethnically diverse undergraduate students. Methods Data were abstracted from the 2012 Maritime Undergraduate Student Sexual Health Services Survey (N = 10,512). Logistic regression was used to explore the predictors of self-rated health and use of university-based health services according to ethnicity. Results Social support (Caucasian: odds ratio (OR) = 1.018; 95% confidence interval (CI) [1.008, 1.028]; African: OR = 1.890; 95% CI [1.022, 1.160]; Other: OR = 1.096; 95% CI [1.023, 1.175]), and depression risk (Caucasian: OR = .899; 95% CI [.844, .914]; Indigenous: OR = .904; 95% CI [.844, .969]; Asian: OR = .894; 95% CI [.839, .953]; Multiracial: OR = .892; 95% CI [.812, .980]) were the most frequent predictors of self-rated health across the different ethnic groups; while year of study (Caucasian: OR = 1.855; 95% CI [1.764, 1.952]; African: OR = 2.979; 95% CI [2.068, 4.291]; Indigenous OR = 1.828; 95% CI [1.371, 2.436]; Asian: OR = 1.457; 95% CI [1.818, 1.797]; Middle Eastern: OR = 1.602; 95% CI [1.088, 2.359]; Other: OR = 1.485; 95% CI [1.093, 2.018]; Multiracial: OR = 2.064; 95% CI [1.533, 2.778]) was found to be the most significant predictor of health service use. Conclusion Findings from this research shed light on the various factors that impact university students belonging to different ethnic groups, their health, and their access to healthcare that addresses their distinct health needs. Nurses can advocate for the development of health promotion and illness prevention strategies that target the needs of the diverse student population.

Preterm neonates hospitalized in the neonatal intensive care unit undergo frequent painful procedures daily, often without pain treatment, with associated long-term adverse effects. Maternal-infant skin-to-skin contact, or kangaroo care (KC), and sweet-tasting solutions such as sucrose are effective strategies to reduce pain during a single procedure; however, evidence of sustained efficacy over repeated procedures is limited. We aimed to determine the relative sustained efficacy of maternal KC, administered alone or in combination with 24% sucrose, to reduce behavioral pain intensity associated with routine neonatal procedures, compared with 24% sucrose alone. Stable preterm infants (n = 242) were randomized to receive KC and water, KC and 24% sucrose, or 24% sucrose before all routine painful procedures throughout their neonatal intensive care unit stay. Pain intensity, determined using the Premature Infant Pain Profile, was measured during 3 medically indicated heel lances distributed across hospitalization. Maternal and neonatal baseline characteristics, Premature Infant Pain Profile scores at 30, 60, or 90 seconds after heel lance, the distribution of infants with pain scores suggesting mild, moderate, or severe pain, Neurobehavioral Assessment of the Preterm Infant scores, and incidence of adverse outcomes were not statistically significantly different between groups. Maternal KC, as a pain-relieving intervention, remained efficacious over time and repeated painful procedures without evidence of any harm or neurological impact. It seemed to be equally effective as 24% oral sucrose, and the combination of maternal KC and sucrose did not seem to provide additional benefit, challenging the existing recommendation of using sucrose as the primary standard of care.

Aims The objective of this study was to compare the influence of breastfeeding and 24% oral sucrose on pain-related electrophysiologic activity, bio-behavioural pain scores, physiologic recovery, and adverse events during heel lance. Study design Single-blind randomized controlled trial. Subjects 39 full-term infants were randomized to receive breastfeeding or 0.24 mL of 24% oral sucrose plus offered non-nutritive sucking 2 min prior to heel lance. Outcome measures The primary outcome of pain-related potential was recorded on electroencephalogram. Secondary outcomes included Premature Infant Pain Profile – Revised (PIPP-R) score, physiologic recovery, and adverse events. Data were analyzed per protocol ( ClinicalTrials.gov : NCT03272594 ). Results Between November 2017 and January 2019, 20 infants were randomized to breastfeeding and 19 infants to receive oral sucrose. Infants who were breastfeeding had an appreciably smaller, yet not statistically different (F[1,15.9] = 0.58, p = 0.64, SE = 11.79), amplitude pain-related potential (peak amplitude 0.29 μV) following heel lance compared to infants who received oral sucrose (peak amplitude 8.97 μV). Mean PIPP-R scores were not statistically significantly different between groups following heel lance, however, they were indicative of low pain across groups. Mean time in seconds to physiologic recovery was faster in breastfeeding infants (M = 17.5, SD = 31.1) compared to oral sucrose (M = 70.8, SD = 144.3). There were no safety concerns. Discussion Breastfeeding and oral sucrose both reduce bio-behavioural responses to pain, however, may differentially modulate pain response in the infant brain. Further research to understand the neurophysiologic effects of these interventions during acute painful procedures is needed.

Skin-to-skin contact between mother and infant, commonly referred to as Kangaroo Care (KC), has demonstrated efficacy as a pain-relieving strategy for infants, yet, it remains underutilized in clinical practice.To evaluate changes in neonatal intensive care unit staff nurse beliefs, utilization, and challenges related to practice change in implementing KC as an intervention for management of procedural pain in preterm infants between 2 time points.Nurses who participated in a larger clinical trial examining the sustained efficacy of KC were asked to complete a questionnaire at 2 time points: 1- and 6 month(s) following study initiation. Identified benefits, expectations, frequency of use, and challenges related to practice change uptake were described using frequencies and percentages. Data from the 2 different time points were compared using χ analysis.Of the 40 nurses approached, all completed the questionnaire (19 at the 1-month and 21 at the 6-month time point). Of the sample (n = 40), 97% of participants indicated that they expected KC to provide good pain relief or better. Staff nurses reported significantly improved preconceived ideas (χ = 22.68, P.01) and significantly fewer concerns (χ = 22.10, P = .01) related to using KC as a pain-relieving intervention between the 2 time points. No significant differences were seen in the frequency of using KC as an intervention between time points.Despite increasingly positive preconceived ideas and reduced concerns, the frequency of using KC for procedural pain relief remained unchanged. Further research addressing ways to overcome barriers to utilizing KC as an intervention for procedural pain is warranted.

BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non–First Nations children. METHODS: Data from a study population of age- and sex-matched First Nations and non–First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health). RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non–First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non–First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non–First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1–3.0, and OR 1.7, 95% CI 1.2–2.3, respectively). INTERPRETATION: First Nations children were diagnosed with more pain than non–First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non–First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

Introduction:. Indigenous children and youth may be quiet about the way they express their pain and hurt which is in contrast to how health professionals are trained to assess it. Objectives:. The aim was to understand how youth from 4 First Nation communities express pain using narratives and art-based methods to inform culturally appropriate assessment and treatment. Methods:. This qualitative investigation used a community-based participatory action methodology to recruit 42 youth between 8 and 17 years of age to share their perspectives of pain using ethnographic techniques including a Talking Circle followed by a painting workshop. Physical pain perspectives were prominent in circle conversations, but emotional pain, overlapping with physical, mental, and spiritual pain perspectives, was more evident through paintings. Art themes include causes of pain and coping strategies, providing a view into the pain and hurt youth may experience. Youth were more comfortable expressing emotional and mental pain through their artwork, not sharing verbally in conversation. Results:. Circle sessions and artwork data were themed using the Indigenous Medicine Wheel. Content of the circle conversations centered on physical pain, whereas paintings depicted mainly emotional pain (eg, crying or loneliness; 74% n = 31) with some overlap with physical pain (eg, injuries; 54%), mental pain (eg, coping strategies; 31%), and spiritual pain (eg, cultural symbols; 30%). Common threads included hiding pain, resilience, tribal consciousness, persistent pain, and loneliness. Conclusion:. Once a safe space was created for First Nation youth, they provided a complex, culturally based understanding of the pain and coping experience from both an individual and community perspective. These engaging, culturally sensitive research methods provide direction for health providers regarding the importance of creating a safe space for young people to share their perspectives.

Aim To determine if differences exist between pediatric intensive care nurses and allied health professionals in empathy, secondary trauma, burnout, pain exposure and pain ratings of self and others. Early and late career differences were also examined. Background Nurses are routinely exposed to patient pain expression. This work context may make them vulnerable to adverse outcomes such as desensitization to patient pain or a compromise in personal wellbeing. Design Cross-sectional study. Methods Data were collected from a convenience sample of pediatric intensive care nurses (n=27) and allied health professionals (n=24), from September 2014–June 2015, at a Canadian health centre. Both groups completed one demographic and three behavioural scales. Participants underwent fMRI while rating the pain of infant and adult patients in a series of video clips. Data were analyzed using parametric and non-parametric methods. fMRI results are reported in a second paper. Results Nurses were significantly more likely to be exposed to pain at work than allied health professionals and scored significantly higher on dimensions of empathy, secondary trauma and burnout. Nurses scored their own pain and the pain of infant and adult patients, higher than allied health participants. Less experienced nurses had higher secondary trauma and burnout scores than more experienced nurses. Conclusions Pediatric intensive care work demands, such as patient pain exposure and may be associated with nurse's higher report of empathy and pain in self and others, but also with higher levels of secondary trauma and burnout, when compared with allied health professionals. This article is protected by copyright. All rights reserved.

Aims To determine if there are brain activity differences between pediatric intensive care nurses and allied health professionals during pain intensity rating tasks and test whether these differences are related to the population observed (infant or adult) and professional experience. Background The underestimation of patients’ pain by healthcare professionals has generally been associated with patterns of change in neural response to vicarious pain, notably reduced activation in regions associated with affective sharing and increased activation in regions associated with regulation, compared with controls. Pediatric nurses, however, have recently been found to provide higher estimates of infants’ pain in comparison to allied health controls, suggesting that changes in neural response of this population might be different than other health professionals. Design Cross-sectional study Methods Functional MRI data were acquired from September 2014-June 2015 and used to compare changes in brain activity in 27 female pediatric care nurses and 24 allied health professionals while rating the pain of infants and adults in a series of video clips. Results Pediatric nurses rated infant and adult pain higher than allied health professionals, but the two groups’ neural response only differed during observation of infant pain; pediatric nurses mainly showed significantly less activation in the medial prefrontal cortex (linked to cognitive empathy) and in the left anterior insula and inferior frontal cortex (linked to affective sharing). Conclusions Patterns of neural activity to vicarious pain may vary across healthcare professions and patient populations and the amount of professional experience might explain part of these differences. This article is protected by copyright. All rights reserved.

BACKGROUND: Published reports of substantial rates of moderate to severe pediatric inpatient pain tend to overlook lower-intensity pain that may be clinically significant.OBJECTIVE: To document the prevalence of clinically significant pain in pediatric inpatients by considering the pain threshold at which each child desires intervention, and to assess sources of pain, pain assessment and intervention, and relationships among demographic and medical variables to reported pain.METHODS: Inpatients or their parents on four hospital units during four nonconsecutive days were eligible for inclusion. Interviews (76 parents; 31 patients) captured experiences of 107 inpatients (three weeks to 18 years of age) including current, worst and usual pain, pain treatment thresholds, sources of pain and help received during the previous 24 h. A chart review provided data regarding demographic and medical variables, and pain assessment and management.RESULTS: In total, 94% of patients experienced pain. The prevalence of clinically significant pain was 8% (current), 62% (worst) and 24% (usual). Current and worst pain was primarily procedural, and usual pain was primarily disease related. On average, patients had 4.03 documented pain assessments over 24 h. Caregiver responses (eg, reassurance) and nonpharmacological interventions were frequently reported (>90%) but infrequently documented (CONCLUSIONS: While recent studies suggest reduced pain in pediatric inpatients, the present findings reveal a continued high frequency of undertreated pain. High rates of procedural pain are preventable and should be targeted given the underutilization of pain management strategies.

All children experience body pain as a result of medical procedures, vaccinations, and a variety of chronic conditions. Children are a vulnerable population and may be even more at risk to experience pain in under-resourced environments. We know that physical pain in childhood causes suffering to the child, family, and caregivers, and can also cause prolonged physiological and immune effects lasting into adulthood. There is evidence that Aboriginal children and youth experience pain at higher rates than their non-Aboriginal counterparts. First Nations youth report that pain issues have kept them from participating in essential developmental activities such as school and sports. Effective pain care increases a child’s ability to participate in activities that are meant to enhance well-being and prepare them to be healthy adults. Currently, there is no reliable way for First Nations children and youth to convey the intensity and quality of their pain. This makes it difficult for health professionals to measure it and likely influences whether it is adequately treated or not. In this paper, we will discuss some of the historical and cultural perspectives that may be helpful in understanding pain in Aboriginal children. In addition, we will discuss what is known about pain expression, assessment, management, and health professionals’ empathy for pain cross-culturally as well as the next logical steps to address some of these issues.

Purpose This study was an in-depth examination of pediatric postoperative pain care. Design and Methods Participant observational data were collected on the care of 10 children. Particular attention was paid to actions when pain scores were ≥5 and to the relationship between pain scores and medications administered. Results A pattern of care emerged of giving pain medications regularly even if they were prescribed pro re nata. Actions when pain scores were ≥5 varied. Recorded pain scores rarely guided treatment choices. Practice Implications The use of pain scores to guide treatment choices needs further debate. Future research should explore the implications of divorcing treatment from pain scores on children's pain experience.

A systematic scoping search to describe the neurophysiological methods used in infant acute pain assessment research was conducted. Of the 2411 abstracts screened, 19 articles were retained. Nine studies utilised near-infrared spectroscopy (NIRS), two utilised functional magnetic resonance imaging (fMRI), and eight utilised electroencephalography (EEG). There was methodological variability in studies utilising NIRS, whereas EEG and fMRI studies reported consistent methods. Of the eight EEG studies, six identified a nociceptive-specific event-related potential. Conclusion While more methodologically rigorous studies are needed, ERPs appear to hold some promise as indicators of infant nociception during clinical procedures to supplement existing measures.

SUMMARY The subjective nature of pain renders its perception in others a challenge for clinicians and informal caregivers responsible for its assessment and relief. Adequate perception of others’ pain relies on different behavioral and neurophysiological mechanisms. Several individual, relational and contextual factors can influence the way the brain reacts to others’ pain and the perception and assessment of this pain. This article focuses on recent neurophysiological and psychological evidence that characterizes these factors, and discusses their potential impact on the perception of others’ pain in a caregiving context. Factors influencing the perception of pain in others are divided into factors related to the self (caregiver), factors related to the other (patient), and factors related to the relationship between those individuals and the context in which the pain is perceived. We propose that the perception of others’ pain plays a crucial role in the treatment provided by clinicians and informal caregivers, and that further research could lead to improving decision-making regarding pain management.

Background Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management. Methods We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ2) analyses. Results Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered. Interpretation For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

Gilin oore d., leblanc d., day a., leiter m.p., laschinger h.s., price s.l. & latimer m. (2010) Journal of Nursing Management 18, 878–888 When respect deteriorates: incivility as a moderator of the stressor–strain relationship among hospital workers Aim To test whether incivility at work exacerbates the relationship between stressors and strain for hospital workers. Background A climate of incivility and disrespect among colleagues was expected to heighten the impact of work stressors on the mental and physical health of care providers. Methods Members of 17 care-providing units from five hospital systems in Canada completed surveys, before and after a civility intervention (eight intervention vs. nine comparison units). Analyses tested whether (1) incivility moderated the stressor-strain relationship at baseline (n = 478), and (2) the stressor–strain relationship decreased for the intervention units relative to comparison units 6 months later (n = 361). Results (1) Pre-intervention, individuals reporting more incivility on their unit showed a stronger stressor–strain relationship. (2) The negative relationship between work overload and mental health was mitigated among intervention group staff 6 months after the introduction of a colleague-based civility programme. Conclusions Besides being a stressor itself, incivility exacerbates the relationship between existing job role stressors and strain among health care workers. Implications for nursing management Colleague civility and respect have an important ripple effect of buffering inevitable work stressors, helping health care providers respond to stress with greater health and resiliency.

Most surgeons undertaking anterior cervical discectomy (ACD) introduce a bone graft or cage into the disc space when the decompression is complete. This is done to prevent segmental collapse, preserve cervical spine alignment and to promote fusion. We have conducted a prospective observational cohort study to investigate the relationship between loss of disc height, cervical spine alignment and clinical outcome in 140 patients undergoing ACD without inter-body graft or cage. At a minimum of 12 months after operation changes in disc space height and cervical spine alignment were correlated with clinical outcome measured by SF36, Neck Disability Index, and visual analogue neck and arm pain scores. There was no relationship between loss of disc height and outcome. Loss of the overall cervical lordosis was present in 71 patients and segmental kyphosis was found in 69. Analysis of clinical outcome showed no significant differences between patients with preserved and abnormal cervical alignment. Neither loss of disc height nor disturbance of cervical alignment compromised clinical outcome in the first year following ACD.

BACKGROUND First Nation children have the highest rates of pain-related conditions among Canadian children, yet there is little research on how this population expresses its pain or how and whether the pain is successfully treated. The aim of this study was to understand how Mi'kmaq children express pain and how others interpret it. METHODS We conducted a qualitative ethnographic study in a large Canadian Mi'kmaq community using interviews and conversation sessions. Participants included children and youth (n = 76), parents (n = 12) teachers (n = 7), elders (n = 6) and health care professionals (n = 13). RESULTS Interpretive descriptive analysis was used and themes regarding pain expression, care seeking and pain management were identified. Pain expression included stoicism and hiding behaviour, and, when pain was discussed, it was via storytelling and descriptive language, such as similes. Participants reported feeling unheard, stereotyped and frustrated when they sought pain care. Frustration led to avoidance of seeking further care, perceptions of racism and repeat visits because of unsuccessful previous treatment. Participants voiced concerns about the utility of the numeric and faces pain scales to describe pain meaningfully. Positive encounters occurred when participants felt respected and heard. INTERPRETATION Mi'kmaq children are stoic and often hide their pain. Community members feel frustrated and discriminated against when their pain is not identified, and conventional pain assessment tools may not be useful. If clinicians consider cultural context, build trust and allow for additional time to assess pain via storytelling or word descriptions as well as a family-centred approach, better pain care may occur.

Skin-to-skin contact (SSC) between mother and infant, commonly referred to as Kangaroo Mother Care (KMC), is recommended as an intervention for procedural pain. Evidence demonstrates its consistent efficacy in reducing pain for a single painful procedure. The purpose of this study is to examine the sustained efficacy of KMC, provided during all routine painful procedures for the duration of Neonatal Intensive Care Unit (NICU) hospitalization, in diminishing behavioral pain response in preterm neonates. The efficacy of KMC alone will be compared to standard care of 24% oral sucrose, as well as the combination of KMC and 24% oral sucrose. Infants admitted to the NICU who are less than 36 6/7 weeks gestational age (according to early ultrasound), that are stable enough to be held in KMC, will be considered eligible (N = 258). Using a single-blinded randomized parallel group design, participants will be assigned to one of three possible interventions: 1) KMC, 2) combined KMC and sucrose, and 3) sucrose alone, when they undergo any routine painful procedure (heel lance, venipuncture, intravenous, oro/nasogastric insertion). The primary outcome is infant’s pain intensity, which will be assessed using the Premature Infant Pain Profile (PIPP). The secondary outcome will be maturity of neurobehavioral functioning, as measured by the Neurobehavioral Assessment of the Preterm Infant (NAPI). Gestational age, cumulative exposure to KMC provided during non-pain contexts, and maternal cortisol levels will be considered in the analysis. Clinical feasibility will be accounted for from nurse and maternal questionnaires. This will be the first study to examine the repeated use of KMC for managing procedural pain in preterm neonates. It is also the first to compare KMC to sucrose, or the interventions in combination, across time. Based on the theoretical framework of the brain opioid theory of attachment, it is expected that KMC will be a preferred standard of care. However, current pain management guidelines are based on minimal data on repeated use of either intervention. Therefore, regardless of the outcomes of this study, results will have important implications for guidelines and practices related to management of procedural pain in preterm infants. ClinicalTrials.gov Identifier: NCT01561547 .

This study was an in-depth examination of pediatric postoperative pain care.Participant observational data were collected on the care of 10 children. Particular attention was paid to actions when pain scores were ≥5 and to the relationship between pain scores and medications administered.A pattern of care emerged of giving pain medications regularly even if they were prescribed pro re nata. Actions when pain scores were ≥5 varied. Recorded pain scores rarely guided treatment choices.The use of pain scores to guide treatment choices needs further debate. Future research should explore the implications of divorcing treatment from pain scores on children's pain experience.

BACKGROUND: Research reporting effective pain care strategies exists, yet it is not translated to care. Little is known about how repeated pain exposure has affected nurses’ ability to be empathetic and use their knowledge to provide evidence-based care. Concerns have been raised regarding the validity of self-report empathy instruments; therefore, a novel video program was developed for testing. It was hypothesized that those who viewed infants in painful and nonpainful states would have a measureable empathy (pain rating) response correlating to the level of pain expressed by the infants.OBJECTIVE: To validate the newly developed Empathy for Infant Pain video program (EIPvp) by determining whether nurse and non-nurse control groups’ pain scores of 24 video clips showing infants undergoing real medical procedures were equal.DESIGN: A descriptive cross-sectional video judgement study.METHODS: Fifty female participants (25 nurses and 25 allied health controls) were asked to score the infant procedural pain level displayed in the EIPvp using a visual analogue scale and a composite score of known infant pain cues. Participants also scored their own sensitivity to painful events.RESULTS: Participants rated the videos contained in the EIPvp similarly in three categories (no, low or high pain); however, there were consistent differences between groups within the categories. Nurses scored facial cues for all categories higher than the control group. Nurses scored their own pain in hypothetical situations and that of the infants consistently higher than the control group.CONCLUSION: The EIPvp yielded predictable responses from both the nurse and non-nurse control groups when scoring the pain expressed in the video clips. Nurses’ detection of pain more often than controls may have been an indication that they have greater knowledge of pain cues, or their empathy levels may have been different as a result of their exposure to, or their perceived relationship with, patients. The EIPvp was validated and has promising potential for training and research purposes.

To test whether incivility at work exacerbates the relationship between stressors and strain for hospital workers.A climate of incivility and disrespect among colleagues was expected to heighten the impact of work stressors on the mental and physical health of care providers.Members of 17 care-providing units from five hospital systems in Canada completed surveys, before and after a civility intervention (eight intervention vs. nine comparison units). Analyses tested whether (1) incivility moderated the stressor-strain relationship at baseline (n=478), and (2) the stressor-strain relationship decreased for the intervention units relative to comparison units 6 months later (n=361).(1) Pre-intervention, individuals reporting more incivility on their unit showed a stronger stressor-strain relationship. (2) The negative relationship between work overload and mental health was mitigated among intervention group staff 6 months after the introduction of a colleague-based civility programme.Besides being a stressor itself, incivility exacerbates the relationship between existing job role stressors and strain among health care workers.Colleague civility and respect have an important ripple effect of buffering inevitable work stressors, helping health care providers respond to stress with greater health and resiliency.

Objective To examine the effects of nurse, infant, and organizational factors on delivery of collaborative and evidence-based pain care by nurses. Design Cross sectional. Setting Two Level III neonatal intensive care units in 2 large tertiary care centers in Canada. Participants A convenience sample of 93 nurses completed survey data on procedures they performed on ill neonates. The 93 nurses performed a total of 170 pain producing procedures on 2 different shifts. Main Outcome Nurse use of evidence-based protocols to manage procedure related pain using a scorecard of nurses' assessment, management, and documentation. Results Procedural pain care was more likely to meet evidence-based criteria when nurse participants rated nurse-physician collaboration higher (odds ratio, 1.44; 95% confidence intervals 1.05-1.98), cared for higher care intensity infants (odds ratio, 1.21; 95% confidence intervals, 1.06-1.39), and experienced unexpected increases in work assignments (odds ratio, 1.55; 95% confidence intervals, 1.04-2.30). Nurses' knowledge about the protocols, educational preparation and experience were not significant predictors of evidence-based care for the most common procedures: heel lance and intravenous initiation. Conclusion Nurse-physician collaboration and nurses' work assignments were more predictive of evidence-based care than infant and nurse factors. Nurses' knowledge regarding evidence-based care was not a predictor of implementation of protocols. In the final statistical modeling, collaboration with physicians, a variable amenable to intervention and further study, emerged as a strong predictor. The results highlight the complex issue of translating knowledge to practice, however, specific findings related to pain assessment and collaboration provide some direction for future practice and research initiatives.

Title. The empathetic response in nurses who treat pain: concept analysis Aim. This paper is a report of a concept analysis of empathy. Background. It is widely accepted that an empathetic response is necessary for nurses to deliver adequate pain relief and therapeutic care. Previous work suggests that empathy is a learned behaviour, and thus can be blocked if necessary to diminish personal distress. Methods. A computerized search of the CINAHL, MEDLINE, PsycINFO, and Web of Science databases from 1980 to 2007 was conducted, using the keywords pain and empathy, both alone and in combination. Similar concepts such as sympathy, caring and compathy were included if the database distinguished between these concepts. Twenty-five relevant articles were reviewed and Rodgers evolutionary concept analysis process was used to clarify the concept. Findings. The recent observation that a mirror-like neural response occurs in the brain of a person witnessing another in pain provides compelling evidence that empathetic arousal may occur independent of the previously described attributes of prior experience or learned cognitive appraisal. Conclusion. While the empathetic response of care providers plays a central role in the recognition and treatment of pain, nurses are taught that regulation of this response is important to protect themselves against the traumatic effects of seeing patients in pain. However, there is emerging evidence that some elements of empathetic arousal are autonomic and therefore unable to be fully controlled; this may have important implications for nurses’ vulnerability.

Nurses are involved in many of the painful procedures performed on hospitalized children. In collaboration with physicians, nurses have an exceptional responsibility to have knowledge to manage the pain; however, the evidence indicates this is not being done. Issues may be twofold: (a) opportunities to improve knowledge of better pain care practices and/or (b) ability to use knowledge. Empirical evidence is available that if used by health care providers can reduce pain in hospitalized children. Theory-guided interventions are necessary to focus resources designated for learning and knowledge translation initiatives in the area of pain care. This article presents the Knowledge Use in Pain Care (KUPC) conceptual model that blends concepts from the fields of knowledge utilization and work life context, which are believed to influence the translation of knowledge to practice. The four main components in the KUPC model include those related to the organization, the individual nurse, the individual patient, and the sociopolitical context. The KUPC model was conceptualized to account for the complex circumstances surrounding nurse's knowledge uptake and use in the context of pain care. The model provides a framework for health care administrators, clinical leaders, and researchers to consider as they decide how to intervene to increase knowledge use to reduce painful experiences of children in the hospital.

A two-group (N = 92) quasi-experimental pre-post test design was used to examine the effects of intra-operative communication by a surgical liaison nurse (SLN) on parental anxiety. Group I received in person progress reports from the SLN. Group II received routine perioperative care. The Speilberger's State-Trait Anxiety Inventory (STAI) Scale and investigator developed family rating scales were distributed to both groups and used as a quantitative as well as a qualitative approach to determine what was helpful for the family members during the operative period. Two hundred and eighty feedback forms were dispersed to various health care professionals including all anaesthetists, surgeons, nurses and other staff in the perioperative care team, including the operating room, day surgery unit and the post anaesthetic recovery room areas. Feedback forms were also circulated to staff from the intensive care unit and the surgical in-patient units. The results showed the anxiety levels were lower for the families who received in person progress reports but the difference by group was not statistically significant. Thematic written responses provided examples of improved care and effective time management behaviours on the part of the health care professionals. Written responses provided validation for the scale scores for both families and health care professionals and were an indication of the support for the role of the surgical liaison nurse. Qualitative findings implied that the surgical liaison nurse facilitated the transfer of necessary information between the perioperative care team and the family thus providing a support mechanism for families under stress.

Knowledge utilization (KU) is an essential component of today's nursing practice and healthcare system. Despite advances in knowledge generation, the gap in knowledge transfer from research to practice continues. KU models have moved beyond factors affecting the individual nurse to a broader perspective that includes the practice environment and the socio-political context. This paper proposes one such theoretical model the Joint Venture Model of Knowledge Utilization (JVMKU). Key components of the JVMKU that emerged from an extensive multidisciplinary review of the literature include leadership, emotional intelligence, person, message, empowered workplace and the socio-political environment. The model has a broad and practical application and is not specific to one type of KU or one population. This paper provides a description of the JVMKU, its development and suggested uses at both local and organizational levels. Nurses in both leadership and point-of-care positions will recognize the concepts identified and will be able to apply this model for KU in their own workplace for assessment of areas requiring strengthening and support.