Injury
Prevention: A Survey of . Clinical Practice l Nancy
Ellen Jones, DrPH,
CPNP
The purpose of this study was to determine what education and training pediatric nurse practitioners receive about injury prevention and control and what kinds of clinical activities PNPs perform with regard to injury prevention and control. Sixty-four members of the Greater New York Chapter of the National Association of Pediatric Nurse Associates and Practitioners were questioned. Data on demographic, professional, and practice characteristics and on education and training and clinical activities in injury prevention and control were collected. Results indicated that advice about child car restraints and automobile seat belts was routinely given by less than 30% of practitioners, information about smoke detectors was given by about 15%, and advice about firearms in the home was given by 7% or less. Implications for counseling to prevent injuries are discussed. J PEDIATR HEALTH CARE. (1992). 6, 182-l 86.
I
njury is probably the most under recognized public health problem facing America today. Yet, it is the leading cause of death and disability among children and young adults. Injuries kill more children and youth than all diseasescombined. They result in numerous hospital admissions and disabling conditions. Injuries causeincalculablepain and suffering and cost society billions of dollars in medical expensesand lost production (National Committee for Injury Prevention and Control [NCIPC], 1989; National Research Council [NRC], 1985). I njuries kill more children
and youth than all
diseases combined.
Many injuries can be prevented and controlled with existing knowledge and technology. However, the shortage of health professionalsand scientists with relevant training in injury control is a major obstacle to injury prevention. Without knowledgeable and interested persons trained in the relevant sciences,preventable injuries will continue to occur. Therefore the Committee on Trauma Research recommends “training health professionals and other scientists in injury reNancy Ellen Jones is assistant professor at Hunter College, Hunter-Bellevue School of Nursing, New York, New York. Supported by a grant from The City University search Award Program.
of New York PSC-CUNY Re-
The author acknowledges the assistance of the New York State Department of Health Injury Control Program and the New York City Children’s Aid Society in the pretesting of the instrument and the greater New Yorkchapterof NAPNAP for participating in the study. Reprint requests: Nancy Ellen Jones, DrPH, CPNP, Assistant Professor, Hunter College, Hunter-Bellevue School of Nursing, 425 East 25th St., New York, NY 10010. 25/l/31799
182
searchand the basic concepts of injury control in order to develop and apply new knowledge about the prevention of injury” (NRC, 1985, p. 47). By virtue of their practice in primary health care settings, pediatric nurse practitioners (PNPs) are in a unique position to apply currently available injury prevention strategies. The Scope of Practice Statement of the National Association of Pediatric Nurse Associates and Practitioners (1983) defines a pediatric nurse practitioner as a nurse trained in primary child health care. Preventive health care and child health advocacy are key components of the PNP’s practice. PNP functions and responsibilities include encouraging health promotion and providing preventive health care that involves anticipatory guidance, health education, and counseling. Thus, the purpose of this investigation was to determine the education and training in injury prevention and control received by PNPs and to determine the clinical activities in injury prevention and control of PNPs. .
METHOD
A survey design was chosen for this descriptive study. The entire membership of the Greater New York Chapter of the National Association of Pediatric Nurse Associatesand Practitioners (NAPNAP) was sampled.The practitioners varied in age, basic nursing education, PNP preparation, years of practice, and nature of employment. A 40-item questionnaire was developed. The major sections were demographic, education, certification, employment characteristics, education and training in injury prevention and control, and clinical activities in injury prevention and control. The validity of the instrument was evaluated by a panel of five experts: three injury control professionals and two PNPs. The reliJOURNAL OF PEDIATRIC HEALTH CARE
Journal of Pediatric Health Care
ability of the instrument was evaluated by test-retest procedures; it was administered to a convenience sample of six PNPs, and a reliability coefficient of 0.81 was obtained. A cover letter, questionnaire, and stamped self-addressed envelope were mailed to 97 members of the Chapter. Six members were not included in the survey because they had participated in the pretesting of the instrument. PNPs were asked to return the questionnaire within 2 weeks. n
RESULTS
Of the 97 questionnaires mailed, 64 (66%) were returned and included in the analyses. Table 1 summarizes selected demographic and professional characteristics of the PNPs. Fifty-nine (92%) of the respondents were PNPs, 62 (97%) were female, and 41 (64%) were over age 35. The Bachelor’s degree was the basic nursing education for 43 (68%) of the practitioners. Thirtv-nine (67%) of the respondents had received their nurse practitioner education in a Master’s program, and 45 (79%) had advanced degrees, Master’s and beyond. Thirty-two (55%) practitioners had worked 6 or more years as a PNP. Forty-four (76%) of the practitioners were certified by the National Board of PNP/As, and 49 (84%) were certified by New York State.
Fifty-nine
(92%) of the respondents were PNPs, 62 (97%) were female, and 41 (64%) were over age 35. Table 2 describes the practice characteristics of the PNPs. Twenty-two (37%) PNPs were employed in hospital outpatient departments. Patient care was the primary responsibility of 40 (70%) practitioners. Primary care was the area of specialty of 32 (55%) PNPs. Fortyone (71%) of the practitioners worked in New York City, and 44 (77%) reported working with children of all ages. PNPs reported that the primary method of payment was Medicaid (70%), and the majority of patients were nonwhite (73%). Table 3 presents information on education and training in injury prevention and control. Fifty-seven (97%) of the respondents reported that content on childhood injuries was included in their nurse practitioner education. Topics discussed with greatest frequency were child abuse (95%), falls (88%), and suicide (82%). Thirty-two (54%) of the practitioners reported receiving training (continuing education) on childhood injuries in the past 2 years. Topics discussed with greatest frequency were child abuse (94%), suicide (56%), and motor vehicle occupants (44%). Table 4 summarizes the advice PNPs give parents and patients on injury prevention. Of the 49 practitioners who report counseling parents and patients on child
Injury Prevention
183
TABLE I Demographic and professional characteristics of a sample of PNPs
n
c. ainn . Profes,.,. PNP Student PNP &3” JCA
PEWENT 59 5
92 a
Female Male
62 2
97 3
Age in years 25-34 35-44 45-54 over 55
23 28 9
36 44 14 6
Basic nur5ing education Dipkxna Associate degree Bachelor? i d&r& Generic II,Iaster’s degree
17
a 68 6
Nurse practitioner educatian Certificate Mar it& program Both Certificate sand Master’s
31 67 2
Highe rt educatiunal degree Dip llama Associate Bachelor’s Master’s Doctorate
7 44 1
7 2 12 77 2
Years employed as PNP Less than 1 1-5 6 or more
7 19 32
12 33 55
Certification National Board of PNPfA ANA More than one Not certified
44 6 6 2
76 10 IO 3
New York State certification Yes No
49 9
84 16
1
safety, 13 (27%) report that 100% of the medical records reflect this guidance. Among practitioners who care for infants and pre-school-aged children, advice to parents was routinely given (100%) on the following interventions: currently approved child car restraints by 12 (27%), smoke detectors in the home by 7 (16%), safe hot water temperatures by 9 (20%), window and/or stairway guards/gates by 23 (50%), syrup of ipecac by 8 (189/o), and firearms in the home by 2 (4%). Among the 42 practitioners who care for elementary school-aged children, advice was routinely given
184
Volume 6, Number 4 July-August 1992
Jones
n
8C?X AS FART OF THE ~~~N~~~~,
PNPs WERE ASKED THE K)tl@%‘fNC
QUEfiTtoNS.
-MY -tm@
Agree
Injuries are not accidents, but are predictable and preventable Anticipatory guidance for injury prevention should be an integral part of child health care
N
%
N
%
N
56
N
%
20
31
38
59
6
9
-
-
6f
59
3
5
-
-
-
-
TABLE 3 Education and training in injury prevention of PNPs
TABLE 2 Practice characteristics of a sample of PNPs
n
n
CHARACTERISTIC
NUMBER
ARCENT
Place of employment Hospital (inpatient) Hospital (outpatient) School health service Private practice Other health-related agency More than one Other
4 22 7 6 5 9 6
7 37 12 10 8 15 10
Primary responsibility current position Patient care Administration Teaching Research
40 4 3 1
70 7 5 2 16
in your
More than one
9
Area of speciaky Primary care School heaith More than one other Practice site New York City New York State Other state
other than NYC
Age of children in practice All ages Newborns only Infants and preschool only School-aged only Adolescent only 0th~ age group Primary method of payment Medicaid Private insurance Out-of-pocket 0ther Race of patients Asian Black Hispanic White
32 5 7 14
55 12 24
41 10 7
71 17 12
44 3 2 2 1 5
77 5 4 4 2 9
35 5 5 s
70 10 10 10
1 15 24 15
2 27 44 27
9
EDUCATION /TRAINING
NUMBER
PERCENT
PNP education Content on injury prevention Yes No
57 2
97 3
Topics discussed Child abuse Fails Suicide Motor vehicle occupant Drownings House fires Pedestrians Other
54 50 47 46 45 34 24 12
95 88 82 81 79 60 42 21
Continuing education Content on injury prevention YeS No
32 27
54 46
Topics discussed Child abuse Suicide Motor vehicle occupants Drownings Falls House fires other Pedestrians
30 18 14 13 12 7 6 5
94 56 44 41 38 22 19 16
(100%) on the following interventions: automobile seat belts by 12 (29%), an approved helmet when bicycling by 9 (21%), smoke detectors in the home by 6 (14%), pedestriansafety by 10 (24%), and firearms in the home by 3 (7%). Of the 41 PNPs who care for adolescents, advice was routinely given (100%) on the following interventions: automobile seatbelts by 10 (24%), drinking and driving by 17 (41%), and firearms in the home by 3 (7%). Fifty-eight (90%) of the practitioners agreed or strongly agreed with the statement: injuries are not accidents, but are predictable and preventable. AU (100%) of the PNPs agreedor strongly agreedwith the statement: anticipatory guidance for injury prevention
journal of Pediatric Health Care
n
TABLE
injury Prevention
185
4 Summary of advice PNPs give to parents and patients about injury prevention 75%
100%
0%
25%
50%
N
%
N
%
N
96
N
%
If you advise parents and patients on child safety, what number (percent) of medical records reflect this counsel? If you care for infants and preschool-aged children, what percent of the time do you advise parents regarding the following:
13
27
15
31
2
4
16
33
3
6
Currently approved child car restraints
12
27
4
9
5
11
12
27
12
27
Smoke detectors in the home that would protect the child’s sleeping area
7
16
6
13
2
4
10
22
20
44
Safe hot water temperatures at the tap
9
20
11
24
8
18
11
24
6
13
Window and/or stairway guards/gates to prevent falls
23
50
9
20
2
4
7
15
5
11
1 ounce bottles of syrup of ipecac Firearms in the home If you care for elementary schoolaged children, what percent of the time do you advise parents and patients regarding the following:
8
18
7
16
9
20
8
18
13
29
2
4
2
4
2
4
7
15
33
72
12
29
7
17
3
7
11
26
9
21
The use of an approved helmet when bicycling
9
21
6
14
5
12
7
17
15
36
Smoke detectors in the home
6
14
7
17
5
12
10
24
14
33
10
24
8
19
5
12
9
21
10
24
3
7
3
7
3
7
7
17
26
62
The use of seatbelts
10
24
6
15
5
12
6
15
14
34
The hazards of drinking and driving
17
41
8
20
4
10
5
12
7
17
3
7
3
3
7
7
5
12
27
66
The use of seatbelts
Pedestrian safety Firearms in the home
N
%
If you care for adolescents, what percent of the time do you advise them regarding the following:
Firearms in the home
should be an integral part of health care provided for infants, children, and adolescents. n
DISCUSSION
The majority of PNPs sampled provided primary care to medically indigent and minority children and youth
in New York City. This is significant becausethe burden of injury falls disproportionately on young children, teenagedmales,personsliving in poverty, and members of minority groups (NCIPC, 1985). A sample of PNPs practicing in other areas of the country would yield somewhat different results. Regardless, practitioners
Volume
186
need to identify the extent of the injury problem and those at risk within their community to implement effective interventions to prevent injuries. Whereas almost 90% of PNPs reported that content on injury prevention was included in their nurse practitioner education, and 50% reported training in injury prevention in the past 2 years, the topic discussed with greatest frequency was child abuse, 95% and 94%, respectively. A possible explanation for the former finding was the impact of the early research on the battered child syndrome (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962) on professional education. The latter finding may be explained by the 1989 New York State regulation requiring all licensed professionals practicing in the state to receive continuing education on child abuse for relicensure. For injury prevention to become a standard of practice for PNPs, efforts to include content on injury control in PNP schools, on the programs of national conferences and local meetings, in textbooks and professional journals, and on the national certification examination should be commensurate with the magnitude of the injury problem.
By the year 2000,
the Department of Health and Human Services seeks to increase to at least 50% the proportion of primary care providers who routinely provide ageappropriate counseling on safety precautions to prevent unintentional injuries.
By the year 2000, the Department of Health and Human Services (1990) seeks to increase to at least 50% the proportion of primary care providers who routinely provide age-appropriate counseling on safety precautions to prevent unintentional (accidental) injuries. With the exception of window and stairway gates, PNPs in this study did not routinely counsel parents and patients on child safety seats and seat belts, smoke detectors in the home, safe hot water temperatures, syrup of ipecac, bicycle helmets, pedestrian safety, drinking and driving, or firearms in the home. The success in meeting the objective for window and stairway gates may reflect the efforts of the New York City Department of Health’s internationally recognized window falls prevention program, “Children Can’t Fly” (Speigle & Lindaman, 1977). Conversely, the low compliance with the seat belt objective may reflect the urban setting of the study and the nature of transportation in New York City, which is largely by bus and subway. Though homicide
6, Number
July-August
Jones
4
1992
is the leading cause of death for children and youth in New York City, and firearms are involved in 59% of homicides (NCIPC, 1989), firearms in the home were discussed by only 7% of the practitioners. The findings of this study are limited by the geographic location of the sample and the data collection methods, which relied on reported rather than observed behavior. Future studies may sample other NAPNAP chapters in different areas of the country, sample the curriculums of PNP schools to determine injury prevention and control content, and use observational techniques to determine the clinical activities of practitioners. A replication of this study in the year 2000 is indicated. Although injury prevention activities should include a variety of approaches such as engineering, enforcement, and education, basic findings from research suggest that engineering strategies (i.e., providing automatic protection by product and environmental design) are the most effective. Enforcement approaches (i.e., requiring behavior change by law or administrative rule) are the second most effective, and educational strategies (i.e., persuading persons at risk to alter their behavior) are least effective (NRC, 1985). With this understanding, PNP health promotion activities for injury prevention should focus on engineering and enforcement approaches (e.g., automatic seat belts and legislation requiring smoke detectors in all residential housing). Child health advocacy efforts should be directed toward modifying hazardous products and environments (e.g., reducing tap water temperatures and installing window guards). n REFERENCES Depamnent of Health and Human Services. (1990). Healthy people 2000: National health promotion and direme prevention objectives. Washington, DC: Author. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., & Silver, H. K. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. National Association of Pediatric Nurse Associates and Practitioners. (1983). Scopeofpractice: Pediati m m e acsociateslpwctitimevx Pitman, NJ: Author. National Committee for Injury Prevention and Control. (1989). Injwy prevention: Meeting the challenge. New York: Oxford University Press. National Research Council, Committee on Trauma Research. (1985). Injwy in America: A continuingpublic health problem. Washington, DC: National Academy Press. Speigle, C. N., & Lindaman, F. C. (1977). Children can’t fly: A program to prevent childhood morbidity and mortality from window fall. American Journal of Public Health, 67, 1143-1147.
Prevention: A Survey of . Clinical Practice l Nancy
Ellen Jones, DrPH,
CPNP
The purpose of this study was to determine what education and training pediatric nurse practitioners receive about injury prevention and control and what kinds of clinical activities PNPs perform with regard to injury prevention and control. Sixty-four members of the Greater New York Chapter of the National Association of Pediatric Nurse Associates and Practitioners were questioned. Data on demographic, professional, and practice characteristics and on education and training and clinical activities in injury prevention and control were collected. Results indicated that advice about child car restraints and automobile seat belts was routinely given by less than 30% of practitioners, information about smoke detectors was given by about 15%, and advice about firearms in the home was given by 7% or less. Implications for counseling to prevent injuries are discussed. J PEDIATR HEALTH CARE. (1992). 6, 182-l 86.
I
njury is probably the most under recognized public health problem facing America today. Yet, it is the leading cause of death and disability among children and young adults. Injuries kill more children and youth than all diseasescombined. They result in numerous hospital admissions and disabling conditions. Injuries causeincalculablepain and suffering and cost society billions of dollars in medical expensesand lost production (National Committee for Injury Prevention and Control [NCIPC], 1989; National Research Council [NRC], 1985). I njuries kill more children
and youth than all
diseases combined.
Many injuries can be prevented and controlled with existing knowledge and technology. However, the shortage of health professionalsand scientists with relevant training in injury control is a major obstacle to injury prevention. Without knowledgeable and interested persons trained in the relevant sciences,preventable injuries will continue to occur. Therefore the Committee on Trauma Research recommends “training health professionals and other scientists in injury reNancy Ellen Jones is assistant professor at Hunter College, Hunter-Bellevue School of Nursing, New York, New York. Supported by a grant from The City University search Award Program.
of New York PSC-CUNY Re-
The author acknowledges the assistance of the New York State Department of Health Injury Control Program and the New York City Children’s Aid Society in the pretesting of the instrument and the greater New Yorkchapterof NAPNAP for participating in the study. Reprint requests: Nancy Ellen Jones, DrPH, CPNP, Assistant Professor, Hunter College, Hunter-Bellevue School of Nursing, 425 East 25th St., New York, NY 10010. 25/l/31799
182
searchand the basic concepts of injury control in order to develop and apply new knowledge about the prevention of injury” (NRC, 1985, p. 47). By virtue of their practice in primary health care settings, pediatric nurse practitioners (PNPs) are in a unique position to apply currently available injury prevention strategies. The Scope of Practice Statement of the National Association of Pediatric Nurse Associates and Practitioners (1983) defines a pediatric nurse practitioner as a nurse trained in primary child health care. Preventive health care and child health advocacy are key components of the PNP’s practice. PNP functions and responsibilities include encouraging health promotion and providing preventive health care that involves anticipatory guidance, health education, and counseling. Thus, the purpose of this investigation was to determine the education and training in injury prevention and control received by PNPs and to determine the clinical activities in injury prevention and control of PNPs. .
METHOD
A survey design was chosen for this descriptive study. The entire membership of the Greater New York Chapter of the National Association of Pediatric Nurse Associatesand Practitioners (NAPNAP) was sampled.The practitioners varied in age, basic nursing education, PNP preparation, years of practice, and nature of employment. A 40-item questionnaire was developed. The major sections were demographic, education, certification, employment characteristics, education and training in injury prevention and control, and clinical activities in injury prevention and control. The validity of the instrument was evaluated by a panel of five experts: three injury control professionals and two PNPs. The reliJOURNAL OF PEDIATRIC HEALTH CARE
Journal of Pediatric Health Care
ability of the instrument was evaluated by test-retest procedures; it was administered to a convenience sample of six PNPs, and a reliability coefficient of 0.81 was obtained. A cover letter, questionnaire, and stamped self-addressed envelope were mailed to 97 members of the Chapter. Six members were not included in the survey because they had participated in the pretesting of the instrument. PNPs were asked to return the questionnaire within 2 weeks. n
RESULTS
Of the 97 questionnaires mailed, 64 (66%) were returned and included in the analyses. Table 1 summarizes selected demographic and professional characteristics of the PNPs. Fifty-nine (92%) of the respondents were PNPs, 62 (97%) were female, and 41 (64%) were over age 35. The Bachelor’s degree was the basic nursing education for 43 (68%) of the practitioners. Thirtv-nine (67%) of the respondents had received their nurse practitioner education in a Master’s program, and 45 (79%) had advanced degrees, Master’s and beyond. Thirty-two (55%) practitioners had worked 6 or more years as a PNP. Forty-four (76%) of the practitioners were certified by the National Board of PNP/As, and 49 (84%) were certified by New York State.
Fifty-nine
(92%) of the respondents were PNPs, 62 (97%) were female, and 41 (64%) were over age 35. Table 2 describes the practice characteristics of the PNPs. Twenty-two (37%) PNPs were employed in hospital outpatient departments. Patient care was the primary responsibility of 40 (70%) practitioners. Primary care was the area of specialty of 32 (55%) PNPs. Fortyone (71%) of the practitioners worked in New York City, and 44 (77%) reported working with children of all ages. PNPs reported that the primary method of payment was Medicaid (70%), and the majority of patients were nonwhite (73%). Table 3 presents information on education and training in injury prevention and control. Fifty-seven (97%) of the respondents reported that content on childhood injuries was included in their nurse practitioner education. Topics discussed with greatest frequency were child abuse (95%), falls (88%), and suicide (82%). Thirty-two (54%) of the practitioners reported receiving training (continuing education) on childhood injuries in the past 2 years. Topics discussed with greatest frequency were child abuse (94%), suicide (56%), and motor vehicle occupants (44%). Table 4 summarizes the advice PNPs give parents and patients on injury prevention. Of the 49 practitioners who report counseling parents and patients on child
Injury Prevention
183
TABLE I Demographic and professional characteristics of a sample of PNPs
n
c. ainn . Profes,.,. PNP Student PNP &3” JCA
PEWENT 59 5
92 a
Female Male
62 2
97 3
Age in years 25-34 35-44 45-54 over 55
23 28 9
36 44 14 6
Basic nur5ing education Dipkxna Associate degree Bachelor? i d&r& Generic II,Iaster’s degree
17
a 68 6
Nurse practitioner educatian Certificate Mar it& program Both Certificate sand Master’s
31 67 2
Highe rt educatiunal degree Dip llama Associate Bachelor’s Master’s Doctorate
7 44 1
7 2 12 77 2
Years employed as PNP Less than 1 1-5 6 or more
7 19 32
12 33 55
Certification National Board of PNPfA ANA More than one Not certified
44 6 6 2
76 10 IO 3
New York State certification Yes No
49 9
84 16
1
safety, 13 (27%) report that 100% of the medical records reflect this guidance. Among practitioners who care for infants and pre-school-aged children, advice to parents was routinely given (100%) on the following interventions: currently approved child car restraints by 12 (27%), smoke detectors in the home by 7 (16%), safe hot water temperatures by 9 (20%), window and/or stairway guards/gates by 23 (50%), syrup of ipecac by 8 (189/o), and firearms in the home by 2 (4%). Among the 42 practitioners who care for elementary school-aged children, advice was routinely given
184
Volume 6, Number 4 July-August 1992
Jones
n
8C?X AS FART OF THE ~~~N~~~~,
PNPs WERE ASKED THE K)tl@%‘fNC
QUEfiTtoNS.
-MY -tm@
Agree
Injuries are not accidents, but are predictable and preventable Anticipatory guidance for injury prevention should be an integral part of child health care
N
%
N
%
N
56
N
%
20
31
38
59
6
9
-
-
6f
59
3
5
-
-
-
-
TABLE 3 Education and training in injury prevention of PNPs
TABLE 2 Practice characteristics of a sample of PNPs
n
n
CHARACTERISTIC
NUMBER
ARCENT
Place of employment Hospital (inpatient) Hospital (outpatient) School health service Private practice Other health-related agency More than one Other
4 22 7 6 5 9 6
7 37 12 10 8 15 10
Primary responsibility current position Patient care Administration Teaching Research
40 4 3 1
70 7 5 2 16
in your
More than one
9
Area of speciaky Primary care School heaith More than one other Practice site New York City New York State Other state
other than NYC
Age of children in practice All ages Newborns only Infants and preschool only School-aged only Adolescent only 0th~ age group Primary method of payment Medicaid Private insurance Out-of-pocket 0ther Race of patients Asian Black Hispanic White
32 5 7 14
55 12 24
41 10 7
71 17 12
44 3 2 2 1 5
77 5 4 4 2 9
35 5 5 s
70 10 10 10
1 15 24 15
2 27 44 27
9
EDUCATION /TRAINING
NUMBER
PERCENT
PNP education Content on injury prevention Yes No
57 2
97 3
Topics discussed Child abuse Fails Suicide Motor vehicle occupant Drownings House fires Pedestrians Other
54 50 47 46 45 34 24 12
95 88 82 81 79 60 42 21
Continuing education Content on injury prevention YeS No
32 27
54 46
Topics discussed Child abuse Suicide Motor vehicle occupants Drownings Falls House fires other Pedestrians
30 18 14 13 12 7 6 5
94 56 44 41 38 22 19 16
(100%) on the following interventions: automobile seat belts by 12 (29%), an approved helmet when bicycling by 9 (21%), smoke detectors in the home by 6 (14%), pedestriansafety by 10 (24%), and firearms in the home by 3 (7%). Of the 41 PNPs who care for adolescents, advice was routinely given (100%) on the following interventions: automobile seatbelts by 10 (24%), drinking and driving by 17 (41%), and firearms in the home by 3 (7%). Fifty-eight (90%) of the practitioners agreed or strongly agreed with the statement: injuries are not accidents, but are predictable and preventable. AU (100%) of the PNPs agreedor strongly agreedwith the statement: anticipatory guidance for injury prevention
journal of Pediatric Health Care
n
TABLE
injury Prevention
185
4 Summary of advice PNPs give to parents and patients about injury prevention 75%
100%
0%
25%
50%
N
%
N
%
N
96
N
%
If you advise parents and patients on child safety, what number (percent) of medical records reflect this counsel? If you care for infants and preschool-aged children, what percent of the time do you advise parents regarding the following:
13
27
15
31
2
4
16
33
3
6
Currently approved child car restraints
12
27
4
9
5
11
12
27
12
27
Smoke detectors in the home that would protect the child’s sleeping area
7
16
6
13
2
4
10
22
20
44
Safe hot water temperatures at the tap
9
20
11
24
8
18
11
24
6
13
Window and/or stairway guards/gates to prevent falls
23
50
9
20
2
4
7
15
5
11
1 ounce bottles of syrup of ipecac Firearms in the home If you care for elementary schoolaged children, what percent of the time do you advise parents and patients regarding the following:
8
18
7
16
9
20
8
18
13
29
2
4
2
4
2
4
7
15
33
72
12
29
7
17
3
7
11
26
9
21
The use of an approved helmet when bicycling
9
21
6
14
5
12
7
17
15
36
Smoke detectors in the home
6
14
7
17
5
12
10
24
14
33
10
24
8
19
5
12
9
21
10
24
3
7
3
7
3
7
7
17
26
62
The use of seatbelts
10
24
6
15
5
12
6
15
14
34
The hazards of drinking and driving
17
41
8
20
4
10
5
12
7
17
3
7
3
3
7
7
5
12
27
66
The use of seatbelts
Pedestrian safety Firearms in the home
N
%
If you care for adolescents, what percent of the time do you advise them regarding the following:
Firearms in the home
should be an integral part of health care provided for infants, children, and adolescents. n
DISCUSSION
The majority of PNPs sampled provided primary care to medically indigent and minority children and youth
in New York City. This is significant becausethe burden of injury falls disproportionately on young children, teenagedmales,personsliving in poverty, and members of minority groups (NCIPC, 1985). A sample of PNPs practicing in other areas of the country would yield somewhat different results. Regardless, practitioners
Volume
186
need to identify the extent of the injury problem and those at risk within their community to implement effective interventions to prevent injuries. Whereas almost 90% of PNPs reported that content on injury prevention was included in their nurse practitioner education, and 50% reported training in injury prevention in the past 2 years, the topic discussed with greatest frequency was child abuse, 95% and 94%, respectively. A possible explanation for the former finding was the impact of the early research on the battered child syndrome (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962) on professional education. The latter finding may be explained by the 1989 New York State regulation requiring all licensed professionals practicing in the state to receive continuing education on child abuse for relicensure. For injury prevention to become a standard of practice for PNPs, efforts to include content on injury control in PNP schools, on the programs of national conferences and local meetings, in textbooks and professional journals, and on the national certification examination should be commensurate with the magnitude of the injury problem.
By the year 2000,
the Department of Health and Human Services seeks to increase to at least 50% the proportion of primary care providers who routinely provide ageappropriate counseling on safety precautions to prevent unintentional injuries.
By the year 2000, the Department of Health and Human Services (1990) seeks to increase to at least 50% the proportion of primary care providers who routinely provide age-appropriate counseling on safety precautions to prevent unintentional (accidental) injuries. With the exception of window and stairway gates, PNPs in this study did not routinely counsel parents and patients on child safety seats and seat belts, smoke detectors in the home, safe hot water temperatures, syrup of ipecac, bicycle helmets, pedestrian safety, drinking and driving, or firearms in the home. The success in meeting the objective for window and stairway gates may reflect the efforts of the New York City Department of Health’s internationally recognized window falls prevention program, “Children Can’t Fly” (Speigle & Lindaman, 1977). Conversely, the low compliance with the seat belt objective may reflect the urban setting of the study and the nature of transportation in New York City, which is largely by bus and subway. Though homicide
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is the leading cause of death for children and youth in New York City, and firearms are involved in 59% of homicides (NCIPC, 1989), firearms in the home were discussed by only 7% of the practitioners. The findings of this study are limited by the geographic location of the sample and the data collection methods, which relied on reported rather than observed behavior. Future studies may sample other NAPNAP chapters in different areas of the country, sample the curriculums of PNP schools to determine injury prevention and control content, and use observational techniques to determine the clinical activities of practitioners. A replication of this study in the year 2000 is indicated. Although injury prevention activities should include a variety of approaches such as engineering, enforcement, and education, basic findings from research suggest that engineering strategies (i.e., providing automatic protection by product and environmental design) are the most effective. Enforcement approaches (i.e., requiring behavior change by law or administrative rule) are the second most effective, and educational strategies (i.e., persuading persons at risk to alter their behavior) are least effective (NRC, 1985). With this understanding, PNP health promotion activities for injury prevention should focus on engineering and enforcement approaches (e.g., automatic seat belts and legislation requiring smoke detectors in all residential housing). Child health advocacy efforts should be directed toward modifying hazardous products and environments (e.g., reducing tap water temperatures and installing window guards). n REFERENCES Depamnent of Health and Human Services. (1990). Healthy people 2000: National health promotion and direme prevention objectives. Washington, DC: Author. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., & Silver, H. K. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. National Association of Pediatric Nurse Associates and Practitioners. (1983). Scopeofpractice: Pediati m m e acsociateslpwctitimevx Pitman, NJ: Author. National Committee for Injury Prevention and Control. (1989). Injwy prevention: Meeting the challenge. New York: Oxford University Press. National Research Council, Committee on Trauma Research. (1985). Injwy in America: A continuingpublic health problem. Washington, DC: National Academy Press. Speigle, C. N., & Lindaman, F. C. (1977). Children can’t fly: A program to prevent childhood morbidity and mortality from window fall. American Journal of Public Health, 67, 1143-1147.
