Enhancing Comfort for Children with Fever at Valentine Medical Clinic Contents

EnhancingComfort for Children with Fever at Valentine Medical Clinic

Contents

Enhancing Comfort for Children with Fever at Valentine Medical Clinic 2

Significance of the Problem 3

PICOT Question 4

Theoretical Framework 5

The Comfort Theory 5

Applications of Comfort Theory to Pediatric Nursing 8

Empirical Literature 8

Practice Recommendations 15

Project Setting 18

Project Mission Vision and Objectives 19

Project Plan 21

Transtheoretical Model (TTM) 21

Contemplation Stage (Getting ready) 21

Action 21

Maintenance 22

Intervening factors and barriers 22

Project Evaluation Plan 22

Plans for Dissemination 23

Conclusion 23

References 25

Appendix 1: VMCSWOT analysis 29

Appendix 2: Project Plan 30

Appendix 3: Project Budget 31

Appendix 4: Comfort Behaviors Checklist 35

Appendix 5: Demographic Data Tool 40

EnhancingComfort for Children with Fever at Valentine Medical Clinic

Feverrefers to a rise in body temperature over and above the normal dailyvariation (NICE, 2007). Fever in children is often self-limiting as amajority of children tolerate temperatures of 390C. Research has also established that this kind of fever isuncomplicated is not harmful to children and instead is a crucialimmunological defense mechanism (Chow &amp Robinson, 2011).Moreover,fever associated with infection rarely exceeds 400C and usually has a minimal risk of causing brain injury (NCCWH,2013). In order to comprehend the most appropriate strategies toenhance comfort in children with fever as a mild treatment mechanism,it is important to comprehend the underlying mechanisms that causefever. The processes that lead to fever encompass the bodytemperature regulation that entails a complex array of physiologicalresponses (Hassan et al, 2013).

Workinglike an internal thermostat, the hypothalamus regulates temperatureinside the body in which pyrogens reset the set point of thethermostat thereby resulting in fever (Mohammed, 2015). However,empirical research is also replete with cases in which factors otherthan the underlying causes of fever can influence body temperature ina self-reinforcing manner that occasions fever and thereforemanagement of this condition ought to be integrative encompassingother measures such as comfort (Lachmann, 2015).Comfort care isespecially vital when dealing with kids since they cannot always tellyou how they feel or what hurts. Observing a child’s level ofcomfort is especially important when dealing with a fever becausefevers can indicate life-threatening illnesses. According to RHM(2015), making children more comfortable when they are confrontedwith fever in itself is an important treatment. It is proposed thatin comfort care for children with fever ought to be characterizedwith special care that involves giving the children frequent smalldrinks of clear fluid and extra breast feeds for the infants belowsix months (Sullivan&amp Farrar, 2011).This proposal seeks to assess the feasibility of improving comfortfor children with fever using Tylenol at Valentine Medical Clinic.

Significanceof the Problem

Feverhas several adverse effects in children some of which might be longterm if it is not managed comprehensively. The major concern here isthat children of age 0-5 are vulnerable to fever, cannot undertakethe necessary mechanisms to defend themselves from fever and mostlybecause they cannot verbally express the discomfort resulting fromfever. Essentially, all this culminate to one major problem:diagnosing the condition and associated causative agent. Some commoncomplications of fever in children below five years include severedehydration and hallucinations (Mohammed, 2015). The use of Tylenolhas been found to be an efficient way of treating fever within a veryshort duration (Schellack, 2011: Graves et al, 2012).

Themanagement of this condition requires expertise as it is more thanjust a medical concern. Schellack (2011) observed that the managementof fever in children is a delicate situation that involves striking abalance between appropriate intervention and patience as seizuresmostly stop on their own (p. 12). The treatment and management offever in children requires an integrative approach (NCCWH, 2013).Comfort has been found to be very critical in the treatment andmanagement of fever in infants and as part of the medicalinterventions, comfort, as designed to be implemented in ValentineMedical Clinic will improve quality of care in the clinic and improvethe working environment. The overriding objective in thisintervention is that it will improve interactions with parentsfurther making it easier to treat children with fever.

PICOTQuestion

Inchildren between the ages of 0-5 at the Valentine Medical Clinic (P),will the implementation of a fever practice guideline (I) comparedwith baseline (C) improve a child’s comfort (O) within 30 minutesof the intervention (T)?

Thetargetpopulationis children of ages 0-5 who are most vulnerable to fever and areusually most affected by the spiral effects of this condition(Mohammed, 2015). This group comprises infants who are not in aposition to articulate the nature of discomfort that confronts themsuch as that which comes with fever (NCCWH, 2013) which poses aserious problem of diagnosis to healthcare practitioners. ValentineMedical Clinic will intervenein this problem by using Tylenol in fever treatment thereby enhancingcomfort for children with fever since comfort is particularlysignificant in the treatment and management of fever in children, acondition that is synonymous with discomfort(McDougall &amp Harrison, 2014: Sawe et al, 2014).Theimplementation of the fever practice guideline at Valentine MedicalClinic comparedto baseline will be structured according to a specific criterion.Comparisons of comfort ought to involve intentional evaluation ofcomfort need, design of comfort metrics to address the identifiedneeds and reassessment of comfort levels after implementation(Kolcaba, 2010). The intended outcome is comfort in children whichhas a gagging effect against the severity of fever (Lachmann, 2015).Febrile seizure, a common effect of child fever, lasts about tenminutes in children (Graves et al, 2012). Valentine Medical Clinicwill assess the efficacy of the respective intervention within a timeframe of 30 minutes.

TheoreticalFramework

Giventhat the proposed measures rely on comfort as a key intervention inthe treatment and management of fever in children, this sectionanalyzes the comfort theory in order to comprehend the underlyingmechanisms through which comfort works in general. The principles andfunctional elements of this framework will be applied to the casescenario visualized at Valentine Medical Clinic.

TheComfort Theory

Thisis a theory of nursing developed by an American nursing theoristKatharine Kolcaba. This theory espouses comfort as playing a key rolein healthcare far beyond common practice. In this theory, comfort isconceived as existing in three fundamental constructs which includeease, relief and transcendence (Kolcaba, 1994: Kolcaba, 2003). Withrespect to healthcare, the theory described four contexts in whichthe comfort of patients can be conceived. The four contexts includethe sociocultural, environmental (situational), psychospiritual andphysical. The dichotomy of patient comfort into four distinct butsomewhat related constructs of human beings by Kolcaba is inrealization of the fact that the underlying causes of human illnessesand discomfort are multifaceted (Goodwin&amp Steiner, 2007).According to this theory, if the comfort needs of patients aresatisfied, the patient finds comfort in thereliefsense. An apt example in this case is that if for instance, a patientis experiencing pain and discomfort resulting from post-operation mayfind comfort if prescribed analgesia is administered. As for thesecond construct,ease,if the patient is confronted with anxiety resulting from certainissues, the patient will find comfort if the issues are addressedthus a comfortable state of contentment for the patient.Transcendence,according to the theory, is more of self-initiated in which thepatients overcome their own challenges to gain comfort.

Inthese theory, a patient’s healthcare needs in most circumstancesamount to patient needs as identified by the family in a particularpractice setting. One of the major strengths of the comfort theory isthat it clearly identifies and recognizes the role played byintervening variables in its operational framework (Halvorsen,2001).The comfort theory recognizes intervening factors as those variablesthat are constant and healthcare providers have no control over them.Such factors as identified by the theory include extent of socialsupport, financial resources and prognosis. The key proposition ofthis theory however, is that “comfort is an immediate desirableoutcome of healthcare”. The diagram below shows the conceptualframework of the Comfort Theory.

Figure1.0:Comfort Theory:

Adoptedfrom Kolcaba (2007)

Asshown in the framework above, the theory also addresses the keyaspects of healthcare including health-seekingbehaviors (HSBs), Institutional integrityand bestpolicies inhealthcare. Institutional integrity involves the wholeness of clinicsat various levels, their financial resources and organizationalvalues while best policies refer to the protocols and proceduresdeveloped by the clinics (Kolcaba, 2007).

Concisely,the comfort theory addresses patient care from a comprehensive pointof view that takes into account the nursing practice, health, patientattributes and the environment. According to the theory, nursing isperceived as a process of evaluating a patient’s comfort needscomplete with the development and implementation of necessaryinterventions to satisfy the identified needs (Kolcaba, 2010).Healthis viewed as an optimal functioning of a system characterized by acommunity in which family plays a key role. Meanwhile, the theoryconsiders as environment any situational setting that can bemanipulated to provide comfort for the patient.

Applicationsof Comfort Theory to Pediatric Nursing

Comforttheory has been tested and applied to several clinical settingsranging from breast cancer patients to persons with urinaryincontinence both in psychometric and experimental approaches(Krinsky et al, 2014).The theory has gained currency in pediatrichealthcare for its wide applicability and comprehensive approach itoffers (Pain et al(2004): Kolcaba &amp DiMarco (2005)).According toKolcaba (2003), the theory is widely used in pediatric nursing sinceit is has few clear concepts, low level of subjectivity and ease ofapplication in the clinical setting. Wilson &amp Kolcaba (2004)observed that perianesthesia nurses had over time come up withpractical guidelines involving the use of Tylenol in treating fevercomplete with advanced care competencies using the theory. The theoryis particularly important to the current work based on the fact thatits application to clinical setting is crucial in promoting patientcomfort structured on its dimensions of transcendence, ease andrelief (Krinsky et al, 2014).

EmpiricalLiterature

Thissection provides a synthesis of empirical literature relevant tocomfort of fever use of Tylenol in treatment of fever and itssignificance to children with fever. In this respect, the systematicapproach adopted in reviewing various empirical literatures willevaluate the objective of the studies, sample size, the methodologyuse and the outcomes of the studies. Moreover, the methodologiesemployed in the studies and subsequent outcomes of various studieswill be compared to each other as well as theory in order to generateinvaluable insight on impacts of comfort on children with fever. Theoutcomes of the empirical literature review will determine thefeasibility of the proposed interventions in enhancing comfort forchildren with fever at Valentine Medical Clinic.

Ina systematic review of literature, Walsh &amp Edwards (2006) focusedon the antipyretic administration, parents’ temperature taking,practices, information seeking behaviors and attitudes. They achievedtheir objectives by searching Medline, CINAHL, PsycINFO, PsycARTICLESand Web of Science databases from 1980 to 2004. The results of theextensive literature review established that most parentsmisclassified mild fever as high. There were several concernsassociated with the “high” fever that included brain damage,febrile convulsions and even death regardless of the parents’socioeconomic class or level of education. The study recommended thatthere was need for professional care for children with fever since“despite successful educational interventions, little has alteredparents’ and caregivers’ management of fever in children” (p.225). More aptly, the researchers pointed out that there is an urgentneed of awareness campaigns anchored on behavioral theories (as thecomfort theory discussed in the preceding section) to target theprecursors of attitude, intelligence, normative influences andperceptions of regulation. The outcomes of Walsh &amp Edwards (2006)have a direct implication for this proposal as the proposedintervention in the PICOT question i.e. theimplementation of a fever practice guideline at Valentine MedicalClinic is synonymous with the recommended “professionalcare for children with fever”. Walsh et al (2006), Walsh et al(2007), Sa’ed (2013), Alqudah et al (2014) and Rockett et al (2015)also echoed the outcomes of Walsh &amp Edwards (2006).

Feverin children is often characterized by pain and discomfort andempirical studies have endeavored to establish the most appropriateway to treat fever-related pain in children. Arencibia&amp Choonara, (2012) performed a narrative review of the efficacyand toxicity of over the counter (OTC) analgestic drugs. Theiroverriding aim of providing a typology that could be used by nursingpractitioners to treat pain in children (p. 1119). They found outthat neither aspirin nor dipyrone were suitable for OTC medicationsince they were associated with risk of agranulocytosis and Reye’ssyndrome respectively. However, the study outcomes showed that bothibuprofen and paracetamol were effective for treating fever-relatedpain in children with less than five years of age and the adverseeffects associated with them were infrequent (p. 1121).

Infeverish children, empirical literatures have shown that symptomaticmanagement is the key to reducing fever-related pain. Bettinelli etal (2013) investigated the differences between pediatrichospitalists, pediatric residents and community pediatricians intheir daily clinical experiences as concerns the treatment ofsymptomatic management of children. Using a questionnaire, the studyobtained data from a sample of 79 physicians from Northern Lombardi,Italy. The outcomes showed that the pediatric residents (n = 20),community pediatricians (n = 30) and pediatric hospitalists showed nosignificant difference as concerns the temperature threshold forsymptomatic fever treatment (p. 5). Additionally, there was nosignificant variations in hoe they treated the role of generalappearance in mediating the threshold for fever treatment, frequencyof ibuprofen prescription, effects of exaggerated fear on itsmanagement and first choice antipyretic drug. However, a significantdifference was noted for the community pediatricians who were foundto prefer homeopathic remedies in acute settings (p &lt 0.001) andprophylaxis (p &lt 0.0001). The paper concluded that the managementof symptomatic fever in children took a universal approach (p. 6).

Allanet al (2010) sought to establish which amongst acetaminophen andibuprofen was more superior in the treatment of pediatric fever. Inorder to achieve this, the researchers conducted a meta-analysis anda randomized controlled trial (RCT) using a sample of 1078 cases andthe outcomes revealed interesting facts. In a meta-analysis of tentrials of ibuprofen (5-10 mg/ kg) and acetaminophen (10-15 mg/ kg),ibuprofen was found to be more superior at 12, 14 and 26 minutes.Moreover, between 14 and 16 minutes of the meta-analysis, the numberof patients who recorded a reduction in fever had increasedsignificantly (15%). In the pitch RCT, ibuprofen (10 mg/ kg 16-18minutes) and acetaminophen (15 mg / kg14-26 minutes) and acombination of the two prescriptions were compared and the resultsrevealed that within the first four hours, ibuprofen was the mostsuperior of the tree and the combination was 53 minutes more superiorthan acetaminophen (p &lt 0.001) (p. 771). In general, the outcomesof the random controlled trial (RCT) showed that ibuprofen and thecombination worked much faster to clear fever relative toacetaminophen. The paper also concluded that ibuprofen cleared feverwith a decrease in adverse events (p. 772). Moreover, Tylenol (15 mg/ kg19 minutes) was found to be equally effective in the interactivemodel established in the second experiment.

Outsidethe clinical setting, the treatment of children with fever has beenfound to rely heavily on the caregivers’ knowledge and ability toensure comfort for the children as a mechanism of fever treatment(Chow &amp Robinson, 2011).Chang et al (2012) assessed thecaregivers’ knowledge about acetaminophen and their understandingof acetaminophen syrup prescriptions when administered to febrilechildren. This study was informed by the fact that fever is one ofthe most common illnesses in children for which caregivers seekmedical advice (p. 42). To achieve their objectives, the researchersemployed a cross-sectional study covering a sample of 102 caregiversof febrile children from whom information was obtained usingself-designed questionnaires. The study results showed thatantipyretic suppository (60%) and antipyretic by oral (66%) were themost commonly used forms of fever management. The study noted grossmisunderstanding of prescriptions by caregivers with even poorercases for caregivers with poor academic backgrounds. Chang et al(2012) concluded that physicians needed to ensure that caregiversfully comprehended prescriptions so as to effectively treat andmanage fever in febrile children (p. 49).

Therole of temperature measurement in the diagnosis of fever has alsobeen elevated in empirical literature. Edelu, Ojinnaka and Ikefuna(2011) sought to use the infrared tympanic thermometer (IRTT) in anoral mode to measure temperature in febrile and afebrile children. Inorder to achieve this goal, both rectal and tympanic temperatureswere measured for 400 febrile and 400 afebrile using the conventionalthermometer and the infrared tympanic thermometer. The mean tympanictemperatures of the febrile and afebrile category were 38.60C and 39.00Crespectively. Additionally, there was a significant differencebetween the tympanic and rectal temperatures in both categories. Thesensitivity of the IRTT was 87.3% with a specificity of 96.5%. Edeluet al (2011) concluded that IRTT was not efficient for measuring corebody temperature of infants but is important in the screening ofchildren with fever in a busy set up.

Thefact that fever in children is majorly caused by self-limitinginfections (Hassan et al, 2013). Bont,Francis, Dinant, and Cals (2014) evaluated the knowledge, attitudesand practice in childhood fever. To achieve this, they utilized aninternet-based survey of 1000 parents in Netherlands. Using a 26-itemcross-sectional survey, responses were gathered from parents withchildren below five years. The outcomes of this study showed that63.4% and 43.7% of the respondents reported having consultedphysicians beyond consultation time with a febrile child. 88.3% ofrespondents were able to define fever and 72% were aware that notevery febrile child was to be treated with paracetamol andantibiotics (p.14). The study concluded that the knowledge attitudesand practice of childhood fever varied with young children (p. 16).

Walshet al (2005) conducted a descriptive study to evaluate Australiannurses’ knowledge and attitudes towards fever treatment andmanagement as well as ascertain their likelihood of administeringparacetamol to febrile children. The study employed the use of aself-report questionnaire to obtain responses from a sample of 51respondents (pediatric nurses) and a test-retest performed toguarantee the instrument reliability. The results showed that thenurses’ average knowledge score on physiology of fever,antipyretics and general management of fever was 62%, which accordingto the researchers “fell short of expectations”. The results alsorevealed that the nurses had positive attitudes towards regularantipyretic administration and benefits if fever while negativeattitudes were recorded one the notion that high temperature ininfants is often unrelated to severity of fever (p. 462).The studyconcluded by observing that the management of fever in infants is akey aspect of pediatric nursing and if consistency and rationality isto be achieved, there is need to enhance nurses’ knowledge andcreate a positive attitudes thus need for continuing education forfever management (p. 464).

El-Radhi(2012) undertook an extensive systematic review of literature on thevarious techniques adopted by physicians and caregivers in themanagement of fever in children below five years. He ascertained thatthere were certain specific strategies that can be employed to managefever in which education was the leading strategy that significantlyenhanced management of fever in children (p.36). The studyascertained that in order to enhance management of fever in children,healthcare professionals ought to consider parental education onchild fever and comfort as a core strategy in the management of feverin children. Moreover, the study established that body temperature isoften controlled from the brain and never exceeds 42.00C. Further, he noted that antipyretic treatment does not targetEuthermia but such it aims at making the child more comfortable (p.38). This outcome make a direct contribution to the course of thisproposal and provides adequate support for the proposed interventionin the PICOT question adopted for Valentine Medical Clinic.Paracetamol was also found to be an effective antipyretic andanalgesic while ibuprofen had substantial negative externalities. Inconclusion, El-Radhi (2012) posited that antipyretics are much moreeffective when used with indications like drugs and not exclusivelyas a treatment for fever and that robust diagnosis ought to beundertaken to establish which disease the associated fever may beharmful (p. 38).

Giventhe medical profession is often characterized by dynamism owing totechnological change, more studies have been dedicated to evaluatingthe trends in fever management. In a more recent study, Rockett et al(2015) investigated the changes that had taken place in the nursingprofess as far as the management of fever in children is concerned.The study employed an array of survey methods to describe the changesthat had taken place in the past few years and evaluate theinstitutional procedures used today and how they influence decisionmaking in the management of fever in children. The survey resultsestablished that the temperatures relied upon to initiate treatmentwere either based on the set protocols or the physicians’determination (p.73). It was also noted that in the treatment ofinfants with fever, nurses working in settings with institutionalawards only initiated therapy at relatively lower temperatures. Afterassessing the changes in the treatment and management of fever, thestudy recommended the development of a “stepwise approach toneuro-specific protocols for fever management” and need for further“specialty training” for nurses (p.74).He concluded thatconventional pediatric care did little to children with fever in thedimensions of antipyreticadministration, reduction of body temperature, comfort and handlingof febrile convulsions.The recommendation for further training echoes earlier studies likeWalsh et al (2006), Alqudah et al (2014) and Sa’ed (2013) and Walsh&amp Edwards (2006).

Enhancingcomfort for children with fever requires a lot of input from theparents as well, therefore it is critical at this point to reviewstudies undertaken to assess the perspective of parents concerningthe various fever treatment and management strategies for children.Craig et al (2014) sought to evaluate the parental perspectivesconcerning the treatment and management of fever in infants. In theextensive systematic review, the study conducted a semi-structuredface-to-face interview with 36 parents of children below three yearsof age who had been admitted at a children’s clinic in Sydney,Australia. The outcomes of this particular study were centered on thetheme of parental empowerment in which parents reported anoverwhelming responsibility in the care for the children, heightenedvulnerability and sought for medical partnerships. In concluding thestudy, Craig et al (2014) emphasized that parents were overwhelmedwith caring for febrile children and were particularly terrified whenconfronted with hospitalization for fear of severity of the infant’scondition (p. 1047).The researchers recommended that there is needthat there was need to come up with family centered care strategiesthat provide the required medical, social and psychological supportfor parents caring for infants with febrile infants. More aptly, itwas noted that there is need to build better alliances “betweenparents and healthcare providers” (p 1051).Valentine Medical Clinicwill exploit this niche by implementing a fever practice guideline.

PracticeRecommendations

Thereview of empirical literature conducted above has generatedinvaluable insights other than contributing directly towardsanswering the PICOT question posed in the elementary sections of thisproposal. The proposed intervention is the implementation of a feverpractice guideline at Valentine Medical Clinic that is intended tolower body temperature and improve the infants comfort relative tobaseline practice. In light of this question, the review has providedan overwhelming support from multiple perspectives.

Amajority of the articles reviewed has exposed sheer ignorance on thepart of nearly all stakeholders as concerns the treatment andmanagement of fever in infants below five years. In particular,Mohammed (2015),Walsh &amp Edwards (2006), Walsh et al (2006), Walsh et al (2007),Sa’ed (2013), Alqudah et al (2014) and Rockett et al (2015) allprovided similar empirical evidence from different study approaches(thus triangulation) to the effect that there is need for astructured manner of practice as regards the treatment and managementof fever. All these studies exposed in one way or the other, theprofessional and general malpractices and negative perceptions withregards to the management of fever in children thereby making theusual (baseline – comparison) practices less efficient. One of themost precise of these studies in this regard, Walsh &amp Edwards(2006) posited that “there is an urgent need of awareness campaignsanchored on behavioral theories (as the comfort theory discussed inthe preceding section) to target the precursors of attitude,intelligence, normative influences and perceptions of regulation”.In one of the most recent studies, Rockett et al (2015) noted that“conventional (thus baseline) pediatric care did little to childrenwith fever in the dimensions of antipyreticadministration, reduction of body temperature, comfort and handlingof febrile convulsions”.

Aspart of the PICOT question, reduction of temperature and improvingcomfort (outcome) in children in 30 minutes (time), outcomes that areeven more specific have been obtained from the literatures reviewed.For instance, Allan et al (2010) conducted two separate studies inthis regard: a meta-analysis and a controlled random trial (CRT).Results of the meta-analysis of ten trials of ibuprofen (5-10 mg/ kg)and acetaminophen (10-15 mg/ kg) in which ibuprofen was found to bemore superior at 12, 14 and 26 minutes. Moreover, between 14 and 16minutes of the meta-analysis, the number of patients who recorded areduction in fever had increased significantly (15%). In the pitchRCT, ibuprofen (10 mg/ kg 16-18 minutes) and acetaminophen (15 mg /kg 14-26 minutes) and a combination of the two prescriptions werecompared and the results revealed thatwithin the first four hours,ibuprofen was the most superior of the tree and the combination was53 minutes more superior than acetaminophen (p &lt 0.001) (p. 771).The essence of the “control” and “treatment” in this studywas to draw the distinction between the baseline prescription and theproposed practice guidelines. Therefore, it is clear from evidencethat it is possible improve comfort in children within 30 minutes ofintervention. (This is referred to as the easedimensionof confidence in the Comfort Theory).

Thetone in these rigorous and reputed studies cannot be mistaken. Theresearchers have made a spirited proposal to have a well-structuredpractice framework for the treatment and management of fever. Thistypology should result in a comprehensive practice guideline thatwill build on the usual practices today by laying emphasis on thereduction of temperature, effective prescription of antipyretic,laying more emphasis on comfort, building a culture of positiveattitude towards customized patient care and ongoing training ofpediatric nurses. The diagram below represents a framework thatharmonizes the proposals obtained from the literature review.

F

Continued training of pediatric nurses

igure2.0:Practice guideline Algorithm(Constructed from Literature Review)

Culture of positive attitude of benefits of fever

Awareness, training of parents and care givers on prescription, treatment and management of fever in children

Justified prescription of antipyretic based on diagnosis

Accurate Measurement of tympanic and rectal temperatures

Tendencies towards strategies that enhance Ease, Relief and Transcendence i.e. dimensions of comfort

A Comprehensive Practice Guideline at Valentine Medical Clinic

ProjectSetting

ValentineMedical Clinic is a healthcare center specializing in pediatric carecomplete with a teaching and referral unit. The proposed practiceguideline project is targeted at the daily clients with an overridingobjective to improve service delivery and therefore enhance customersatisfaction. The organization has a culture of introducing newtechniques and nursing protocols and the proposed practice guidelinewill immediately be identical with past successes of the clinic. Thisproject has its background in the analysis of customer feedbacks thatis usually done every month. The operations manager proposed the ideawhich was subsequently approved by the Valentine Medical Clinicmanagement board on March 17 2015. This approval paved way forfeasibility studies which have so far painted a more positiveprospect for the project and by extension, the company. Valentine isendowed with several resources as well as several challenges all ofwhich continue to shape its business operations.

Thebusiness strengths include culture of innovation and use oftechnology, strong business partnerships with the world’s tophealthcare providers like the Community Health Systems Inc. (CHS),the VMC brand strength, financial resources and infrastructure,efficient supply chain management (SCM) practices, highly qualifiedstaff and specialization in pediatric healthcare. The businessweaknesses are specialization in pediatric healthcare, challengesresulting from economies of scale and lack of control interests incertain ventures. As for opportunities, the increasing trends towardsspecialization, comfort in healthcare and necessity for morequalified healthcare personnel present real promise to the business.However, the business is threatened by the ever-changing policyregulations in the healthcare sector and stiff competition from newentrants into the industry specializing in pediatric healthcare (seeappendix 1 for summary of VMC SWOT Analysis).

ProjectMission Vision and Objectives

Theproposed project has a missionthat is:

Toprovide high quality pediatric healthcare for millions of patientsaround the world with utmost professionalism while enhancing comfortfor our patients

Theproject visionis:

Tobe the most preferred pediatric healthcare provider by patients andemployees, an industry leader complete with corporate success andorganizational competence.

Theproject has the following long term and short-termobjectives

  1. To enhance comfort in treating children with fever

  2. To reduce time taken in improving comfort in patients

  3. To create a culture of positive attitude towards treatment and management of fever in children with fever

  4. To ensure robust diagnosis and prescription of antipyretic

  5. To ensure accurate measurement of tympanic and rectal temperatures

  6. To ensure continued training of nurses on treatment and management of fever in children

  7. To facilitate extensive awareness campaigns regarding care for children with fever

  8. To establish the Valentine Medical Clinic Foundation to facilitate care for children with febrile seizures and spiral infections resulting from adverse effects of fever

ProjectPlanTranstheoreticalModel (TTM)

Theproject will adopt the Transtheoretical Model (TTM) of change inhealthcare originally developed by Prochaska &amp DiClemente in1983. This integrative biopsychosocial model is often used toconceptualize the processes and activities of structured behaviorchange and has been applied in facilitating healthcare reforms indiverse settings (Pro Change,http://www.prochange.com/transtheoretical-model-of-behavior-change,accessed on 9 August 2015).This model is complete with stages thanmakes it easy to apply and enables evaluation of progress. The stagehas certain specific stages that include precontemplation (notready), contemplation (getting ready) preparation (ready), action andmaintenance. At this point, the stage is at the contemplation stageand the following section integrates the project with theTranstheoretical Model (TTM).

ContemplationStage (Getting ready)

Atthis stage, the concerned parties are much more critical of theprospects of change. According to the theory this stage comesinvolves undertaking feasibility studies and weighing the benefitsand costs of the proposed changes. In the contemporary world, this isthe point in which blue prints are ready complete with proceeds aswell as risk analyses. In the Valentine Medical Clinic project, thisrepresents the feasibility study and the prescriptions for change asoutlined in the algorithm in figure 2.0 in the preceding section.

Action

Thisis stage of the Transtheoretical Model (TTM) where individualsimplement the prescribed changes. In the proposed project, this isthe next immediate stage after approval of the proposal document. Atthis point, nurses will undergo further training, more sophisticatedthermometers will be used to measure temperature and robust diagnosisof fever undertaken.

Maintenance

Accordingto the theory, this is the stage where individuals and organizationshave achieved significant feat and are not willing to relapse for theproceeds of change that they have harnessed. At Valentine MedicalClinic, the proposed evaluation and monitoring team will undertakeperiodic performance appraisals to ensure that the set standards areupheld at all costs.

Interveningfactors and barriers

Giventhat it is in the nature of human beings is likely to resist change,the process is bound to face certain barriers. These barriers includerequired resources, time and lack of goodwill in some employees. Theprocess will rely on the creation of a common organizational culturethat will form the required transformative atmosphere (See Appendix2).

ProjectEvaluation Plan

Theproject will be implemented in stages making project appraisalrelatively easy. The process will involve the use of SERVQUALquestionnaires that have been found to be very effective inevaluating the level of service delivery in the hospitality industry.Since the designed project is aimed at increasing service deliverythrough pediatric healthcare, this questionnaire will be tailored tosuit the project at Valentine Medical Clinic. The current monitoringand evaluation team will be tasked with assessing the progress andmaking the necessary recommendations to the project manager. Thecriteria of information flow between the team and the project managercomplete with feedbacks will be timed to ensure there are no timelags in the system. Once the project has been fully rolled out, thefinancial books can be evaluated to see if there has been anysignificant change in revenues attributable to the proposed project.

Plansfor Dissemination

Theproject is set to be launched during the annual stakeholder meetingon December 4 2015. The AGM attracts a host of regional andinternational leaders and the accompanying publicity will be crucialin propagating the report far beyond the organizational andprofessional constraints. Additionally, a completed copy of thereport is scheduled for publishing in the EuropeanJournal of Nursing and Psychologyin the summer of 2016 which conventionally attracts wide readership.Moreover, hard copies of the report will be provided with theinternal memo usually circulated in the organization every month sothat employees can familiarize themselves with the report before itis launched officially.

Conclusion

Thisproposal was designed to assess the feasibility of improving comfortfor children with fever at Valentine Medical Clinic by providingresponses to a PICOT question developed at the elementary stages ofthis paper. This objective has been accomplished courtesy of thetheoretical and empirical works that have shaped this report. Thereview of empirical literature conducted in this report has generatedinvaluable insights other than contributing directly towardsanswering the PICOT question posed in the elementary sections of thisproposal. The proposed intervention is the implementation of a feverpractice guideline at Valentine Medical Clinic that is intended tolower body temperature and improve the infants comfort relative tobaseline practice. In light of this question, the review has providedan overwhelming support from multiple perspectives. Moreover, thepracticalities of the respective recommendations have also beenaddressed in the report that is complete with a performance appraisalcriteria.

References

Allan,G. M., Ivers, N., &amp Shevchuk, Y. (2010). Treatment of pediatricfever Are acetaminophen and ibuprofen equivalent?Canadian Family Physician,56(8),773-773.

Alqudah,M., Johnson, M., Cowin, L., &amp George, A. (2014). An InnovativeFever Management Education Program for Parents, Caregivers, andEmergency Nurses. Advancedemergency nursing journal,36(1),52-61.

Arencibia,Z. B., &amp Choonara, I. (2012). Balancing the risks and benefits ofthe use of over-the-counter pain medications in children. Drugsafety,35(12),1119-1125.

Bettinelli,A., Provero, M. C., Cogliati, F., Villella, A., Marinoni, M.,Saettini, F., &amp Lava, S. A. G. (2013). Symptomatic fevermanagement among 3 different groups of pediatricians in NorthernLombardy (Italy): results of an explorative cross-sectional survey.Italianjournal of pediatrics,39(1),1-6.

Bont,E. G., Francis, N. A., Dinant, G. J., &amp Cals, J. W. (2014).Parents’ knowledge, attitudes, and practice in childhood fever: aninternet-based survey. BritishJournal of General Practice,64(618),e10-e16.

Chang,M. C., Chen, Y. C., Chang, S. C., &amp Smith, G. D. (2012).Knowledge of using acetaminophen syrup and comprehension of writtenmedication instruction among caregivers with febrile children.Journalof clinical nursing,21(1‐2),42-51.

Chow,A., &amp Robinson, J. L. (2011). Fever of unknown origin inchildren: a systematic review. WorldJournal of Pediatrics,7(1),5-10.

Craig,S., Tong, A., Isaacs, D., &amp, De J. C. (2014). Parentalperspectives on evaluation and management of fever in young infants:an interview study. Archivesof disease in childhood,archdischild-2013.

Edelu,B. O., Ojinnaka, N. C., &amp Ikefuna, A. N. (2011). Fever detectionin under 5 children in a tertiary health facility using the infraredtympanic thermometer in the oral mode. ItalJ Pediatr,37(8).

El-Radhi,A. S. M. (2012). Fever management: Evidence vs current practice.Worldjournal of clinical pediatrics,1(4),29.

Goodwin,M., &amp Steiner, S. H. (2007). A Novel Theory for Nursing EducationHolistic Comfort. Journalof Holistic Nursing,25(4),278-285.

Graves,R. C., Oehler, K., &amp Tingle, L. E. (2012). Febrile seizures:risks, evaluation, and prognosis. AmFAM Physician,85(2),149-53.

Halvorsen,K. E. (2001). Assessing public participation techniques for comfort,convenience, satisfaction, and deliberation. Environmentalmanagement,28(2),179-186.

Hasan,S. F., Akhtar, R., Mustufa, M. A., Kazmi, S. U., &amp Nadeem, M.(2013). To Evaluate the Efficacy and Reliability of CommonlyAvailable Tests for the Diagnosis of Dengue Fever in Children inKarachi. PakistanJournal of Medical Research,52(3),84.

Kolcaba,K. (2003). Comfort theory and practice. Avision for holistic.

Kolcaba,K. (2010). The Comfort Line. 2010.

Kolcaba,K., &amp DiMarco, M. A. (2004). Comfort Theory and its applicationto pediatric nursing. Pediatricnursing,31(3),187-194.

Krinsky,R., Murillo, I., &amp Johnson, J. (2014). A practical application ofKatharine Kolcaba`s comfort theory to cardiac patients. AppliedNursing Research,27(2),147-150.

Lachmann,H. J. (2015). Autoinflammatory syndromes as causes of fever ofunknown origin. ClinicalMedicine,15(3),295-298.

McDougall,P., &amp Harrison, M. (2014). Fever and feverish illness in childrenunder five years. NursingStandard,28(30),49-59.

Mohammed,M. (2015). Causes,Fever in Children Under 5Years Knowledge, Attitude and Practices ofMothers And Health Team Towards The Management of Acutely FebrileChildren(Doctoral dissertation, UOFK).

NationalCollaborating Centre for Women`s and Children`s Health (UK. (2013).Feverish illness in children: assessment and initial management inchildren younger than 5 years.

Pain,A. S. P. A. N., Comfort, S. W. T., Krenzischek, D. A., Wilson, L.,Newhouse, R., Mamaril, M., &amp Kane, H. L. (2004). Clinicalevaluation of the ASPAN pain and comfort clinical guideline. Journalof Perianesthesia Nursing,19(3),150-159.

Polat,M., Kara, S., Tezer, H., Tapısız, A., Derinöz, O., &amp Dolgun,A. (2014). A current analysis of caregivers’ approaches to feverand antipyretic usage. TheJournal of Infection in Developing Countries,8(03),365-371.

Rockett,H., Thompson, H. J., &amp Blissitt, P. A. (2015). Fever managementpractices of neuroscience nurses: what has changed?. Journalof Neuroscience Nursing,47(2),66-75.

Sa’ed,H. Z., Al-Jabi, S. W., Sweileh, W. M., Nabulsi, M. M., Tubaila, M.F., Awang, R., &amp Sawalha, A. F. (2013). Beliefs and practicesregarding childhood fever among parents: a cross-sectional study fromPalestine. BMCpediatrics,13(1),66.

Sawe,H. R., Murray, B. L., Reynolds, T. A., D`Acremont, V., Kilowoko, M.,&amp Kyungu, E. (2014). Causes of fever in outpatient Tanzanianchildren. TheNew England journal of medicine,370(23),2242-2242.

Schellack,N. (2011). Febrile seizures in children. SAPharmaceutical Journal,79(3),10-13.

Sullivan,J. E., &amp Farrar, H. C. (2011). Fever and antipyretic use inchildren. Pediatrics,127(3),580-587.

Sullivan,J. E., &amp Farrar, H. C. (2011). Fever and antipyretic use inchildren. Pediatrics,127(3),580-587.

vanden Anker, J. N. (2013). Optimising the management of fever and painin children. InternationalJournal of Clinical Practice,67(s178),26-32.

Walsh,A. M., Edwards, H. E., Courtney, M. D., Wilson, J. E., &ampMonaghan, S. J. (2006). Paediatric fever management: continuingeducation for clinical nurses. NurseEducation Today,26(1),71-77.

Walsh,A. M., Edwards, H. E., Courtney, M. D., Wilson, J. E., &ampMonaghan, S. J. (2005). Fever management: paediatric nurses’knowledge, attitudes and influencing factors. Journalof Advanced Nursing,49(5),453-464.

Walsh,A., &amp Edwards, H. (2006). Management of childhood fever byparents: literature review. Journalof advanced nursing,54(2),217-227.

Walsh,A., Edwards, H., &amp Fraser, J. (2007). Influences on parents’fever management: beliefs, experiences and information sources.Journalof clinical nursing,16(12),2331-2340.

Wilson,L., &amp Kolcaba, K. (2004). Practical application of comfort theoryin the perianesthesia setting. Journalof PeriAnesthesia Nursing,19(3),164-173.

Appendix1: VMCSWOT analysis

Strengths

– -Strong partnerships

-Brand Strength

-Financial Resources and Infrastructure

-Supply Chain Management Practices

-Highly qualified staff

– Specialization in pediatric healthcare

Weaknesses

-Lack of control interests in certain ventures

-Managerial challenges resulting from economies of scale

Opportunities

– Trends towards specialization

– comfort in healthcare

– necessity for more qualified healthcare personnel

Threats

-Fierce competition from new market entrants

-Regulatory frameworks in external markets

-Macroeconomic dynamism

Appendix2: Project Plan

  1. Pre-Contemplation

Raw Ideas by Operations Manager

2. Contemplation

-Writing of n official blueprint

-Conducting feasibility Studies

4 Months

Intervening Factors &amp Barriers

-Resources – Goodwill

-Time – Resistance

6 Months

6 Months

3. Action

-Training of nurses

-Provision of require capital investments

Pediatric Healthcare Guideline Practices at Valentine Medical Clinic (VMC)

-Improving comfort in children with fever within 30 minutes of intervention

Regularly

4. Maintenance

-Implementing reports of the evaluation and monitoring team

Appendix3: Project Budget

EXPENSES

&nbsp

&nbsp

&nbsp

&nbsp

REVENUE

&nbsp

&nbsp

&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbspDirect

Estimated # of patients

Unit cost

Total cost

Source of money

Billing

&nbsp

&nbsp

Staff salary for patients education&nbsp and administration of Tylenol

60

5mins x60=

300mns=5hrs

5hrs x $20.00

$100.00

Included in staff salaries

&nbsp

&nbsp

&nbsp

Cost of purchase of Tylenol syrup 25% of 60 pts=15pts

15

&nbsp

10-pack 1 dose vial with syringes, $31.35 each

2 packs

$62.70

Clinic’s

budget

Reimbursement for VFC underinsured/underinsured/

medicaid

25% of 60=15pts

&nbsp

15 pts

$20/pt

$300.00

Cost of purchase for Tylenol

75% of 60= 45pts

45

10 pack 1 dose syringe

$22.63 each

5 packs

$113.15

&nbsp

Clinic’s

budget

Sliding scale fee for uninsured

29% of 60 = 17pts

17pts

$10/pt

$170.00

Needles for vaccine injection

60

Box of 100 0

$30.00 each

$30.00

Clinic’s

budget

Reimbursement from Medicaid/Medicare and private insurances

46% of 60= 28pts

28pts

$30/pt

$840.00

alcohol swabs

60 (2 per patients)-120

Box of 200 x 1

$3.50 per box.Total&nbsp $3.50

Clinic’s

budget

&nbsp

&nbsp

&nbsp

Indirect

&nbsp

&nbsp

&nbsp

&nbsp

&nbsp

&nbsp

&nbsp

Staff Handouts, flyers and posters

15

&nbsp

$30.00

DNP student

&nbsp

&nbsp

&nbsp

Misc. staff reward/celebration

&nbsp

&nbsp

$50.00

DNP student

&nbsp

&nbsp

&nbsp

Patients handouts and flyers

60

&nbsp

$30.00

DNP student

&nbsp

&nbsp

&nbsp

Total Expenses

&nbsp

&nbsp

429.35

&nbsp

Total Revenue

&nbsp

$1,310.00

&nbsp

Student $ 120.00

Clinic $309.35

Net Balance

&nbsp

+ $1,000.65

Appendix4: Comfort Behaviors Checklist

Howis patient acting right now? Please circle best response.

NA=sleeping,ornotappropriate for this patient because of diagnosis or age .

(Forexample, if patient is sleeping questions 3-5 are circled NA.)

NA No Somewhat Moderate Strong

Vocalizations

1.awake 0 1 2 3 4

2.moaning 0 1 2 3 4

3.complaining 0 1 2 3 4

4.content sounds/talk 0 1 2 3 4

5.crying/shouting 0 1 2 3 4

MotorSigns…………………………………………………………………………

6.peaceful 0 1 2 3 4

7.agitated 0 1 2 3 4

8.rapid pacing 0 1 2 3 4

9.fidgety 0 1 2 3 4

10.muscles relaxed 0 1 2 3 4

11.rubbing an area 0 1 2 3 4

12.guarding 0 1 2 3 4

Performance………………………………………………………………………….

13.anxious movements 0 1 2 3 4

14.accepts kindness 0 1 2 3 4

15.likes touch/ 0 1 2 3 4

handholding

16.able to rest 0 1 2 3 4

17.able to eat 0 1 2 3 4

18.calm, at ease 0 1 2 3 4

19.purposeless 0 1 2 3 4

movements

20.tries to move away 0 123 4

Facial……………………………………………………………………………….

21.appears depressed 0 1 2 3 4

22.grimaces/winces 0 1 2 3 4

23.relaxed expression 0 1 2 3 4

24.hyper-vigilant 0 1 2 3 4

25.appears frightened 0 1 2 3 4

orworried

26.smiles 0 1 2 3 4

Miscellaneous……………………………………………………………………….

27.unusual breathing 0 1 2 3 4

28.focuses mentally 0 1 2 3 4

29.able to converse 0 1 2 3 4

30.awakens smoothly 0 1 2 3 4

(Continueon next page)

Ifthis is the onlycomfort/pain instrument being used, ask the patient:

30.Do you have any pain? No__Yes

[Pleaserate your pain from 0 to 10, with 10 being the highest possiblepain].

__(rating)

31.Taking everything into consideration, how comfortable are you rightnow?

[Pleaserate your total comfort from 1 to 10, with 10 being the highestpossible comfort.]

___(rating)

Adaptedby K. Kolcaba from: Ladislav Volicer. “Management of advancedAlzheimer’s dementia/The comfort checklist.” From Volicer &ampothers (1988). ClinicalManagement of Alzheimer’s Disease.,Rockville, MD. Aspen Publications.

Otheropen-ended information…………………………………………

(changein medication use, recent injury, recent decline in functionalstatus, staff reports of comfort/discomfort, changes in appetite,ambulation, etc.)

Scoringof the Behaviors Checklist

Subtractnumber of “not appropriate” (NA) from 30, to obtain totalanswered.

Multiplytotalanswered (step1)by 4,to obtain totalpossible score.

Reversecode: numbers 2, 3, 5, 7, 8, 9, 11, 12, 13, 19, 20, 21, 22, 24, 25, 27 toobtain rawcomfort responses.

Addrawcomfort responses (step3) for all questions not marked NA, to obtain rawcomfort score.

  1. Divide actual comfort score (step 4) by total possible score (step 2) and round to two decimal places. (If the third decimal place is a 5 or greater, round the second decimal place up to the next number.)

  1. Report score as a 2-digit number (percent without the % sign or decimal). Higher scores indicate higher Comfort.

Appendix5: Demographic Data Tool

Directions:Please put a check mark next to your answer or fill in the blank.

YOURCHILD’S NAME HERE_AGE_

1. Is your child male or female?

(1) MALE

(2) FEMALE

(3) DON`T KNOW

(4) REFUSED

2. What is your relationship to the child?

(1) MOTHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE)

(2) FATHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE)

(11) GRANDMOTHER

(12) GRANDFATHER

(13) AUNT

(14) UNCLE

(15) FEMALE GUARDIAN

(16) MALE GUARDIAN

(17) SISTER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)

(18) BROTHER (BIOLOGICAL, STEP, FOSTER, HALF, ADOPTIVE)

(19) COUSIN

(20) IN-LAW OF ANY TYPE

(22) OTHER RELATIVE / FAMILY MEMBER

(23) PARENT’S BOYFRIEND / MALE PARTNER

(24) PARENT’S GIRLFRIEND / FEMALE PARTNER

(25) PARENT’S PARTNER, but SEX REFUSED

(26) OTHER NON-RELATIVE OR FRIEND

(77) DON’T KNOW

(99) REFUSED

3. In general, how would you describe your child’s health? Would you say [his/her] health is excellent, very good, good, fair, or poor?

(1) EXCELENT

(2) VERY GOOD

(3) GOOD

(4) FAIR

(5) POOR

(6) DON`T KNOW

(7) REFUSED

4. What was your child’s birth weight?

___ ___ ___ POUNDS/OUNCES/GRAMS

(1) DON`T KNOW

(2) REFUSED

5. Was your child born premature, that is, more than 3 weeks before [his/her] due date?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

6. Does your child currently need or use medicine prescribed by a doctor, other than vitamins?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

7. Is [his/her] need for prescription medicine because of ANY medical, behavioral or other health condition?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

8. Hearing problems?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

9. Vision problems that cannot be corrected with standard glasses or contact lenses?

(1) YES)

(2) NO

(3) DON`T KNOW

(4) REFUSED

10. Bone, joint, or muscle problems?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

11. A brain injury or concussion?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

12. Is there a place that your child USUALLY goes when [he/she] is sick or you need

advice about [his/her] health?

(1) YES

(2) NO

(3) THERE IS MORE THAN ONE PLACE

(4) DON’T KNOW

(5) REFUSED

13. Is it a doctor’s office, emergency room, hospital outpatient department, clinic, or some other place?

(1) DOCTOR’S OFFICE

(2) HOSPITAL EMERGENCY ROOM

(3) HOSPITAL OUTPATIENT DEPARTMENT

(4) CLINIC OR HEALTH CENTER

(5) RETAIL STORE CLINIC OR “MINUTE CLINIC”

(6) SCHOOL (NURSE, ATHLETIC TRAINER, ETC)

(7) FRIEND/RELATIVE

14. During the past 12 months/Since (his/her) birth, did your child see a doctor, nurse, or other health care professional for any kind of medical care, including sick-child care, well-child check-ups, physical exams, and hospitalizations?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

15. During the past 12 months/Since (his/her) birth, did your child see a dentist for any kind of dental care, including check-ups, dental cleanings, x-rays, or filling cavities?

(1) YES

(2) NO

(3) DON`T KNOW

(4) REFUSED

16.Ifyour child is less than 24 MONTHS, SKIP this question. Mental healthprofessionals include psychiatrists, psychologists, psychiatricnurses, and clinical social workers. During the past 12 months, hasyour child received any treatment or counseling from a mental healthprofessional? (1) YES (2) NO (3)DON`T KNOW (4) REFUSED

17.During the past 12 months, has your child taken any medicationbecause of difficulties with [his/her] emotions, concentration, orbehavior? (1) YES (2) NO (3) DON`TKNOW (4) REFUSED

18. Has your child ever received therapy services to meet (his/her) developmental needs, such as Early Intervention, occupational therapy, speech therapy, or behavioral therapy?

(1) YES (2) NO (3) DON`T KNOW (4) REFUSED

19. During the past 12 months / Since (his/her) birth, how often did you get the specific information you needed from your child’s doctors and other health care providers? Would you say never, sometimes, usually, or always?

(1) NEVER

(2) SOMETIMES

(3) USUALLY

(4) ALWAYS

(5) DON`T KNOW

20. During the past week, how many days did you or any family member take your child on any kind of outing, such as to the park, library, zoo, shopping, church, restaurants, or family gatherings?

___ ___ ___ NUMBER OF DAYS CHILD VISITED TO PUBLIC EVENTS

(1) DON`T KNOW(2) REFUSED