Researchers from Children's Hospital of Philadelphia describe findings in pediatric in children.(Report) - Biotech Week

New research, 'Pediatric antifungal utilization: new drugs, new trends,' is the subject of a report. According to a study from the United States, 'The frequency and severity of invasive fungal infections in immunocompromised patients has increased steadily over the last 2 decades. In response to the increased incidence and high mortality rates, novel antifungal agents have been developed to expand the breadth and effectiveness of treatment options available to clinicians.'

'Despite these therapeutic advances, the impact of the availability of new antifungal agents on pediatric practice is unknown. A retrospective cohort study was conducted using the Pediatric Health Information System database to describe the changes in pediatric antifungal therapy at 25 freestanding United States children's hospitals from 2000 to 2006. All pediatric inpatients who received a charge for one or more of the following agents were included in the analysis: conventional amphotericin B (AMB), lipid amphotericin B, fluconazole, itraconazole, voriconazole, flucytosine, caspofungin, and micafungin. Underlying conditions and fungal infection status were ascertained. A total of 62,842 patients received antifungal therapy, with prescriptions significantly increasing during the 7-year study period (p=0.03). The most commonly prescribed antifungal agent was fluconazole (76%), followed by amphotericin preparations (26%). Prescription of AMB steadily decreased from 2000 to 2006 (p=0.02). Prescription of voriconazole steadily increased during the study period and replaced AMB for the treatment of aspergillosis. The echinocandins steadily increased in prescription for treatment of fungal infections, particularly in disseminated/systemic candidiasis,' wrote P.A. Prasad and colleagues, Children's Hospital of Philadelphia (see also Life Sciences).

The researchers concluded: 'We found that the number of pediatric inpatients requiring antifungal therapy has increased significantly and the choice of treatment has changed dramatically with the introduction of newer antifungal agents.'

Prasad and colleagues published their study in The Pediatric Infectious Disease Journal (Pediatric antifungal utilization: new drugs, new trends. The Pediatric Infectious Disease Journal, 2008;27(12):1083-8).

For more information, contact P.A. Prasad, The Children's Hospital of Philadelphia, The Children's Hospital of Philadelphia, Dept. of Infection Prevention and Control, Philadelphia, PA USA..

Publisher contact information for the The Pediatric Infectious Disease Journal is: Lippincott Williams & Wilkins, 530 Walnut St., Philadelphia, PA 19106-3621, USA.

Keywords: United States, Philadelphia, Life Sciences, Pediatric, Antifungals, Clinical Trial Research, Pharmaceuticals, Drug Development, Therapy, Treatment, Amphotericin B, Drugs, Itraconazole, Voriconazole, Fluconazole.

CHPA comments on US FDA's public meeting on pediatric cough/cold medicines. - Nutraceuticals International

CHPA comments on US FDA's public meeting on pediatric cough/cold meds

The US Food and Drug Administration has rejected calls made at a public hearing on pediatric over-the-counter cough and cold medicines for a ban on products aimed at children aged between two to six years old. The federal agency warned that such a move could backfire, but there are concerns about the lack of scientific evidence to support the use of cough and cold drugs for children.

In response, the Consumer Healthcare Products Association said it is pleased that the FDA continues to gather information surrounding children's OTC cough and cold medicines, saying 'the makers of OTC oral pediatric cough and cold medicines have developed a multi-year plan specifically designed to help improve the safe use of these products and reaffirm the efficacy of these medicines. The leading makers of these medicines remain committed to working with FDA and pediatric experts to ensure that parents and caregivers continue to have appropriate treatment choices for their children.'

Also reacting to the news was French company Boiron, which has launched a range of homeopathic products in the USA to address these concerns (see page xx).

In its statement, the CHPA said the makers of these medicines have begun implementation of a 'ground-breaking, comprehensive program. The initiative will advance the science, confirm effectiveness, enhance packaging and dosing technologies, and reach millions of parents, caregivers and health care providers with valuable information and education on the proper use and storage of OTC oral pediatric cough and cold medicines.' This program includes:

- a comprehensive and scientifically rigorous efficacy and safety program for children aged two to under 12 to advance the science and ensure the highest level of scientific rigor. This program includes pharmacokinetic studies to confirm the dosing for the eight most commonly used OTC oral cough and cold ingredients. Once these dosing studies are finalized, it will begin its research to revalidate the effectiveness of these medicines;

- continued collection and review of available safety data. A comprehensive safety review in 2007 and data from the US Centers for Disease Control and Prevention show that the majority of adverse events associated with OTC oral pediatric cough and cold medicines are a direct result of accidental ingestion. Reducing these preventable errors is the cornerstone of the CHPA's national educational program; and

- a comprehensive, national education program which to date has reached more than 100 million parents and caregivers and will reach even more over the next year. The campaign focuses on the root causes of adverse events and speaks directly to parents, day care and health care providers, and other caregivers. The CHPA is partnering with a number of organizations in these efforts, including the American Pharmacists Association and the American Association of Family Physicians. These education campaigns will underscore the importance of following the directions on the label, using the correct dose, storing medicines safely and consulting with a doctor if there are any questions.

Pediatric Physical Activity and Fitness - Cardiopulmonary Physical Therapy Journal

ABSTRACT

The importance of physical activity in childhood and adolescence cannot be overstated. Since adequate amounts of physical activity provide multiple health benefits and will improve or maintain physical fitness, it should be an integral component of children's lives. However, children and adolescents are much less active than in previous decades. The causes of this phenomenon are numerous, including social and environmental factors, and practices in schools. Physical therapists should consider these factors and the unique response to exercise by the pediatric population when prescribing exercise. Physical therapists can intervene to increase regular physical activity in children and adolescents at a variety of levels. At the Individual Level, we can support physical activity in the treatment of children with disabilities and for wellness. At the School Level, we can become active volunteers or consultants to enhance physical activity in the school environment. At the Policy Level, we can support policies that increase opportunities for physical activity in the schools, communities, and society. We need to change the way physical activity is perceived as not only an individual behavior choice, but also the result of many choices made for us in our environment. As physical therapists, we are uniquely positioned to advocate and provide guidance for increased physical activity among children and adolescents, their families, and the society as a whole.

INTRODUCTION

Physical activity can be described as any bodily movement produced by skeletal muscles, while physical fitness is defined as the ability to perform physical activity.1,2 Physical activity can prevent disease-a sedentary lifestyle leads to increased morbidity and mortality, while physical activity confers many positive health benefits to children and adolescents.1,3-6 Physical activity decreases health care costs and improves quality of life and can be individualized to age and ability.7,8 Since adequate amounts of physical activity will improve or maintain physical fitness, a central component of health and wellness, physical activity should be an integral component of children's lives.7 As physical therapists, we are uniquely positioned to advocate and provide guidance for increased physical activity among children and adolescents, their families, and the society as a whole.

The importance of adequate physical activity in childhood and adolescence cannot be overstated. Physical activity provides specific health benefits, including weight management, blood pressure control, and improved musculoskeletal and cardiopulmonary function. The value of physical activity for improved mental health has also been demonstrated for children and adolescents. A connection has been reported between physical activity and the prevention and treatment of depression.9 A lifestyle that lacks physical activity as a child is likely to lead to sedentary adulthood, setting the stage for heart disease, diabetes, high blood pressure, obesity, and some forms of cancer.1 Because children spend an abundance of time in school, this is a prime area for changing the social and physical environment to support and promote a healthy lifestyle, including opportunities for regular physical activity. In addition, since many adults make decisions that impact the lifestyles of children, it is essential for parents, teachers, coaches, and health care professionals to support physical activity.

WHERE ARE WE NOW?

Not so long ago in the US, children had physical education (PE) every day in school. Those who lived close enough walked to and from school, and after school children had to be coaxed indoors from informal games of kickball or Capture the Flag to do homework (written longhand) or eat dinner. Summers were filled with unstructured play, mostly outdoors, and TV was for watching occasionally, since program choices were limited. Fast-forward to a new century where a child can spend an entire school day without PE or active play at recess, only to spend the remainder of the waking hours indoors because of safety concerns or a desire to partake in the myriad of entertainment on television and computers.3,4,10-14 The problem only worsens as cars replace bicycling and walking as the preferred method of transportation.6,9 At the same time, parents and other adults model decreasing amounts of physical activity and increase incidence of overweight and obesity.4,11 There are many sociocultural and environmental factors that affect the activity patterns of children and consequently, their fitness levels.

Children and adolescents are not as active as in previous generations, but what are the current rates of physical activity?3

The first Surgeon General's Report on the state of physical activity and health in Americans was released by the US Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) in 1996.4 The following conclusions concerning adolescents were reported. Nearly half of Americans aged 12 to 21 years are not vigorously active on a regular basis and one fourth report no vigorous activity. Physical activity declines dramatically during adolescence; 72% of 9th graders participate in vigorous physical activity on a regular basis, compared with only 55% of 12th graders. Daily participation in PE by high school students dropped from 42% in 1991 to 25% in 1995. In addition, only 19% of all high school students reported being physically active for 20 minutes or more in the physical education classes they did attend. Children walk or ride bicycles much less than in the past. In 1995, youth aged 5 to 15 walked or cycled 40% less than in 1977. In addition, children make only 31% of trips to or from school of 1 mile or less by walking, and only 2% ride a bicycle.6,9 Trends show an association between inactivity and certain demographic factors. Low socioeconomic status has been related to decreased physical activity, and inactivity is more common among females than males.3 White females are most likely to engage in physical activity while black and Hispanic females are least likely.15,16

We must reconsider our assumption that solely by virtue of their ages, children experience sufficient amounts of activity. Even very young children are at risk. In a recent report, it was found that only16% of kindergarten programs provide daily PE, while 59% have PE 1 to 2 times per week, and 13% provide PE less than once a week. Schools with an increased percent of low-income or minority students are more likely to have no physical education in kindergarten, precisely the population most at risk.5 Even toddlers have fallen victim to this trend of inactivity. A study in the United Kingdom reported low levels of activity in 3 year olds equipped with accelerometers to monitor movement. The toddlers were physically active for only 20 minutes per day.17

The risks of inactivity are numerous, chief of which is obesity. Although increased caloric intake and decreased physical activity can both be implicated, in US adolescents, the decline in physical activity appears to play a much larger role.18 Overweight and obesity in children and adolescents have more than doubled in the past 20 years.3 In addition, this trend persists into adulthood, setting children up for a lifetime of increased risk for disease.1,15 Obesity has been implicated in many diseases in the pediatric population and has resulted in the replacement of the term Adult-Onset diabetes with Type II diabetes, as this condition increasingly includes more children.5,19 Health conditions resulting from overweight and obesity include glucose intolerance, hypertension, and dyslipidemia, and it is not uncommon for children to exhibit all three of these cardiovascular risk factors.5,9,20 Other health problems related to obesity include obstructive sleep apnea, nonalcoholic steatohepatitis, and slipped capital femoral epiphysis.3 In addition, overweight girls are more likely to experience anxiety, loneliness, low self-esteem, and anger.5

Other conditions, common in the pediatric population, present a barrier to participation in physical activity. School age children with asthma are often restricted from participating in physical education or sports because of concern that the asthma will be exacerbated.21 Medical recommendations to manage symptoms and optimize physical performance should be followed to allow the child to participate in PE class and sports.21 It is also a challenge to provide adequate opportunities for physical activity for children and adolescents with cerebral palsy, mental retardation, and other chronic conditions. Lack of physical fitness is more prevalent in people with disabilities due to social and physical barriers.22 Children with disabilities may also be denied opportunities for physical activity because of the emphasis on other life issues resulting from their condition. Finally, concerned parents of children with congenital or chronic conditions may hold them back from activity.

HOW DID WE GET HERE?

Many aspects of the physical and social environment affect the fitness levels of children and adolescents in the United States. Each of these factors points to a potential area of intervention.

In the physical environment, most communities are designed around the automobile; the location of grocery stores and restaurants encourages driving rather than walking.8 It has been demonstrated that 43% of people with safe places to walk within 10 minutes of home meet recommended activity levels, compared to 27% of those without safe places to walk.8 The proximity of housing developments to parks, trails, and greenways has been shown to increase levels of physical activity.8

Social factors such as exaggerated fear of kidnapping contribute to declining numbers of children who routinely walk to and from school.14 In addition, safety concerns in many neighborhoods have been shown to restrict children's performance of physical activity after school hours.10-12 Children are frequently instructed to stay indoors after school when home alone while parents work. Indoor activities are necessarily less physical than those performed outdoors. This, along with increased availability of media entertainment, establishes a preference of many children for the more sedentary activities of watching TV and playing video and computer games. More than 25% of children in the US watch at least 4 hours of TV per day, and TV viewing has been negatively associated with physical activity and fitness patterns.3,15 Even in preschool children, having a TV in the bedroom has a strong relationship to being overweight.6 Young children are exposed to far more visual media than in the past. The number of television programs geared to children, and the expanding market of children's videos, many of which are labeled 'educational,' tempt parents to rely on these for diversions during meal preparation, household chores, working from home, and even during transportation-on portable video/DVD players in cars.

Societal factors reveal other reasons for declining physical activity in children and adolescents. The increase in single-family households and families where both parents work outside the home may limit involvement in sports or other organized physical activities after school. Lack of time, transportation needs, and financial considerations may all factor into a child's inability to participate. It is also increasingly uncommon to see children playing unstructured games together after school, whether in a neighborhood or the local park.14 Sports programs, after-school programs, and safety issues may all be factors in reducing the number of spontaneous neighborhood kickball and football games that occur with children at varying levels of abilities.

Since children and adolescents spend so many waking hours in an academic setting, it is not difficult to make the case that the school environment plays an important role in determining the amount of physical activity available. In the name of academic accountability and budgetary concerns, PE has taken a back seat to other subjects. This is evidenced by the decline in physical education in the 1990s as reported above. Forty four percent of high school students in the US are not enrolled in PE, and Illinois is currently the only state that requires daily PE up through grade 12.23 However, the Youth Risk Behavior Survey (YRBS) reports a slight increase in daily PE programs in 2003.23 Other factors affecting physical fitness include the number of minutes spent in vigorous physical activity during a physical education class, which the majority of high school students report to be less than 20 minutes per class.4 National standards for PE teachers are voluntary, so many children lack adequately trained instructors.13 In addition, the emphasis on sports over instruction and availability of lifetime physical activity is another concern. Students might be more interested in physical activity if it wasn't equated primarily with team sports, but rather promoted with a variety of activities such as martial arts, rock climbing, dancing, roller blading, and skateboarding. In the future, more attention may be paid to the balance of physical activity and academic endeavors in the school environment. There has been no evidence that time spent in PE harms academic performance.9 In fact, a preliminary study found a positive relationship between fitness scores and academic achievement, demonstrating yet another benefit of physical activity. Fit children performed better on cognitive tasks and processed stimuli faster than sedentary children.24

One factor that may affect the participation of children and adolescents in physical activity is the risk involved. Fear of injury may influence a parent's decision not to allow a child to participate in a program of physical activity or sports. Many injuries are the result of improper equipment or the lack of safety equipment such as helmets or faceguards. Many states do not even have requirements for protective equipment in PE classes.13 In addition, many coaches are volunteers with limited training. Good coaching principles can go a long way toward injury prevention. In addition to injuries, excessive physical activity in the pediatric population can lead to menstrual abnormalities and bone weakening.4

HOW ARE CHILDREN AND ADOLESCENTS DIFFERENT THAN ADULTS?

'Children are not just small adults' is a refrain often used by pediatricians. This statement undoubtedly applies to exercise performance. Differences can be seen in cardiovascular and pulmonary responses and metabolic systems. To provide appropriate exercise or activity programs for children and adolescents, it is vital to understand the differences in children's response to exercise as compared with adults.

Cardiovascular differences include alterations in heart rate (HR), cardiac output, and peripheral circulation.21 Heart rates are higher in children at rest and with submaximal exercise, and they decrease with age. At puberty, peak HR begins to fall 7 to 8 beats per minute each decade. As age increases, submaximal HR decreases, but variables such as obesity, heat, and poor cardiovascular fitness, may cause it to remain elevated. Estimating maximum HR with the '220 minus the age' formula doesn't become meaningful until the late teenage years, as maximum heart rates can vary too widely before this age.25 Recovery to resting HR occurs more quickly in children than adults. Resting cardiac index is about the same for children and adults when body size is taken into account, 3-5 L/min per m^sup 2^. However, a lower cardiac output is observed in children relative to adults at a given exercise level, due to a lower stroke volume. During childhood and adolescence, the concentration of hemoglobin in the blood increases progressively, improving the rate of oxygen delivery. Oxygen extraction is improved in children over adults, measured by a higher arterial-to-venous difference.21

The work of breathing during exercise is greater in children than adults.26 This is due to children's smaller exhaled volumes per minute at the same workload. However, because of higher respiratory rates, total minute ventilation is higher at the same workload when body size is taken into account. This high total minute ventilation per body weight translates to greater work of breathing in children than adults at the same level of exercise.26 However, since anatomical dead space is smaller in children, a higher portion of inspired air is delivered to the alveoli.25

Disparity in exercise performance in children and adolescents can be due to differences in size. Measurements should take body mass into consideration, so that the effects of size can be considered separately. Other variations may be due to differences in sex. In general, girls have higher submaximal and maximal heart rates than boys. Until puberty, hemoglobin concentration and blood volume are about equal; after puberty, girls tend to have lower blood hemoglobin levels. In addition, girls tend to have lower maximal ventilation compared to boys.21

Aerobic capacity, determined by VO^sub 2^ max, increases with age and maturation primarily due to increased size.26 In boys, VO^sub 2^ max increases steadily from age 6 to 18 and then decreases with age; VO^sub 2^ max in girls increases until 14 to 16 years of age and then starts a steady decline.25 At puberty, boys generally have greater muscle mass, and girls have greater body fat, resulting in higher VO^sub 2^ max for boys.21

Temperature regulation during exercise is more difficult for children than adults for several reasons. Exercise produces heat that dissipates through evaporation by sweating or convection on the skin's surface. In children, the amount of sweat produced by each sweat gland is decreased.25 Increased blood flow to the skin and muscles results in decreased venous return that can increase HR. Since heart rates are already higher in children, it can be difficult for them to meet the increased demand. In addition, children have a larger surface area to mass ratio, which results in greater convection, resulting in increased heat loss in cold temperatures. Therefore, children and adolescents will tolerate physical activity for shorter periods in extreme temperatures than will adults.25

WHERE DO WE WANT TO BE?

To meet a goal of Healthy People 2010 'To improve health, fitness, and quality of life through daily physical activity,' objectives must be established and progress toward these objectives measured.27 The US Dept of Health and Human Services' Healthy People 2010 and the President's Council on Physical Fitness and Sports established objectives related to physical activity in children and adolescents. The Youth Risk Behavior Survey (YRBS), National Health and Nutrition Examination Survey (NHANES), and other data sources provided information on the status of progress toward the objectives specified in Healthy People 2010.27

1. Objective 22-6: Increase the proportion of adolescents who engage in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days. In 1997, 20% of students in grades 9 through 12 met this objective, and the target is 30%.

2. Objective 22-7: Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion. In 1997, 64% of students in grades 9 through 12 met this objective, and the target is 85%.

3. Objective 22-8: Increase the proportion of the Nation's public and private schools that require daily physical education for all students. In 1994, the percent of middle and junior high schools that met this objective was 17%, and the percent of senior high schools was only 2%. The targets for middle/junior high schools and senior high schools are 25% and 5%, respectively.

4. Objective 22-9: Increase the proportion of adolescents who participate in daily school physical education. In 1997, 27% of students in grades 9 through 12 met this objective, and the target is 50%.

5. 22-10: Increase the proportion of adolescents who spend at least 50% of school physical education class time being physically active. In 1997, 32% of students in grades 9 through 12 met this objective, and the target is 50%.

6. 22-11: Increase the proportion of children and adolescents who view television 2 or fewer hours per day. From 1988-1994, 60% of persons aged 8 to 16 years met this objective, and the target is 75%.

Other established goals affecting the pediatric population address the issue of access to opportunities for physical activity, such as availability of school facilities after hours, and increased proportion of trips made by walking and bicycles.27 The individual recommendations for adolescents include daily physical activity for a total of 30 minutes at moderate intensity, with an acknowledgement that greater amounts of physical activity are even more beneficial.4

HOW DO WE GET THERE?

There are many ways to measure the components of physical fitness, ie, cardiorespiratory and muscular endurance, muscular strength, flexibility, agility, and body composition. In 1966, the President's Challenge Physical Fitness Award Program started collecting measures of fitness in school-aged children.28 Measuring and tracking changes in these components provides a report card for meeting fitness goals in children and adolescents, individually, and as a group. These tools can be obtained at www.presidentschallenge.org or www.fitnessgram.net.28,29

Endurance is the ability of the body to continue the performance of a task and depends on oxygen transport, the ability of the heart and lungs to pump oxygenated blood to muscles and tissues and dispose of the waste products of metabolism. Endurance can be measured by a variety of tests in different modes. Walking and running tests include the 1-mile walk/run, the 12 or 6 minute walk, the shuttle test, and treadmill tests that incrementally increase speed and incline such as the Modified Balke protocol.30 (For information on administering these tests, see Ohtake's article on exercise testing elsewhere in this issue). Other endurance testing modes include bicycle ergometer tests, such as the McMaster Cycle Test, a 3-mile bicycle ride, a 400-meter swim, or a 3-minute step test.30,31 There are standards for many endurance tests with which to compare a child's performance time.

Measuring muscle strength by manual muscle testing is second nature to physical therapists. In addition to this assessment, there are standards for measuring the number of curl-ups and pull-ups/push-ups performed in one minute.28,30 Likewise, measuring range-of-motion to determine flexibility is a standard practice of physical therapists. The Sit-and-Reach test is another measure of the flexibility of the lower extremities and the lower back and standards are also published for this test.28,30

Body composition, in addition to weight, is another measure of physical fitness. The Body Mass Index (BMI) is a useful tool to assess a child's weight for height, but is measured differently for children than adults, using growth charts to take into account age and sex. Also, normal ranges for BMI are not defined below 3 years of age. The American Academy of Pediatrics recommends the BMI as the primary tool to define childhood overweight and obesity.3 A BMI calculator specifically for children can be found at www.getkidsinaction.org or www.cdc.gov/growthcharts.32,33 Another tool to measure the ratio of lean body mass to fat is skin-fold measurement. These can be taken at several sites, and in children, the triceps and subscapular measurements can be averaged together and compared to a standard.31

An exercise prescription for children and adolescents, as for adults, should include the components of mode, frequency and duration, and intensity. In addition to these components, physical therapists should consider other issues, such as maturation and skill level, the school environment, and safety. Arguably, the overall goal of an exercise program for the pediatric population is to establish a lifelong habit of regular physical activity. This program should change with the child's developmental stage, interests and abilities, and available resources. For young children, active play in place of an exercise program is recommended.

The most important aspect of selecting a mode for children and adolescents is to find an activity that is enjoyable, with the duration and frequency dependent on the chosen mode. The variety of possible activities is endless and may include group or individual activities (Table 1). Group activities provide socialization and may appeal to many children, but those who have less self-confidence or limited skills may not feel comfortable in a group setting.

Exercise intensity is an important component of any exercise prescription and it allows the tracking of the response to activity. Even though heart rate monitoring is a reliable measure of intensity, few children who are able are willing to track this regularly, with the exception of the student athlete in training. The Rating of Perceived Exertion (RPE) is an easy tool for children to learn and continue to use during various tasks involving physical activity and has been correlated with HR.30 There is also a reliable RPE scale for young children which includes faces depicting various amounts of effort.34 The OMNI rating scale of perceived exertion is another valid and reliable measure for use with children.35,36

Energy expenditure of daily physical activity in children with diabetes or obesity should be considered, so that caloric intake can be taken into account. One approach presented by Bar-Or37 is to assign 'exercise exchanges' equal to 100 kilocalories to various physical activities. The duration of the activity depends on the body mass of the child, with less time needed for children with greater body mass. Another tool for determining energy cost of particular activities is the Compendium of Physical Activities, published by the President's Council on Physical Fitness and Sports.38

Safety considerations are more important in children because children are physically and emotionally immature. Excessive exercise or sports trauma has the chance of causing overuse injuries or injury to the epiphyseal growth plate.30 The risk of injury can be decreased by the use of appropriate safety equipment, adequate skills preparation, and matching athletic opponents by size, skill, and maturation levels.25 Also, adequate training and supervision and appropriate clearance for sports by a pre-performance physical is recommended.

WIDER CIRCLES OF INFLUENCE

Physical therapists often think in terms of one-on-one interaction with a patient or client and are probably most comfortable with this level of interface. However, there are multiple levels of intervention in the Social Ecological Model, also known as the Multilevel Model that impact the physical fitness of children and adolescents (Figure 1).39 The many factors that influence physical activity necessitate a multileveled approach and physical therapists are uniquely positioned to intervene at a variety of levels.

The Individual Level

When a child or adolescent is referred to physical therapy, we should consider the patient's long-term physical fitness in addition to the primary reason for the PT consult. Make a routine of talking to patients and their parents about the importance of regular physical activity; by addressing this issue you are demonstrating its importance. One of the goals for discharge from rehabilitation services should be the ability of the patient or caregiver to carry out a regular program of physical activity to improve health in the long-term. Physical activity should also be supported for children with disabilities, especially in light of evidence that persons with developmental disabilities have much lower levels of fitness.22 The American Physical Therapy Association is collaborating with the Health and Human Services Office on Disability in a nationwide initiative that matches physically fit mentors with children who are disabled to provide guidance and training in physical activity.40 This 'buddy system' strategy illustrated by, 'I Can Do It, You Can Do It' is recommended by the CDC's Task Force on Community Preventive Services to increase physical activity.6

When prescribing an exercise program, take into account not only the social and physical environment in which the client lives, but identify and address any apparent barriers. Such barriers have been shown to be among the most powerful predictors of performing a recommended health behavior.41 Think about prescribing exercise not in terms of what you know the patient should do or what you want the patient to do, but start with what they will do, even if the activity is modest or low intensity. The aim is to get the child engaged and not overwhelmed by an intricate or demanding program. Become familiar with resources available to the child and family locally as well as nationally. Many resources and tools are available on the Internet (Table 2).

Assessing the readiness of an older child or adolescent to participate in physical activity is crucial to the success of an exercise program. The Transtheoretical Model, also known as The Stages of Change, is a concept to assess the willingness of an individual to adopt a change in behavior.42 Identifying the stage of readiness of an individual will help you tailor the type and amount of information you give. This strategy can be delivered and followed up on in person, or by telephone or mail (Figure 2).6 As you may know from your own experience, when patients or clients reach the stage where an activity program is sustained, encouragement and continued support is still needed and appreciated.

And don't forget that you can be a role model for others by maintaining a regular physical activity program. Children, especially teenagers, are quick to identify a 'phony' that doesn't take the advice they dispense. They will notice whether you take the stairs instead of the elevator to get to the treatment room, or how close you park your car to the clinic entrance.

The Group/Interpersonal Level

There is some evidence that parents and other adult role models influence the physical activity levels of children and adolescents.2,8 A program of physical activity should intuitively be more successful if it includes the entire family, but evidence in this area is inconclusive, and schoolbased interventions have been found to be more effective.6,9 This area would benefit from further well-designed studies. Building or strengthening social networks of peers to provide support for increased physical activity has been shown to be effective.6,9 Examples may include walking groups with peers, or joining a health club or a exercise class with a friend.

Bar-Or37 has written extensively on pediatric exercise and notes 'children with a 'visible' defect often decline to exercise with their healthy peers but gladly join a program with other children who have a similar condition.' Physical therapists are in a prime position to set up an 'exercise support group' for children with a chronic disease or disability, provided infection control or other special accommodations are considered. Another strategy to consider is to join with other health care professionals, eg, pediatricians, nutritionists, and health behavior experts, to develop or strengthen interventions to support physical activity for children. For example, Jim Zachazewski and Laura Healey, physical therapists in Massachusetts, developed a program with input from childhood educators, child life specialists, and nutritionists. 'Kids On The Move' is a program that provides guidance for a healthy lifestyle.43

The Institutional (School) Level

Due to the vast number of hours children spend in school, this is a prime area to effect change in the physical fitness of our youth. Physical activity levels have been shown to increase as a result of school-based interventions.4,6,9 By intervening at this level we could affect a majority of children in the country. Physical therapists who work in the school system have an inside view of ways to enhance physical activity in a particular school. However, any interested physical therapist can offer to present a session about the benefits of physical activity to any class or after-school program. Don't forget about children in preschool and daycare settings-activity patterns are set early in life. School-based health clinics or school nurses can identify and counsel children at risk for obesity as well as track effects of activity on a chronic health problem such as asthma or diabetes. Volunteering or contracting your services to these children to complement the school's efforts would be invaluable.

There is strong evidence to recommend making changes in PE classes as a way to significantly increase levels of physical activity in children.6,9 Physical therapists have the skills to consult with a PE department to assess developmentally appropriate, aerobic, and strengthening aspects of a PE program. Many of the activities available to children require particular skills, such as throwing or kicking a ball, swinging a bat or racquet, or mastering a sequence of movements. Thus, it is important to give children the opportunity to learn these skills in a nonthreatening environment. If a physical education class where these skills are taught is high pressure or intimidating, children may never develop the self-efficacy needed to accomplish these skills and this may lead to life-long avoidance of these activities. The actual levels of activity in PE classes should be assessed. The amount of time elementary school children spend being physically active in PE has been shown to increase with school-based interventions.4 Activity levels can be increased in current PE classes by substituting soccer for softball or having the entire team run the bases when a batter makes a base hit.6,9 The most promising evidence for intervening in the area of physical education is a recent report demonstrating that even slight increases in school PE can reduce the number of children classified as overweight. A mere 1-hour increase in physical education per week resulted in a 31% drop in BMI among overweight and at-risk girls in first grade.5 Also of importance is the finding that modifying the PE curriculum is universally effective-across racial, ethnic, and socioeconomic status, with girls and boys, and in urban as well as rural settings.6

The Community Level

To support physical fitness, the physical and social environment must be conducive to physical activity. There is strong evidence for the effectiveness of community-wide campaigns to promote physical activity.6,9 Physical therapists can write newspaper or magazine articles and letters to the editor with the purpose of promoting activity. Physical activity has been shown to increase when access to places for physical activity increases.6,8,9 Physical therapists can look in her or his own community to identify ways to enhance physical activity for all its residents. An assessment of the presence and continuity of walking and biking trails can be performed and the results presented at a town council meeting.44 Volunteer or contract your services to a local YMCA or community center for sports or exercise classes. Spurred on by an increase in children's sports injuries, Danny Smith, a PT in Tennessee, holds clinics for Little League coaches on preventing injuries.43 Join a neighborhood watch or start a community group to address the safety in neighborhoods to make them more attractive for physical activity. One recommendation is to encourage schools to make facilities available for community members to use after school hours or in inclement weather, such as basketball courts, a swimming pool, or hallways for walking.

The Policy Level

The way to affect the largest number of youth is through a change in policy. There are many opportunities to advocate for local policy change to enhance physical activity in our pediatric population.11 Become active on a Town Council to advocate for walking/bicycle trails or accessibility to sports or playground equipment. The Surgeon General's Report recommends advocating for daily PE for grades K-12 with a physical education specialist.4 Attend School Board meetings to monitor policies and advocate for increasing PE requirements, increased physical activity in after-school programs, or not withholding recess as a punishment. On a State or National level, physical therapists can advocate for public health policies to enhance physical activity. The National Association of State Boards of Education provides sample policies for use at the State, school district, or individual school level to promote physical activity in schools and communities.45 Policies of reimbursement by insurance companies are another area of intervention. Since Medicare recently changed its stance and now classifies obesity as a disease, this could increase the coverage for treatment of obesity by the government and the many third party payers who follow their lead.46 We should advocate for medical insurance coverage of physical activity programs for children with or at-risk of overweight and obesity.

CONCLUSION

As clinicians, we need to think outside the box of the treatment rooms, rehab departments, or hospital wards where we treat children and adolescents one-on-one. We should consider enhancing physical activity at the many other levels of intervention.11 As academicians, we need to ensure that our PT and PTA students have the knowledge and skills to practice in the wider circles of intervention and that they demonstrate this in an accredited program. As community members, we need to hold our schools and neighborhoods responsible for giving all of our children the knowledge, skills, and opportunities not only for physical activity during the school day, but outside the school environment as well. As citizens, we need to support laws that make the physical environment safe and available for physical activity and advocate for those most vulnerable in our society, the children. We need to change the way physical activity is perceived. It is not only an individual behavior choice to be active or not, but also the result of many choices made for us in our environment.

If we are successful in bringing about change to increase the physical activity of children and adolescents for the long term, which in turn can lead to increased physical fitness, we have the potential to change the health of future generations. It is APTA's position that physical therapy is a health profession whose primary purpose is the promotion of optimal health and function-increasing physical activity in those with whom we interact fulfills this important role.

[Reference]

REFERENCES

1. NIH Consensus Development Conference. Physical Activity and Cardiovascular Health. Bethesda, Md; December 18-20, 1995.

2. US Department of Health and Human Services. Promoting Physical Activity: A Guide For Community Action. Champaign, III: Human Kinetics; 1999.

3. American Academy of Pediatrics Policy Statement. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112(2):424-430.

4. US Department of Health and Human Services. A Report of the Surgeon General: Physical Activity and Health. Available at: http://www.surgeongeneral.gov. Accessed April 26, 2004.

5. NIHCM Foundation. Obesity in Young Children: Impact and Intervention. Washington, DC; August, 2004.

6. Centers for Disease Control and Prevention. Increasing physical activity: a report of recommendations of the Task Force on Community Preventive Services. MMWR 2001; 50(No. RR-18).

7. Physical Activity, Fitness, and Health Consensus Statement. Bouchard C, Shephard RJ, Stephen T, ed. Champaign, Ill; 1993.

8. A Primer on Active Living By Design. A National Program of the Robert Wood Johnson Foundation. Administered by the University of North Carolina's School of Public Health in Chapel Hill; 2004.

9. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity: a systematic review. Am J Prev Med. 2002;22(45):73-107.

10. Molner BE, Gortmaker SL, Bull FC, Buka SL. Unsafe to play? Neighborhood disorder and lack of safety predict reduced physical activity among urban children and adolescents. Am J Health Promotion. 2004;18(5):378-386.

11. Nestle M, Jacobsen MF. Halting the obesity epidemic: a public health policy approach. Public Health Reports. 2000;115:12-24.

12. Gordon-Larsen P, Griffiths P, Bentley ME, et al. In young black girls, safety concerns, lack of recreation options contribute to weight problems. Am J Prev Med. In press.

13. Centers for Disease Control and Prevention. Fact Sheet: Physical Education and Activity. CDC's School Health Policies and Programs Study (SHPPS) 2000.

14. Layden, T. Get out and play! Newsweek. 2004;November 15:80-86.

15. Gordon-Larsen P, McMurray RG, Popkin BM. Adolescent physical activity and inactivity vary by ethnicity: the National Longitudinal Study of Adolescent Health. J Pediatri. 1999;35(3):301-306.

16. Kimm SYS, Glynn NW, Kriska AM, et al. Decline in physical activity in black girls and white girls during adolescence. N Eng J Med. 2002;347(10):709-715.

17. Reilly JJ, Jackson DM, Montgomery C, et al. Total energy expenditure and physical activity in young Scottish children: mixed longitudinal study. Lancet. 2004;363(9404):211-212.

18. Sutherland L. Adolescent obesity largely caused by lack of physical activity. Presented at Experimental Biology '03. April 14, 2003, San Diego, Calif.

19. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. US Surgeon General's web site. Available at: http://www.surgeongeneral. gov/topics/obesity. Accessed October 3, 2002.

20. Harrell JS, McMurray, RG, Amorim L, Creighton D, Bangdiwala SI. One in eight North Carolina schoolchildren display 3 or more heart risks. Presented at American Heart Association scientific meeting. November 9, 2003. Orlando, Fla.

21. Rowland TW. Endurance exercise fitness. In: Rowland TW. Exercise and Children's Health. Champaign, Ill: Human Kinetics; 1990.

22. National Center on Physical Activity and Disability. Achieving Beneficial Fitness for Persons with Developmental Disabilities. Department of Disability and Human Development at the University of Illinois at Chicago; October 2001.

23. Youth Risk Behavior Surveillance System. Available at: http://www.cc.gov/HealthyYouth/yrbs/index.htm. Accessed November 2, 2004.

24. Mitchell M. Physically fit children appear to do better in classroom, researchers say. News Bureau of University of Illinois at Urbana-Champaign. Available at : http://www.news.uiuc.edu/news/04/101 8fitness.html. Accessed October 30, 2004.

25. Plowman SA. Children aren't miniature adults: similarities and differences in physiological responses to exercise, Part 1. ACSM's Health and Fitness Journal. 2001;5(5):11-17.

26. Cerny FJ. Pediatrics. In: Cerny FJ, Burton HW. Exercise Physiology for Health Care Professionals. Champaign, Ill: Human Kinetics; 2001.

27. US Department of Health and Human Services. Healthy People 2010: Physical Activity and Fitness. Available at: http://www.health.gov/healthypeople/document/HTML/Volume2/22Physical.htm. Accessed April 26, 2004.

28. President's Challenge. President's Council on Physical Fitness and Sports. Available at: http://www.presidentschallenge.org. Accessed November 2, 2004.

29. Cooper Institute for Aerobic Research. Fitnessgram. Dallas, TX. Available at: http://www.coperinst.org/. Accessed November 2, 2004.

30. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore, Md: Williams & Wilkins; 1995.

31. Kuntzleman C. The healthy-for-life checkup and endurance. In: Kuntzleman, C. Healthy Kids for Life. New York, NY: Simon & Schuster Inc; 1988.

32. Get Kids in Action. BMI calculator. Available at: http://www.getkidsinaction.org. Accessed November 10, 2004.

33. Centers for Disease Control and Prevention. Growth charts for children and adolescents. Available at: http://www.cdc.gov/growthcharts. Accessed November 4, 2004.

34. Groslambert A, Hintzy F, Hoffman MD, Dugue B, Rouillon JD. Validation of a rating scale of perceived exertion in young children. International J Sports Med. 2001;22(2):116-119.

35. Pfeiffer KA, Pivarnik JM, Womack CJ, Reeves MJ, Malina RM. Reliability and validity of the Borg and OMNI rating of perceived exertion scales in adolescent girls. Med Sci Sports Ex. 2002;34(12):2057-2061.

36. Utter AC, Robertson RJ, Nieman DC, Kang J. Children's OMNI scale of perceived exertion: walking/running evaluation. Med Sci Sports Ex. 2002;34(1):139-144.

37. Bar-Or O. Training considerations for children and adolescents with chronic disease. In: Hasson SM ed. Clinical Exercise Physiology. St. Louis, Mo: Mosby; 1994.

38. President's Council on Physical Fitness and Sports. Compendium of physical activities. PCPFS Research Digest. June 2003;4(2).

39. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly. 1988;15(4):351-377.

40. US Department of Health and Human Services Office on Disability. 'I Can Do It-You Can Do It'. Available at: http://www.hhs.gov/od/physicalfitness.html#3. Accessed November 2, 2004.

41. Strecher VJ. The health belief model. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, Calif: Jossey-Bass Inc; 1997.

42. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, Calif: Jossey-Bass Inc; 1997.

43. Johnson, LH. The challenges of modern society. PT Magazine. November 2002:42-48.

44. Emery J, Crump C, Bors P. Reliability and validity of two instruments designed to assess the walking and bicycling suitability of sidewalks and roads. Am J Health Promotion. 2003;18(1):38-46.

45. National Association of State Boards of Education. Healthy Schools: Sample Policies to Encourage Physical Activity. Available at: http://www.nasbe.org/HealthySchools/physical_activity.html. Accessed June 9, 2003. These policies first appeared in Fit, Healthy, and Ready to Learn: A School Health Policy Guide by the National Association of State Boards of Education. Reprinted with permission of the author.

46. Stein R. North Carolina Health Insurer to Offer Coverage for Weight Problems. Washington Post. October 13; AO2: 2004.

[Author Affiliation]

Anne Mejia Downs, PJ, MPH, CCS

Department of Physical Therapy, Indiana University, School of Health and Rehabilitation Sciences, Indianapolis, IN Department of Rehabilitation Services, Clarian Health Partners, Indianapolis, IN

[Author Affiliation]

METROPOLITAN HOSPITAL CENTER CELEBRATES GRAND OPENING OF NEW PEDIATRIC INPATIENT UNIT. - States News Service

NEW YORK, NY -- The following information was released by the New York City Health and Hospitals Corporation (HHC):

Metropolitan Hospital Center today announced the grand opening of its new, $3.2 million Pediatric Inpatient Unit, which integrates the highest quality medical care for children with a beautiful, nurturing environment that fosters patient safety and healthy recovery. Alan Muraoka, who plays the proprietor of 'Hooper's Store' on 'Sesame Street,' was the Master of Ceremonies at the special event.

'Metropolitan's new inpatient unit is the successful realization of our wish to provide our youngest patients with the most beautiful surroundings possible,' said Meryl Weinberg, BSN, MA, Executive Director of Metropolitan Hospital Center. 'Our children and their families are receiving the highest quality medical care in a setting that clearly demonstrates our commitment to their health and well being.'

Metropolitan Hospital provides comprehensive care to thousands of newborns, infants, children and adolescents through its inpatient and ambulatory care services. The new 7,500-square-foot Pediatric Inpatient Unit accommodates 14 patients and each of the eight bedrooms has the latest in high-tech medical equipment as well as a flat screen television and its own bathroom and shower facilities. The centerpiece of the unit is a sparkling new playroom equipped with a spectacular, 250-gallon saltwater aquarium.

The space conforms to American Institute of Architects guidelines and was designed to provide a child-friendly environment with an emphasis on patient safety. It replaces a unit that was originally opened in 1955 and had become antiquated.

'Our goal is to provide a bit of joy and happiness in the lives of our patients,' added Ms. Weinberg.

Dorothy Johnson, RN, who is head nurse of the pediatric unit and has worked in Metropolitan's Pediatric Services since 1978, cut the ribbon at the entrance to the new space. Also participating in the event was Lynda D. Curtis, Senior Vice President of the New York City Health and Hospitals Corporation (HHC) and its South Manhattan Healthcare Network. Metropolitan Hospital Center is a member facility of HHC. They were joined by Jenny Morgenthau, Executive Director of the Fresh Air Fund, who announced the kickoff for registration of the organization's popular summer programs.

Funding for the $3.2 million renovation project was provided by a New York State HEAL grant, the Starlight Children's Foundation, the New York City Health and Hospitals Corporation, and the Metropolitan Hospital Center Auxiliary.

More than 1,300 babies were delivered at Metropolitan Hospital Center in 2011. The hospital's Pediatric Ambulatory Care Service has more than 30,000 visits annually, including well baby care, preventive care, a Children's Asthma Program, nutrition counseling services and adolescent medicine services.

About Metropolitan Hospital Center

Metropolitan Hospital Center (MHC) is the community hospital of choice for residents of East Harlem, northern Manhattan and neighboring communities. Metropolitan provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science. Metropolitan Hospital Center is part of the New York City Health and Hospitals Corporation (HHC), the largest municipal hospital and health care system in the country.

Pediatric Asthma: Changing Practices in Telehealth Nursing - AAACN Viewpoint

Author's Note: For these endeavors I would like to thank Sheila Haas, Cedlia Gatson-Grindel, and Ida Androwich for 'getting me hooked' on evidence-based practice. Their presentation on nursing intervention and outcomes classification, standardized terminology, and using evidence-based practice at the 2006 AAACN Annual Conference in Atlanta was full of information and practical ideas.

Asthma continues to be the most common chronic disorder among children. It is estimated that approximately 5 million children are affected in the U.S. It is the third leading cause of hospitalization of children, numbering more than 200,000 children yearly. Asthma is the leading cause of school absence of children between the ages of 5 and 17 years, representing 10 million missed school days per year (Asthma and Allergy Foundation of America [AAFA], 2003).

It is a harsh reality that children do die of asthma. Statistics show that each year, approximately 5,000 Americans die from asthma. This is a growing health problem throughout developed countries of the world. It is estimated that 9.6% or 26.5 million adults and children have asthma, according to the Centers for Disease Control and Prevention. Individuals with asthma use more health care resources than non-asthmatic patients, representing a 2.8 fold higher cost of medical care per year (American Lung Association [ALA], 2003). The long-range goal for asthma treatment is control of asthma exacerbations by eliminating and minimizing trigger factors, identifying effective medications, and promoting optimal daily health habits.

Challenge for Telehealth Nurses

The telehealth nurse has a big challenge when taking a pediatric asthma call. Using only parental/caregiver assessment descriptions and focused interviewing, and sometimes talking and listening to the child, the nurse must determine the child's respiratory status. Pulmonologists and allergists recommend aggressive and prompt treatment during acute asthma episodes, which can effectively reverse a child's status from urgent to non-urgent (Nasser, 2005).

In 2001, the After Hours Program at St. Louis Children's Hospital collaborated with the hospital pulmonologists and subscribing community pediatricians to develop an innovative pediatric asthma guide. The guideline is based on the zone identification model to classify asthma acuity (see Table 1). This model is used widely in pediatric practices. Each zone has identifying signs and symptoms. The guideline provides specific treatment and follow-up procedures to correspond with the zones. The subscribing pediatricians are asked to contractually agree to have the telehealth nurses triage, assess, plan, and actively intervene in caring for the child with asthma. Per physician standing order and protocol, nurses can refill asthma rescue medications. In order to provide the next level of care and home maintenance during urgent asthma episodes, this program provides the nurse with the ability to order and initiate the administration of oral steroids.

Asthma Guideline

The following is an abstracted version of the pediatric asthma guideline.

Red Zone

* Children under 6 months of age, give one albuterol (Ventolin�) or levalbuterol HCI (Xopenex�) nebulized treatment and send to Emergency Unit (EU).

* Children over 6 months of age, give one albuterol or levalbuterol HCI nebulized treatment or albuterol MDI 4 (metered dose inhaler); 4 to 6 puffs and send to EU.

Yellow Zone

* Children less than 6 months of age are given one albuterol or levalbuterol HCI nebulized treatment, and the RN is to contact the on call physician for further instructions.

* Children over 6 months of age are given up to 3 'back-to-back' rescue treatments, 2 to 3 albuterol or levalbuterol HCI nebulized treatments (each 20 minutes apart), or albuterol MDI 4 puffs (2 to 3 times, 20 minutes apart). The RN makes followup in one hour. Give the parent or caregiver symptoms indicating a worsening condition that requires a call back sooner than one hour.

* The algorithim has several alternative choices for the RN to select specific patient situations, such as two rescue treatments given prior to call, oral steroids started within past 48 hours, etc.

* If the nurse identifies that the child still remains in the Yellow Zone after 2 to 3 rescue treatments have been given during the one hour followup call, oral steroids are initiated. A list of contraindications is reviewed for patient safety. They are:

* Type I diabetes.

* Active chickenpox or chickenpox exposure or varicella vaccine within 21 days.

* MMR within 14 days.

* Other underlying medical problems

* The oral steroid is called to the pharmacy of choice and the parent is asked to see the pediatrician within 24 hours for evaluation. Worsening symptoms are reviewed, and the parent is instructed to call back if further help is needed or questions arise.

Green Zone

* Give rescue treatments every 4 hours.

* Each time give 1 nebulizer treatment or 4 puffs of inhaler with aerochamber.

* Start or continue routine asthma medications, including inhaled steroids.

* Follow the action plan from your physician, if available.

Outcome Data

The current pediatric asthma guideline has been in use for 5 years. Parents have been cooperative with the care instructions and many have voiced satisfaction with the treatment outcomes. The pediatricians remain supportive of the program. The departmental quality improvement (Ql) committee, nursing staff, and advisory board continually review the guideline for quality assurance. In 2005, 5,423 asthma calls were taken by the call center. Asthma consistently has remained the 10th most common primary problem reported by parents to the After Hours Service. In 2002, the effectiveness of the program was reviewed. It was found that from January 2001 to January 2002, 5,411 children were evaluated in the St. Louis Children's Hospital EU with a diagnosis of asthma. Of those, 7.8% were referred by the After Hours call center. Of those asthma patients not receiving pre-hospital telehealth care, 36% were admitted. Of those patients receiving pre-hospital telehealth care, only 15% were admitted. This outcome demonstrates a significant difference when well-trained and skilled telehealth nurses initiate asthma home care for reliever therapies.

The next step is to thoroughly evaluate the effectiveness of the asthma guideline. Efforts have been initiated to apply the principle of evidence-based practice (EBP) to evaluate patient outcomes. A small sample of asthma calls from March 1, 2006, to May 31, 2006, has been retrieved, and a care plan has been developed (see Table 2). Standardized terminology and patient outcomes have been identified using the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) reference texts.

Evidence-Based Practice for Pediatric Asthma Prevention

Telehealth nursing is an excellent clinical setting for EBP. With the electronic clinical information system, there is a wealth of information gathered, stored, and retrieved. The symptom-based guideline used offers concrete practice to evaluate pediatric patients. The clinical application of EBP for pediatric asthma intervention will be focused on the effectiveness of oral steroid administration at home and teaching parents how to give reliever therapies in the home setting. The information gathered will assist QI monitoring by evaluating appropriateness and thoroughness of guidelines used by nurses.

Conclusion

The scope of practice for telehealth nursing is rapidly expanding. Caring for the child with asthma is an excellent example of this movement. The nurse can provide aggressive guidance and intervention while keeping the child at home. Using the symptom-based pediatric asthma guideline, the nurse is able to teach parents about the etiology of asthma, triggers, respiratory assessment, and purpose of medications for rescue, control, and appropriate intervention. The parent is empowered to effectively and successfully treat his or her child during asthma attacks in the home setting. Effective and prompt home care protects the child from the emotional trauma of an EU or hospital visit.

[Sidebar]

Using the symptom-based pediatric asthma guideline, the nurse is able to teach parents about the etiology of asthma, triggers, respiratory assessment, and purpose of medications for rescue, control, and appropriate intervention.

[Reference]

References

American Lung Association (ALA). (2003). Childhood asthma: An overview. New York: Author.

Asthma and Allergy Foundation of America (AAFA). (2003). Asthma facts and figures. Washington, DC: Author.

Nasser, R. (2005). Asthma. In A. Osborn (Ed.), Pediatrics (pp. 825-828). Philadelphia: Mosby.

[Author Affiliation]

Virginia Muraoka-Meyer, MSN, RNC, FNP

[Author Affiliation]

Psychometric instrument evaluation: the Pediatric Family Satisfaction Questionnaire. (Continuing Education Series). - Pediatric Nursing

Patient satisfaction, also called satisfaction or client satisfaction, has received increased attention in the last decade as a reliable and valid measurement of quality of care. This is also believed to be true among the pediatric patient population. Due to the stature of children, parents are seen as the consumers or patients in proxy. Parents are the child's advocates within the health care system and, therefore, represent the patient point of view. The importance of parental satisfaction studies is supported by research findings that indicate that parental perception does not always equal health care professional perception of various phenomena in the health care setting (Bournaki, 1987; Bradford, 1991; Graves & Hayes, 1996; Graves & Ware, 1990; Horner, Rawlins, & Giles, 1987; Thornton, 1996; Tughan, 1992). Parental satisfaction studies indicate that health care providers often under or overestimate parental needs and satisfaction (Bradford, 1991; Thornton, 1996), presumably inhibiting improvement of quality of care.

In preparation for studying parental satisfaction with hospital care in general inpatient pediatric units, the existing literature on parents in hospitals was searched and analyzed to identify an instrument suitable for the purpose of the study. The search resulted in the selection of the Pediatric Family Satisfaction Questionnaire (PFSQ) (Budreau & Chase, 1994) as the most suitable instrument. There were three broad steps used in the selection process: (a) selecting satisfaction as the indicator of quality of care that would be measured, (b) identifying the criteria for selecting an instrument to measure the concept, and (c) verifying that an instrument meets all the criteria for selection. The process engaged in each step will be presented, but it was the third step that proved to be the most time-consuming, particularly identifying the psychometric properties of the instrument. To determine if the instrument selected met the criterion of having satisfactory psychometric properties, it was necessary to test the instrument ourselves with data made available to us.

Selecting Satisfaction as Quality of Care Outcome Measure

Although satisfaction measurements are but one method of measuring outcomes, they are considered by many to be one of the most important ones in improving quality of care. Patients' points of view add a new dimension to quality, the personal value, the degree to which health care satisfies patients, which Palmer, Donabedian, and Povar (1991) choose to call 'the acceptability of care' (p. 58). According to Vuori (1989), the term quality can refer to effectiveness, efficiency, equity, acceptability, accessibility, adequacy, and scientific-technical quality of care. In this context, Vuori (1987) identified three possible functions for patient satisfaction. It can serve as an attribute for quality care indicating that care can not be of high quality unless the patient is satisfied. Patient satisfaction can be an indicator for quality care reflecting the patient's views of the received care. Or, patient satisfaction can function as a precondition for quality care assuming that the more satisfied patients will cooperate more effectively and show a greater compliance to treatment and, thus, will more likely return to the services again.

Patient satisfaction measurements can and should improve quality of care by providing important marketing data and by helping to improve the quality of risk management programs (Scott & Smith, 1994). They can be used in goal-setting programs, to improve employee performance, or to recognize high-performance employees (Strasser & Davis, 1991). Patient satisfaction can serve to assess consultations and patterns of communication within the health care system and as feedback on alternative treatment choices (Fitzpatrick, 1991).

Patient satisfaction has been defined as 'judgment made by a recipient of care as to whether his or her expectations for that care have been fulfilled' (Palmer et al., 1991, p. 56). It is a means of measuring acceptability of care, where acceptability is the degree to which health care satisfies the patient (Palmer et al., 1991). To explain the inextricable links of patient satisfaction and quality of care, quality of health care has further been defined as 'the production of improved health and satisfaction of a population within the constraints of existing technology, resources, and consumer circumstances' (Palmer et al., 1991, p. 58). Thus, to be able to interpret the quality of care, the degree of acceptability and the expectations of the patient must be known (Allanach & Golden, 1988; Scardina, 1994; Scott & Smith, 1994) and 'care cannot be of high quality unless the patient is satisfied' (Vuori, 1987, p. 107).

Identifying the Criteria for Instrument Selection

It was decided that the instrument needed to meet two broad criteria. One of these was consistency with the theoretical framework of the study and with the empirical findings related to that theoretical framework. The second was the instrument had to have adequate psychometric properties. However, these distinctive criteria are interconnected, as a study's theoretical framework must be kept in mind when assessing the psychometrics of an instrument (Ferketich & Muller, 1990; Giuffre, 1995; Nunnally, 1978).

The theoretical framework of the proposed study on parental satisfaction is based on: (a) Donabedian's (1980; 1982; 1988) structure, process, and outcome approach to quality care; (b) Price's (1993) preliminary theory on quality nursing care; and (c) empirical findings on the needs of parents whose children are hospitalized.

For quality assessment, Donabedian (1988) categorized quality indicating information into: (a) structure, (b) process, and (c) outcome. Structure refers to the setting where the care is carried out. Process refers to what is actually done when giving and receiving care. Outcome refers to the effects of the care on the patient's health status. Donabedian's framework is based on the assumption that good structure increases the likelihood of good process, and good process increases the likelihood of good outcome. According to Donabedian (1988), appropriate management of interpersonal relationships to carry out the necessary technical care in each case is the key to successful outcomes. The quality of health care is the optimal intertwining of technical care and the management of the interpersonal relationships between the health care provider and the patient (Donabedian, 1982).

In a qualitative study on parents' perceptions of the meaning of quality nursing care, Price's (1993) findings indicated that parents experienced quality nursing care as a four-stage process. The process included: (a) maneuvering or getting in touch with the parents and the child; (b) getting to know the parents and the child; (c) establishing a positive relationship between the nurse and the parents and child; and (d) meeting the biopsychosocial needs of the parents and child, which was described by the parents as quality nursing care.

Several empirical studies have indicated basic parental needs related to their child's hospitalization. These needs refer to: (a) information, (b) being able to stay with the child and take care of the child, (c) being trusted, (d) trusting health care providers, (e) support and guidance, (f) human and physical resources, (g) financial assistance, (h) other family members, (i) hope, (j) the child's development and education, and (k) coordination of care (Bragadottir, 1999; Farrell & Frost, 1992; Fisher, 1994; Kasper & Nyamathi, 1988; Kirschbaum, 1990; Kristjansdottir, 1991; 1995; Terry, 1987).

The key role of nurses and physicians in providing care to hospitalized children and their parents is reflected in parental self-perceived needs, where parents expressed the need to be able to trust nurses and physicians and to be trusted by nurses and physicians (Bragadottir, 1999; Kristjansdottir, 1991, 1995; Terry, 1987). In Terry's (1987) study, parents chose physicians and nurses as the persons most likely to meet their needs. These findings support the proposition that nursing care, with medical care, is of most importance in meeting parental needs in hospitals and, therefore, is most important for parental satisfaction. This indicates that parental satisfaction questionnaires must be nursing sensitive to be of true value as outcome measurements.

Instrument Evaluation

Whether developing a new instrument or evaluating an existing one, the instrument needs to be psychometrically sound and feasible. The usefulness of an instrument as an outcome measure depends on its reliability, validity, sensitivity, feasibility, and clinical practicability (Abdellah & Levine, 1965; Aday, Begley, Lairson, & Slater, 1993). The following questions were used to evaluate existing parental satisfaction instruments identified in the literature:

1. What was the purpose of the instrument?

2. What is the theoretical and empirical framework of the instrument?

3. Does it reflect the conceptual definition of the variables in the proposed study?

4. Was the instrument developed for the same population and setting as it is intended to be used in the proposed study?

5. Is the readability level of the instrument appropriate for the population?

6. How long and complex is the instrument?

7. What evidence is available related to the instruments reliability and validity? (Burns & Grove, 1993; McDowell & Newell, 1987; Radosevich, 1997; Waltz, Strickland, & Lenz, 1991).

Consistency with the theoretical framework and related empirical findings. To identify publications on parental satisfaction CINAHL 1982-1999, Medline 1985-1999, and PsycINFO 1984-1999 computerized databases were searched using a number of keywords. The articles identified from the literature reporting satisfaction studies among parents of hospitalized children were few and varied in perspective and methodology. Bergman's (1995) point about how little had been done in patient-centered areas of satisfaction, especially for children seemed more than true. Table 1 gives an overview of identified general parental satisfaction instruments for inpatient pediatric units.

Based on the available information, the PFSQ (Budreau & Chase, 1994) instrument seemed to best serve the purpose of the proposed parental satisfaction study. It was developed to ensure a family-centered approach in general pediatric health care settings. The instruments content validity had been established, but its psychometric soundness was still in question.

For further investigation on the value of the PFSQ, its authors provided data for psychometric analysis from several years of parent satisfaction surveys at a large Midwest hospital and clinics. Information on the readability and complexity of the PFSQ was not available.

Several procedures are used to estimate reliability (Burns & Grove, 1993; Carmines & Zeller, 1979; Crocker & Algina, 1986; Krowinski & Steiber, 1996). The most common method of internal consistency testing is Cronbach's coefficient alpha (Cronbach, 1951). Homogeneous or internally consistent items measure the same thing, and the closer the Cronbach's coefficient alpha is to 1.0, the higher the internal consistency. For new instruments under development, Cronbach's coefficient alpha of .70 is considered satisfactory but should preferably be at least .80 for well established instruments (Carmines & Zeller, 1979; Nunnally, 1978).

Construct validity involves three steps: (a) specifying the theoretical relationship between concepts, (b) examining the empirical relationship between the measures of the concepts, and (c) interpreting the empirical evidence as to how it clarifies the construct validity of the particular measure (Carmines G Zeller, 1979; Nunnally, 1978). Factor analysis is the most common statistical analysis used for construct validity testing (Kim & Muller, 1978a; 1978b; Krowinski & Steiber, 1996; Nunnally, 1978). It involves testing the interrelationship among items that measure the same concept or factor. This clustering of related items through correlation is called factor loading. Higher factor loading indicates a strong interrelationship among items, indicating an instrument's validity (Burns & Grove, 1993; Cronbach, 1951; Kim & Mueller, 1978a). Factor loading of .30 or more is desirable (Kim & Mueller, 1978b; Nunnally, 1978).

Adequacy of the psychometric properties of the PFSQ. The SPSS statistical software package was used for testing the reliability and construct validity of the PFSQ. The instruments' content validity was already established to some extent (Budreau & Chase, 1994), but no statistical tests had been done to assess its psychometric soundness.

Cronbach's coefficient alpha (Cronbach, 1951) was used to estimate the internal consistency reliability. It was computed for the total scale and for each of the four subscales: (a) hospital services and accommodations, (b) nursing care, (c) medical care, and (d) child life therapy. Treating each subscale as a separate scale is especially important with satisfaction measures, as they usually include several diverse factors (Krowinski & Steiber, 1996). When interpreting the results of internal consistency, the number of items and their nature need to be considered. A higher number of items, greater test variance, and approximation to normal distribution increase the alpha level (Ferketich, 1990; Nunnally, 1978; Waltz et al., 1991).

The construct validity of the PFSQ was tested with factor analysis. Factor analysis includes several mathematical procedures involving a series of multiple regression analyses (Kim & Mueller, 1978a; 1978b). There are two types of factor analysis: exploratory factor analysis and confirmatory factor analysis. Both include three steps: (a) the development of the covariance matrix, (b) the extraction of the initial factors, and (c) the rotation to a terminal solution (Burns & Grove, 1993; Crocker & Algina, 1986; Kim & Mueller, 1978b). The initial step involves exploring the interdependence among the items. The core difference between exploratory factor analysis and confirmatory factor analysis is that a hypotheses on the number of the common factors guides the assessment of the rotated factor solution in the latter procedure (Kim & Mueller, 1978a; 1978b). For the factor analysis of the PFSQ, varimax rotation was used for an orthogonal solution (Kim & Mueller, 1978a). The formerly identified four factors of the PFSQ served as the hypothesis guiding the interpretation of the factor analysis.

Results

The analyzed data were collected from October 1994 through March 1997 with the bulk of the cases from 1995 (45%) and 1996 (36%). The total sample consisted of 848 cases. The majority of the participants were mothers (83%). In some instances, mothers and fathers had answered jointly, mothers and patients jointly, or fathers only. Most of the children had been hospitalized in a pediatric medical or surgical unit (92%) with a minority (8%) being hospitalized in a specialty unit such as the pediatric bone marrow transplant unit, the pediatric intensive care unit, or the neonatal intensive care unit.

Cronbach's alpha. The results of the Cronbach's alpha internal consistency testing are presented in Table 2. The alpha for the total instrument including all 35 items was .83. Due to missing data, only 327 cases were included in the reliability testing of the total scale. The subscales of nursing care (scale II) had an alpha of .92, and the subscale of medical care (scale III) an alpha of .83, indicating high internal consistency. The subscale of hospital services and accommodation (scale I) and the child life therapy subscale (scale IV) showed low internal consistency with an alpha of .65 and .53, respectively.

Due to substantial missing data in the child life therapy subscale and the relatively low internal consistency of that subscale, Cronbach's alpha was also computed without the child life therapy subscale to obtain a more reliable estimate of the internal consistency. The alpha for the total instrument, omitting subscale IV, was .90, based on 675 cases and 30 items.

The alpha for each subscale if an item was deleted showed significant difference in two instances. For the subscale of medical care, the alpha increased to .92 if the item 'the doctors were caring and concerned' was deleted, and in the subscale of child life therapy, the alpha increased to .90 if the item 'the child life therapist recognized the patient's individual needs' was deleted.

For the total instrument no significant changes in alpha were identified when items were deleted. In turn, however, when the subscale IV of child life therapy was deleted entirely, the alpha for the total instrument increased substantially.

Factor analysis. Due to substantial missing data, low internal consistency, and low loading in earlier stages of the factor analysis, subscale IV was excluded from the final stages of the factor analysis for construct validity testing. The guiding hypothesis of four main factors was not supported. Solutions of three and four factor rotation showed a secondary loading of most items. The rotation of the axis showed a terminal solution of two main factors as indicated by the factor matrix in Table 3, with a fairly distinct clustering of items. A scree plot supported this interpretation suggesting two main factors.

For factor I, 18 items showed a loading of [greater than or equal to] .30, and for factor II, 10 items showed a loading of [greater than or equal to] .30. However, three of these items showed secondary loading: (a) overall satisfaction, (b) doctors information about test results and changes in patient's condition, and (c) doctors including parents in decision making and care planning. Two of the items had a loading of < .30, 'the unit and patient rooms were clean' and 'the patient was not disturbed by noise,' and two items did not have trivial loading on either factor, 'the admission procedure went smoothly' and 'the doctors were caring and concerned.'

Discussion

Reliability. The Cronbach's alpha reliability tested satisfactory internal consistency for the total PFSQ instrument, its alpha being above .80 (Carmines & Zeller, 1979; Nunnally, 1978). Two of the four subscales showed a satisfactory alpha coefficient, scale II of nursing care and scale III of medical care. These subscales have significantly more items, 12 and 11, than subscale I of hospital services and accommodation and subscale IV of child life therapy, which have 7 and 5 items, respectively. A scale with few items may show a low alpha, and adding items to a scale may raise the alpha (Ferketich, 1990, 1991; Nunnally, 1978). Another reason for a low alpha may be that the interim items in subscales I and IV are not measuring the same concept. Low alpha indicates that a scale needs improvement by adding, dropping, or changing items. In the case of subscales I and IV, the reason for a low alpha may well be high divergence of interim items or few items. However, adding items to a scale increases the burden on participants, making administration of the instrument less feasible. To this author's knowledge no studies have been done on the burden of the PFSQ. Asking participants about how well they understand the questionnaire and how long it takes them to answer it may shed a light on what changes are appropriate for increasing the reliability of the instrument, especially subscales I and IV. The divergent nature of parental needs and their numbers makes it difficult to keep the instrument short and still measure all the indicators of parental satisfaction. It may even be true that Cronbach's alpha is not the best test for reliability in this case (Ferketich, 1990). Theta and omega are other statistical tests of internal consistency not used as commonly as Cronbach's alpha, yet they may better suit the testing of instruments with diverse interim items (Carmines & Zeller, 1979; Ferketich, 1990).

Construct validity. The construct validity testing with factor analysis indicated that changes need to be made on the PFSQ. The hypothesis of four factors was not supported. The factor analysis indicated two main factors, nursing care and medical care. These results are in concordance with empirical findings indicating nursing care and medical care are the core indicators of parental satisfaction (Knafl, Cavallari & Dixon, 1988; Terry, 1987). The lack of loading or low factor weights of some of the items raises questions about whether they are of any clinical value and should, therefore, be deleted (Burns & Grove, 1993). Few responses for subscale IV, child life therapy, and subjective evaluation of parents' comments to the open ended questions indicated that child life therapy is not of concern to many parents although it may be of importance to some (Bragadottir, 1999; Kasper & Nyamathi, 1988). Items on accommodation showed none or low factor weight indicating little contribution to parental satisfaction as a whole. The item of teamwork among health care providers and the item of discharge preparation loaded more heavily on factor I indicating their consistency with the nursing care items. The item of doctors caring and concern loaded on neither factor, indicating no contribution to the overall parental satisfaction. A factor loading of .30 or more is desirable (Kim & Mueller, 1978b; Nunnally, 1978). At a cutting point of .30, three items had a secondary loading. To avoid this the cut-off point can be set higher (Burns & Grove, 1993), which, however, was not done in this case. Setting the cutting point higher and deleting items loading under the cutting point may strengthen the instrument psychometrically.

Conclusion

It should be noted here that the different types of validity are interrelated as are reliability and construct validity. Any factorial composition of measures plays a part in all three types of validity: content validity, criterion-related validity, and construct validity (Nunnally, 1978). Reliability and validity are matters of degree rather than all-or-none properties (Waltz et al., 1991). Instrument validity and reliability are situation bound and can vary from one sample to another. Tests of reliability and validity do not really assess an instrument in itself, but rather the use of it in certain populations and settings (Carmines & Zeller, 1979).

Although not discussed here, reliability can be tested with factor analysis (Burns & Grove, 1993; Carmines & Zeller, 1979). Deleting items that have low factor weights increases an instrument's reliability (Burns & Grove, 1993). Also, the reliability increases the more items loading high on the same concept (Kim & Mueller, 1978b). As pointed out by Ferketich (1991) 'the argument for achieving the goal of similarity among items is central to the estimates of both reliability and validity' (p. 167). The theoretical framework balanced with the mathematical criteria must, however, always lead the development of an instrument (Ferketich & Muller, 1990). What Giuffre (1995) calls 'healthy dose of judgment' (p. 36) must be mixed with statistical tests when evaluating an instrument's soundness. As Nunnally (1978) puts it, in judging the usefulness of a particular method of analysis, the researcher needs to question how much it helps the program of research.

Based on the content analysis and statistical testing reported here, the PFSQ is considered a promising instrument for evaluating parental satisfaction in general inpatient pediatric units. Reliability for the total instrument was satisfactory. Based on the factor analysis, construct validity tested satisfactory to some extent, indicating two main factors showing relatively high loading of most items.

For the development of the PFSQ, a two-step initial procedure is suggested. Led by the theoretical and empirical framework of the proposed study, the first step should be to evaluate the importance of items, especially the ones in subscales I and IV, to identify whether they need rewording, additional items, or deletion of items. This could be done by analyzing parents' comments to each of the factors and by further use of the instrument where parents are asked about the importance of each item, how well they understand the questions, and how long it takes to answer the questionnaire. The second step should be to test the revised instrument statistically repeating the procedures reported in this paper. It is suggested that items not loading on a factor nor explaining any of the variance be deleted. A reliable and valid shorter version of the PFSQ may make it a feasible instrument for nurse clinicians and nurse managers to use for ongoing quality control in pediatric units. However, further development of the instrument is suggested. The psychometric strengths of the PFSQ support its further development.

 Table 1. Studies on Parental Satisfaction in the Hospital      Author         Instrument          Purpose          Framework  Bradford, 1991   The Survey of     To investigate    Not reported                  Parental          whether pedi-                  Satisfaction      atric staff                  (SPS) (Dare &     accurately                  Hemsley, 1986),   estimated the                  a 35-item         concerns of                  scale.            parents and                                    assess the role                                    of staff level                                    of contact with                                    parents on                                    their subse-                                    quent accuracy.  Budreau &        The Pediatric     To develop a      Family-centered Chase, 1994      Family            family-centered   approach influ-                  Satisfaction      parental          enced by                  Questionnaire     satisfaction      Risser's (1975)                  (PFSQ), a 35-     questionnaire.    conceptual                  item, 5-point,                      framework and                  Likert-type                         the modified                  questionnaire                       Caring Beha-                  offering parti-                     viors Assess-                  cipants com-                        ment (Cronin &                  ments to each                       Harris, 1988,                  of the factors.                     Henry, 1992).  Thornton, 1996   Risser's          To determine      The enabling                  25-item,          the level of      and empowering                  self-report       congruence bet-   model of                  instrument,       ween parents'     helping rela-                  revised and       satisfaction      tionships                  adapted. A        with nursing      (Dunst, Tri-                  25-item,          care in a pedi-   vette, Davis, &                  5-point,          atric neuro-      Cornwell,                  Likert-type       science setting   1988).                  questionnaire.    and the nurses'                                    perceptions of                                    parents'                                    satisfaction.  Vandvik,         10-cm visual      To identify       Not reported Hoyeral,         analog scales.    areas of & Fagertum,                        parental dis- 1990                               satisfaction                                    with the                                    hospital care                                    of rheumatic                                    children.      Author            Factors         Reliability  Bradford, 1991   * Information        Not reported                  * Emotional sup-                    port                  * Discussion of                    outlook/prog-                    nosis,                  * Discussion of                    impact on daily                    life                  * Financial                    problems                  * Marital tension                  * Sibling                    problems                  * Contact with                    other families  Budreau &        * Hospital service   Not reported Chase, 1994        and accommo-                    dation                  * Nursing care                  * Medical care                  * Child life                    therapy  Thornton, 1996   * Professional       Not reported                    items                  * Educational                    items                  * Trust items  Vandvik,         * Reception to       Not reported Hoyeral,           the ward & Fagertum,      * Patient exami- 1990               nation by the                    physician                  * Ward atmos-                    phere and set-                    up                  * Patient exami-                    nation/treat-                    ment by the                    physiotherapist                  * School/                    preschool                  * Information                    (regarding dis-                    ease/treatment)  Table 2. Reliability of the PFSQ                                                N of                                               Cases      Alpha                                                for        for Factors and Items                            Subscale   Subscale  I. Hospital Service and Accommodation          772       .6538  1.  The admission procedure went smoothly. 2.  The unit and patient rooms were clean. 3.  The decor and furnishings were     suitable. 4.  The patient was not disturbed by     noise. 5.  The hospital staff worked together as     a team. 6.  We were adequately prepared for     discharge. 7.  Overall, we were satisfied with the     care we received at UIHC.  II. Nursing Care                               775       .9205  The nurses: 8.  were caring and concerned. 9.  were gentle with the patient. 10. checked the patient's condition     closely. 11. notified the doctor when necessary. 12. were aware of changes in the treatment     plan. 13. gave treatment and medication on time. 14. were skillful with procedures and     equipment. 15. kept us informed. 16. answered our questions clearly. 17. explained the patient's condition and     care in terms we understood. 18. listened to what we had to say. 19. included us in making decisions and     planning care.  III. Medical Care                              770       .8326  The doctors: 20. were caring and concerned. 21. were familiar with the medical     history. 22. were knowledgeable and skillful. 23. were available when needed or called. 24. responded promptly to changes in the     patient's condition. 25. had clear, honest communication with     us. 26. gave us information about treatments     and tests before they were done. 27. kept us informed of test results an of     changes in the patient's condition. 28. gave us complete explanations. 29. answered our questions clearly. 30. included us in making decisions and     planning care.  IV. Child Life Therapy                         371       .5290  The child life therapists: 31. introduced themselves and explained     their function. 32. were caring and supportive. 33. provided assistance to make the pa-     tient's hospital stay less stressful. 34. recognized the patient's individual     needs. 35. provided age-appropriate toys, games,     playrooms, and activities.                                                            * Total                                              Alpha for   Instrument                                              Subscale      Alpha                                               if Item     if Item Factors and Items                             Deleted     Deleted  I. Hospital Service and Accommodation  1.  The admission procedure went smoothly.     .6546       .8290 2.  The unit and patient rooms were clean.     .6398       .8281 3.  The decor and furnishings were     suitable.                                  .6205       .8264 4.  The patient was not disturbed by     noise.                                     .6546       .8246 5.  The hospital staff worked together as     a team.                                    .5744       .8223 6.  We were adequately prepared for     discharge.                                 .5998       .8283 7.  Overall, we were satisfied with the     care we received at UIHC.                  .5835       .8240  II. Nursing Care  The nurses: 8.  were caring and concerned.                 .9136       .8268 9.  were gentle with the patient.              .9158       .8272 10. checked the patient's condition     closely.                                   .9160       .8261 11. notified the doctor when necessary.        .9154       .8253 12. were aware of changes in the treatment     plan.                                      .9205       .8271 13. gave treatment and medication on time.     .9184       .8230 14. were skillful with procedures and     equipment.                                 .9149       .8261 15. kept us informed.                          .9112       .8231 16. answered our questions clearly.            .9085       .8230 17. explained the patient's condition and     care in terms we understood.               .9119       .8229 18. listened to what we had to say.            .9105       .8238 19. included us in making decisions and     planning care.                             .9089       .8228  III. Medical Care  The doctors: 20. were caring and concerned.                 .9221       .8758 21. were familiar with the medical     history.                                   .8197       .8223 22. were knowledgeable and skillful.           .8183       .8234 23. were available when needed or called.      .8127       .8219 24. responded promptly to changes in the     patient's condition.                       .8154       .8243 25. had clear, honest communication with     us.                                        .8018       .8177 26. gave us information about treatments     and tests before they were done.           .8066       .8179 27. kept us informed of test results an of     changes in the patient's condition.        .8018       .8153 28. gave us complete explanations.             .8013       .8165 29. answered our questions clearly.            .8048       .8173 30. included us in making decisions and     planning care.                             .8042       .8167  IV. Child Life Therapy  The child life therapists: 31. introduced themselves and explained     their function.                            .4582       .8270 32. were caring and supportive.                .4167       .8227 33. provided assistance to make the pa-     tient's hospital stay less stressful.      .4098       .8226 34. recognized the patient's individual     needs.                                     .8992       .8734 35. provided age-appropriate toys, games,     playrooms, and activities.                 .4300       .8257                                               ** Instru-                                              ment Alpha                                                if Item                                                Deleted                                              (Subscales Factors and Items                            I, II, III)  I. Hospital Service and Accommodation  1.  The admission procedure went smoothly.      .8980 2.  The unit and patient rooms were clean.      .8967 3.  The decor and furnishings were     suitable.                                   .8959 4.  The patient was not disturbed by     noise.                                      .8993 5.  The hospital staff worked together as     a team.                                     .8921 6.  We were adequately prepared for     discharge.                                  .8946 7.  Overall, we were satisfied with the     care we received at UIHC.                   .8919  II. Nursing Care  The nurses: 8.  were caring and concerned.                  .8942 9.  were gentle with the patient.               .8945 10. checked the patient's condition     closely.                                    .8936 11. notified the doctor when necessary.         .8937 12. were aware of changes in the treatment     plan.                                       .8930 13. gave treatment and medication on time.      .8932 14. were skillful with procedures and     equipment.                                  .8939 15. kept us informed.                           .8920 16. answered our questions clearly.             .8918 17. explained the patient's condition and     care in terms we understood.                .8925 18. listened to what we had to say.             .8915 19. included us in making decisions and     planning care.                              .8907  III. Medical Care  The doctors: 20. were caring and concerned.                  .9274 21. were familiar with the medical     history.                                    .8949 22. were knowledgeable and skillful.            .8936 23. were available when needed or called.       .8922 24. responded promptly to changes in the     patient's condition.                        .8929 25. had clear, honest communication with     us.                                         .8902 26. gave us information about treatments     and tests before they were done.            .8919 27. kept us informed of test results an of     changes in the patient's condition.         .8899 28. gave us complete explanations.              .8909 29. answered our questions clearly.             .8909 30. included us in making decisions and     planning care.                              .8900  IV. Child Life Therapy  The child life therapists: 31. introduced themselves and explained     their function. 32. were caring and supportive. 33. provided assistance to make the pa-     tient's hospital stay less stressful. 34. recognized the patient's individual     needs. 35. provided age-appropriate toys, games,     playrooms, and activities.  * N of cases = 327, alpha for total instrument with 35 items = .8303  ** N of cases = 675, alpha for total instrument with 30 items = .8974  Table 3. Factor Matrix                                                      Fac-     Fac- Items                                               tor I   tor II  1.  The admission procedure went smoothly. 2.  The unit and patient rooms were clean.                   .228 3.  The decor and furnishings were suitable.         .313 4.  The patient was not disturbed by noise.          .294 5.  The hospital staff worked together as a team.    .450 6.  We were adequately prepared for discharge.       .442 7.  Overall, we were satisfied with the care we     received at UIHC.                                .588    .383  The nurses: 8.  were caring and concerned.                       .717 9.  were gentle with the patient.                    .677 10. checked the patient's condition closely.         .635 11. notified the doctor when necessary.              .656 12. were aware of changes in the treatment plan.     .570 13. gave treatment and medication on time.           .577 14. were skillful with procedures and equipment.     .609 15. kept us informed.                                .719    .201 16. answered our questions clearly.                  .835 17. explained the patient's condition and care in     terms we understood.                             .758    .248 18. listened to what we had to say.                  .820 19. included us in making decisions and planning     care.                                            .802    .207  The doctors: 20. were caring and concerned. 21. were familiar with the medical history.                  .638 22. were knowledgeable and skillful.                         .735 23. were available when needed or called.            .254    .605 24. responded promptly to changes in the     patient's condition.                             .204    .624 25. had clear, honest communication with us.         .263    .813 26. gave us information about treatments and     tests before they were done.                     .209    .694 27. kept us informed of test results and of                  .702     changes in the patient's condition.              .315    .836 28. gave us complete explanations.                   .221    .838 29. answered our questions clearly. 30. included us in making decisions and planning     care.                                            .334    .691 

References

Abdellah, F.G., & Levine, E. (1965). Better patient care through nursing research. New York: Macmillan Publishing Co., Inc.

Aday, L.A., Begley, C.E., Lairson, D.R., & Slater, C.H. (1993). Evaluating the medical care system. Effectiveness, efficiency, and equity. Ann Arbor: Health Administration Press.

Allanach, E.J., & Golden, B.M. (1988). Patients' expectations and values clarification: A service audit. Nursing Administration Quarterly, 12(3), 17-22.

Bergman, D.A. (1995). Thriving in the 21st century: Outcome assessment, practice parameters, and accountability. Pediatrics, 96 (4, Pt. 2), 831-835.

Bournaki, M.C. (1987). Accuracy of nurses' assessment of maternal needs during childhood hospitalization. Unpublished master's thesis, Boston University School of Nursing, Boston, MA.

Bradford, R. (1991). Staff accuracy in predicting the concerns of parents of chronically ill children. Child: Care, Health & Development, 17(1), 39-47.

Bragadottir, H. (1999). A descriptive study of the extent to which self-perceived needs of parents are met in pediatric units in Iceland. Scandinavian Journal of Caring Sciences, 13(3), 201-207.

Budreau, G., & Chase, L. (1994). A family-centered approach to the development of a Pediatric Family Satisfaction Questionnaire. Pediatric Nursing, 20(6), 604-608.

Burns, N., & Grove, S.K. (1993). The practice of nursing research. Conduct, critique, and utilization (2nd ed.). Philadelphia: W.B. Saunders Company.

Carmines, E.G., & Zeller, R.A. (1979). Reliability and validity assessment. Beverly Hills: Sage Publications.

Crocker, L., & Algina, J. (1986). Introduction to classical and modern test theory. New York: Holt, Reinehart and Winston.

Cronbach, L.J. (1951). Coefficient alpha an the internal structure of tests. Psychometrica, 16(3), 297-334.

Cronin, S.N., & Harrison, B. (1988). Importance of nurse caring behaviors as perceived by patients after myocardial infarction. Heart and Lung, 17(4), 374-380.

Dare, J., & Hemsley, R. (1986). Design and evaluation of a questionnaire to identify emotional distress and its causes in parents of children with liver disorders. Paper presented at 58th British Paediatric Association meeting, York.

Donabedian, A. (1980). Explorations in quality assessment and monitoring (Vol. 1). The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press.

Donabedian, A. (1982). Explorations in quality assessment and monitoring (Vol. 2). The criteria and standards of quality. Ann Arbor, MI: Health Administration Press.

Donabedian, A. (1988). The quality of care how can it be assessed? JAMA, 260(12), 1743-1748.

Dunst, C., Trivette, C.M., Davis, M., & Cornwell, L.J. (1988). Enabling and empowering families of children with health impairments. Children's Health Care, 17(2), 71-81.

Farrell, M.F., & Frost, C. (1992). The most important needs of parents of critically ill children: Parent's perception. Intensive and Critical Care Nursing, 8(3), 130-139.

Ferketich, S. (1990). Focus on psychometrics. Internal consistency estimates of reliability. Research in Nursing & Health, 13(6), 437-440.

Ferketich, S. (1991). Focus on psychometrics. Aspects of item analysis. Research in Nursing & Health, 14(2), 165-168.

Ferketich, S., & Muller, M. (1990). Factor analysis revisited. Nursing Research, 39(1), 59-62.

Fisher, D.M. (1994). Identified needs of parents in a pediatric intensive care unit. Critical Care Nurse, 14(3), 82-90.

Fitzpatrick R. (1991). Surveys of patient satisfaction: II-designing a questionnaire and conducting a survey. British Medical Journal, 303(6793), 1129-1132.

Giuffre, M. (1995). Reading research critically: Assessing the validity and reliability of research instrumentation--Part 1. Journal of Post Anesthesia Nursing, 10(1), 33-37.

Graves, C., & Hayes, V.E. (1996). Do nurses and parents of children with chronic conditions agree on parental needs? Journal of Pediatric Nursing, 11(5), 288-299.

Graves, J.K., & Ware, M.E. (1990). Parents' and health professionals' perceptions concerning parental stress during a child's hospitalization. Childrens Health Care: Journal of The Association of the Care of Children's Health, 19(1), 37-42.

Henry, P. (1992, January). Nursing behaviors perceived as indicators of caring by parents in the PICU. Paper presented at the Challenge of Pediatric and Neonatal Nursing: Integrating Research into the Art and Science of Clinical Practice Conference, Newport Beach, CA.

Horner, M.M., Rawlins, P., & Giles, K. (1987). How parents of children with chronic conditions perceive their own needs. Maternal-Child-Nursing, 12(1), 40-43.

Kasper, J.W., & Nyamathi, A.M. (1988). Parents of children in the pediatric intensive care unit: What are their needs? Heart & Lung, 17(5), 574-581.

Kim, J.O., & Mueller, C.W. (1978a). Introduction to factor analysis. What it is an how to do it. Beverly Hills: Sage Publications.

Kim, J.O., & Mueller, C.W. (1978b). Introduction to factor analysis. Statistical methods and practical issues. Beverly Hills: Sage Publications.

Kirschbaum, M.S. (1990). Needs of parents of critically ill children. Dimensions of Critical Care Nursing, 9(6), 344-352.

Knafl, K.A., Cavallari, K.A., & Dixon, D.M. (1988). Pediatric hospitalization. Family and nursing perspectives. Glenview: Scott, Foresman and Company.

Kristjansdottir, G. (1991). A study of the needs of parents of hospitalized 2- to 6-year-old children. Issues in Comprehensive Pediatric Nursing, 14(1), 49-64.

Kristjansdottir, G. (1995). Perceived importance of needs expressed by parents of hospitalized 2- to 6-year-olds. Scandinavian Journal of Caring Sciences, 9(2), 95-103.

Krowinski, W.J., & Steiber, S.R. (1996). Measuring and managing patient satisfaction (2nd ed.). Chicago: American Hospital Publishing, Inc.

McDowell, J., & Newell, C. (1987). Measuring health: A guide to rating scales and questionnaires. New York: Oxford University Press.

Nunnally, J.C. (1978). Psychometric theory (2nd ed.). New York: McGraw-Hill Book Company.

Palmer, R.H., Donabedian, A., & Povar, G.J. (1991). Striving for quality in health care. An inquiry into policy and practice. An n Arbor, MI: Health Administration Press.

Price, P.J. (1993). Parents' perceptions of the meaning of quality nursing care. Advances in Nursing Science, 16(1), 33-41.

Risser, N.L. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing Research, 24(1), 45-51.

Radosevich, D.M. (1997). A framework for selecting outcome measures for ambulatory care research. Journal of Ambulatory Care Management, 20(4), 1-9.

Scardina, S.A. (1994). SERQUAL: A tool for evaluating patient satisfaction with nursing care. Journal of Nursing Care Quality, 8(2), 38-46.

Scott, A., & Smith, R.D. (1994). Keeping the customer satisfied: Issues in the interpretation and use of patient satisfaction surveys. International Journal for Quality in Health Care, 6(4), 353-359.

Strasser, S., & Davis, R.M. (1991). Measuring patient satisfaction for improved patient services. Management series. Ann Arbor, MI: American College of Health Care Executives.

Terry, D.G. (1987). Children's health care: Brief report. The needs of parents of hospitalized children. Children's Health Care: Journal of The Association of The Care of Children's Health, 16(1), 18-20.

Thornton, N.G. (1996). Congruence between patient satisfaction with nursing care of their children and nurses' perceptions of parent satisfaction. AXON, 18(2), 27-37.

Tughan, L. (1992). Visiting in the PICU: A study of the perceptions of patients, parents, and staff members. Critical Care Nursing Quarterly, 15(1), 57-68.

Vandvik, I.H., Hoyeral, H.M., & Fagertun, H. (1990). The first stay in a pediatric rheumatology ward. Associations between parent satisfaction and disease and psychosocial factors. Scandinavian Journal of Rheumatology, 19(3), 216-222.

Vuori, H. (1987). Patient satisfaction--An attribute or indicator of the quality of care? Quality Review Bulletin, 13(3), 106-108.

Vuori, H. (1989). Research needs in quality assurance. Quality Assurance in Health Care, 1(2-3), 147-159.

Waltz, C.F., Strickland. O.L., & Lenz, E.R. (1991). Measurement in nursing research (2nd ed.). Philadelphia: F.A. Davis Company.

SPECIAL RESEARCH ISSUE ON PARENTS

The purpose of this continuing education series is to foster the pediatric nurse's understanding of parents of children undergoing health care experiences.

Providing quality care to children who are ill, disabled, or hospitalized includes giving attention to the needs, concerns, and wisdom of the parents. Nurses with a greater understanding of parents' experiences when their children are acutely or chronically ill are better prepared to provide the support and knowledge parents need to care for their children as well as the skills needed to cope with the stressors that accompany these experiences.

This continuing education series features three research articles on parent issues. The first article presents the results of research that compared satisfaction with social support received, perception of the impact of the child's illness, and coping behaviors of parents of children with life threatening and non-life threatening chronic illness. The second article discusses findings of a study that compared outcomes for parents who participated in empowering and traditional approaches to asthma education. The third article reports on the psychometric testing of the Pediatric Family Satisfaction Questionnaire (PFSQ).

ASSIGNMENT

Katz, S. (2002). Severity of child's chronic illness and parents' social support, perception, and coping behaviors. Pediatric Nursing, 28(5), 453-463.

McCarthy, M., Herbert, R., Brimacombe, M., Hansen, J., Wong, D., & Zelman, M. Empowering parents through asthma education. Pediatric Nursing, 28(5), 465-473.

Bragadottir, H., & Reed, D. (2002). Psychometric instrument evaluation: The Pediatric Family Satisfaction Questionnaire. Pediatric Nursing, 28(5), 475-482.

 Earn 3.0 Contact Hours  Questions  1.  In Katz's study, the least frequently used     coping behavior of parents of children with     life threatening illnesses was      a. keeping close contact with the medical        services.     b. distancing oneself from the family.     c. involvement in the care of the child.     d. use of emotional coping behaviors.     e. use of family integration coping behaviors.  2.  The likely reason that parents of children     with non-life threatening illnesses generally     used fewer coping behaviors than parents     of children with life threatening illnesses     was      a. the higher frequency of hospital visits of        the parents of children with non-life        threatening illness.     b. parents of children with non-life threatening        illnesses use more family coping        behaviors.     c. the chronic fatigue of parents whose        children had non-life threatening illnesses.     d. parents of children with non-life threatening        illnesses have less compelling        reasons to use a wide array of coping        behaviors.     e. parents of children with non-life threatening        illnesses use their social support        system to a greater extent.  3.  Katz proposes that fathers of children with     life threatening illnesses expressed satisfaction     with the social support received     from the medical team because      a. they received more informal support        from significant others.     b. they were less involved in the care of the        child.     c. they had more frequent contact with        their children and increased decision        making than fathers in the past.     d. the family participated in medical consultations.     e. the medical team discussed the illness        only with fathers.  4.  The lack of significant differences between     fathers and mothers of children with life     threatening and non-life threatening illnesses     in the perception of the child's illness     was most likely influenced by      a. the cultural factor that encouraged        fathers to participate in the care of the        child.     b. the economic factor--the parents' concerns        about the financial situation.     c. the high cost of medical care for chronic        illnesses in Israel.     d. the fact that fathers and mothers shared        identical concerns regarding the child's        illness.     e. similar personality traits of parents influenced        their perception of the illness.  5.  Recommendations for clinical nursing     included      a. discouragement of the use of too many        coping behaviors.     b. encouragement of families to be self-supportive.     c. discouragement of expression of frustration        and denial.     d. referral of parents to spiritual guidance        and help.     e. provision of relevant illness-related        information to the parents.  6.  During the past two decades asthma rates     have increased more dramatically in adults     than in children.      a. True.     b. False.  7.  Which of the following is considered to be     the 'cornerstone of asthma management?'      a. Individualized pharmacotherapy.     b. Patient education.     c. Exercise program.     d. Environmental control.  8.  Which of the following factors have been     documented as consequences of empowerment?      a. A partnership between clients and professionals.     b. Mutual respect and trust.     c. Mutual decision making.     d. All of the above.     e. None of the above.  9.  Educational programs are more likely to     have empowering outcomes for participants     when      a. the educator uses an authoritarian        approach to deliver the educational program.     b. expert professionals provide the educational        sessions.     c. content is based on the educator's and        participants' perceptions of learning        needs.     d. the nurse educator is positioned as the        expert, and parents' expertise is not promoted.     e. the focus of the program is on provision of        information.  10. McCarthy and colleagues compared outcomes     for parents who participated in     empowering and traditional approaches to     asthma education. Which of the following     outcomes showed comparable results     between the two groups of parents?      a. Knowledge.     b. Sense of control.     c. Ability to make decisions.     d. Ability to provide care.  11. The most common method for tesing the     internal consistency of an instrument is     Cronbach's coefficient alpha. For new instruments     under developent, what is considered     a satisfactory Cronbach's coefficient alpha?      a. .10.     b. .30.     c. .50.     d. .70.     e. .90.  12. For well-established instruments, what is     considered a satisfactory Cronbach's coefficient     alpha?      a. .20.     b. .40.     c. .60.     d. .80.     e. 1.00.  13. Factor analysis is the most common statistical     analysis for construct validity testing.     What does this test involve?      a. Testing the interrelationship among        items that measure different concepts.     b. Testing the interrelationship among        items that measure the same concept or        factor.     c. Testing the relationship between the        items of an instrument and the theoretical        framework of a study.     d. Testing an instrument for a given setting        and population.     e. Testing the relationship between the reliability        and the validity of an instrument.  14. The results of the reliability testing of the     PFSQ showed a Cronbach's coefficient     alpha of .83. What does this indicate?      a. High internal consistency between        items.     b. Low internal consistency between        items.     c. High factor loading of items.     d. Low factor loading of items.     e. None of the above.  15. The construct validity testing of the PFSQ     in this study indicated that changes need     to be made on the instrument. The factor     analysis indicated      a. four main factors: hospital services and        accommodation, nursing care, medical        care, and child life therapy.     b. three main factors: nursing care, medical        care, and child life therapy.     c. three main factors: hospital services and        accommodation, nursing care, and        medical care.     d. two main factors: nursing care and medical        care.     e. one main factor: nursing care 

Objectives:

1. Discuss the importance of pediatric nurses assuming a family-centered approach to patient care.

2. Discuss examples of issues facing parents of ill, disabled, or hospitalized children.

3. List three features of an empowering approach to asthma education.

4. Describe the steps needed to select an instrument to measure parent satisfaction.

5. Identify additional opportunities pediatric nurses may have to learn more about the parents' perspective.

This activity for 3.0 contact hours is provided by Anthony J. Jannetti, Inc., which is accreditted as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA). Anthony J. Jannetti, Inc. is an approved provider of continuing education by the California Board of Registered Nursing, CEP No. 5387.

Articles accepted for publication in the continuing education series are refereed manuscripts that are reviewed in the standard Pediatric Nursing review process with other articles appearing in the journal.

This test was reviewed and edited by Judy A. Rollins, MS, RN, Pediatric Nursing associate editor; Veronica D. Feeg, PhD, RN, FAAN, Pediatric Nursing editor; and Marion E. Broome, PhD, RN, a Pediatric Nursing Editorial Board member.

[ILLUSTRATION OMITTED]

Helga Bragadottir, PhD(c), MSN, RN, is Nursing Director, Landspitali-University Hospital, Reykjavik, Iceland, and Doctoral Student, The University of Iowa College of Nursing, Iowa City, IA.