搜索结果：Journal of obstetric, gynecologic, and neonatal nursing : JOGNN

To map existing evidence on the needs and roles of grandparents of infants in the NICU. We searched five databases: CINAHL, MEDLINE, Scopus, APA PsycNet, and ProQuest Dissertations and Theses Global. We also reviewed reference lists and explored unpublished studies and gray literature. We included sources in which the authors described the needs and roles of grandparents of infants in the NICU as described by grandparents, parents, and health care professionals. Two independent reviewers screened titles and abstracts and then assessed full texts using predefined inclusion and exclusion criteria. We resolved disagreements through discussion or adjudication by the first author. We selected 22 publications, including quantitative, qualitative, and mixed-methods studies; a meta-review; and opinion papers. We extracted the following data: authors, publication year, country, aims, study design, methods, sample, data collection tools, and key findings. We created a summary table and wrote a narrative synthesis to connect findings with our objective. Through the scoping review, we found that grandparents needed to be involved in the care of their grandchildren and to understand the NICU environment. As they sought to bond with their grandchildren, grandparents also provided key emotional and practical support for parents. To meet the needs of grandparents, health care professionals in the NICU should answer their questions within the bounds of privacy limitations and offer tailored interventions. Because recent research on this topic remains limited, we recommend further studies to address this gap and strengthen family-centered care in NICUs.

To explore intrapersonal, interpersonal, and organizational factors that contribute to disrespect and abuse of women in labor by nurses and midwives in the United States. Qualitative descriptive design. Anonymous online survey. Nurses and midwives (N = 124: 90 nurses and 36 midwives) who cared for women in labor during hospital births in the United States for at least 2 years. We used convenience and snowball sampling to recruit participants for an anonymous online survey. This study represents the qualitative strand of a mixed-methods approach guided by Patient Abuse in Healthcare Theory. We analyzed the data using reflexive thematic analysis. We identified eight themes that represented contributing and protective factors for disrespect and abuse of women in labor by nurses and midwives. Three themes represented factors that contributed to disrespect and abuse: Manifestations of Personal and Ethical Shortcomings in Clinical Conduct; Systemic and Structural Deficiencies as Catalysts for Disrespectful Conduct; and Patient, Family, and Interactional Friction. Five themes represented factors that were protective and deterred disrespect and abuse: Leadership Commitment and Enforced Accountability, Investment in the Work Environment and Resources, Staff Competencies, Well-being, and Self-awareness, Adherence to Professional and Ethical Standards, and Patient Empowerment and Education. Our findings support the Patient Abuse in Healthcare Theory and show how intrapersonal, interpersonal, and organizational factors contribute to and mitigate disrespect and abuse of women during labor by nurses and midwives in the United States from their own perspectives. We recommend future researchers investigate interventions designed to address these factors and foster respectful maternity care.

Medicaid is the nation's largest public health insurer and the primary payer of perinatal care; it covers more than 70 million low-income residents and 41% of births. The One Big Beautiful Bill Act (OBBBA), which was signed into law on July 4, 2025, introduced the largest Medicaid funding reductions in the program's history-an estimated $1.1 trillion over 10 years. In this article, we describe the major OBBBA provisions related to eligibility and Medicaid financing and the anticipated effects of these provisions on the delivery of perinatal care services and related outcomes. Although pregnant women are exempt from some of these provisions, systemwide coverage losses and structural changes in Medicaid financing are expected to increase the numbers of uninsured individuals; increase administrative burdens for states, providers, and families; increase financial strain on health care organizations; and reduce access to care. These effects will vary across states and compound longstanding challenges in perinatal health, including persistent racial and geographic inequities, widespread closure of obstetric units, and lagging maternal and infant outcomes. Collectively, these policy shifts threaten to worsen maternal and infant morbidity and mortality, particularly in underserved communities. We conclude with recommendations for practice and policy to safeguard perinatal health amid deep structural reductions in Medicaid support. The purpose of this series is to critically examine emerging federal and state health policy changes and their implications for the health and well-being of women, childbearing families, and young children and to provide evidence-based analyses that inform the nurses who care for these populations. The author solicitation and preparation of each article are overseen by series coordinators Mindy B. Tinkle, PhD, RN, WHNP-BC, CNE, FAAN, associate professor, and Nick Edwardson, PhD, MS, associate professor, College of Nursing, University of New Mexico, Albuquerque, NM.

To provide a conceptual understanding of the breastfeeding experiences, challenges, and support needs of women in the workforce. PubMed, CINAHL, and PsycINFO. We included reports of primary qualitative studies that were published from 2014 to 2024 in which researchers described the breastfeeding experiences of women in the workforce. We selected 13 reports for inclusion with a combined sample size of 188 women aged 20 to 48 years. We extracted the following data from included studies: methodological characteristics (sample size, qualitative design, data analysis, data collection, and length of interview), demographic characteristics of participants (country, age group, employment setting/type, nature of work, and length of paid leave), direct participant quotes, and key concepts and themes about the breastfeeding experiences of women in the workforce. Using a published method for meta-ethnography, we synthesized the extracted data and identified four overarching themes, each with three subthemes: Juggling Milk and a Paycheck (subthemes: Torn Between Desk and Cradle, The Balancing Act, and Milk on the Clock), The Emotional Dance of Motherhood (subthemes: Hearts Full, Minds at Ease; Shadows of Exhaustion; and Against the Odds), The Village in Question (subthemes: Whispers and Judgments, Absent Anchors, and Hands That Hold), and The Policy Pendulum (subthemes: Written But Not Real, Clocking Out From Care, and When Care and Career Collide: Influence on Work). These themes and subthemes highlighted logistical challenges, inadequate workplace policies, the importance of supportive environments, women's emotional stress, and women's resilience. Our findings indicate that structural, emotional, social, and policy-related factors shaped the breastfeeding experiences of the participants in the included articles. We emphasize the need for targeted interventions and workplace policies to optimize breastfeeding experiences and outcomes among women in the workforce.

Since the U.S. Supreme Court's decision in Dobbs v. Jackson Women's Health Organization and accelerating over the past year, reproductive health policy in the United States has become increasingly fragmented and unstable. Recent federal actions have introduced new barriers across the continuum of reproductive care. These actions include changes to Title X family planning funding, substantial reductions to Medicaid, rescission of federal Emergency Medical Treatment and Labor Act (EMTALA) guidance related to pregnancy emergencies, and renewed regulatory scrutiny of mifepristone. Together, these changes affect access to contraception, miscarriage management, abortion, emergency pregnancy care, and assisted reproductive technologies such as in vitro fertilization (IVF). We examine how overlapping and, at times, internally inconsistent federal and state policies are reshaping reproductive health care delivery. We review the role of Title X in sustaining the reproductive health safety net, analyze how insurance loss and clinic destabilization limit contraceptive access, and describe how conflicts between abortion bans and EMTALA obligations delay emergency care. We also examine how political challenges to the U.S. Food and Drug Administration's authority over mifepristone threaten evidence-based management of early pregnancy loss and abortion and how rhetorical federal support for IVF contrasts with the absence of enforceable coverage protections. Nurses play a critical role in identifying gaps in care and advocating policies that protect evidence-based reproductive health services. The purpose of this series is to critically examine emerging federal and state health policy changes and their implications for the health and well-being of women, childbearing families, and young children and to provide evidence-based analyses that inform the nurses who care for these populations. The author solicitation and preparation of each article are overseen by series coordinators Mindy B. Tinkle, PhD, RN, WHNP-BC, CNE, FAAN, associate professor, and Nick Edwardson, PhD, MS, associate professor, College of Nursing, University of New Mexico, Albuquerque, NM.

The United States has long been a leader in protecting human health through environmental regulation. Since 2025, however, environmental deregulation has reversed or eliminated many air, land, water, and climate protections. This shift in federal policy has, and will continue to have, serious consequences for the health of pregnant women, infants, and children. In this article, we examine environmental regulatory changes since January 2025 and evaluate their current and potential effects on maternal, infant, and child health outcomes. We use Bardach's eight-fold path to review major federal actions, including the revocation of the greenhouse gas endangerment findings, the weakening of toxic air pollution standards and their enforcement, and the rollback of environmental justice programs that directly address the disproportionate burden of environmental pollution on women, infants, and children in at-risk communities. We conclude with policy and practice recommendations to strengthen environmental health protections and safeguard maternal and child health amid ongoing deregulation. The purpose of this series is to critically examine emerging federal and state health policy changes and their implications for the health and well-being of women, childbearing families, and young children and to provide evidence-based analyses that inform the nurses who care for these populations. The author solicitation and preparation of each article are overseen by series coordinators Mindy B. Tinkle, PhD, RN, WHNP-BC, CNE, FAAN, associate professor, and Nick Edwardson, PhD, MS, associate professor, College of Nursing, University of New Mexico, Albuquerque, NM.

Extreme heat and air pollution, which are exacerbated by climate change, worsen maternal and neonatal health, especially for non-White women. Because of the wide array of health risks related to climate change, advocating for individual patients alone is not sufficient to create necessary change. Although nurses experience numerous barriers to engaging in public policy, their engagement remains a critical aspect to improving maternal and neonatal health outcomes related to climate change. Professional nursing organizations can provide nurses with resources and offer the necessary skills to effectively advocate and participate in public policy at the local, state, or national level. In this commentary, I review the importance of nurse engagement in climate change advocacy and public policy.

To explore midwives' experiences of precepting in relation to the demands of clinical practice. Secondary, supplementary qualitative data analysis. Virtual interviews. A total of 18 midwives (16 certified nurse-midwives and 2 certified midwives) who practiced in New Jersey. We used data from a primary study of in-depth, semistructured interviews conducted from June 2023 to February 2024. We used qualitative description methodology and analyzed data using content analysis. We organized relevant codes using the major categories of the differentiated job demands-resources model, in which job demands are classified as hindrances or challenges and resources that can mitigate strain are identified. We found that precepting had a paradoxical effect on respondents' well-being. In the absence of adequate resources, precepting exacerbated exhaustion and in some cases led respondents to reduce or withdraw from teaching responsibilities. Conversely, when supported by collegial collaboration, shared responsibility, and personal agency in accepting students, precepting was a meaningful source of professional purpose and renewal. Although precepting can foster professional engagement and renewal, it may also increase strain and contribute to burnout, particularly within health systems already facing staffing shortages and high turnover. The dual nature of precepting in midwifery underscores the role of system-level support in sustaining the midwifery workforce and clinical education.

To examine factors associated with cesarean birth by race and ethnicity in a health system with a large proportion of midwife-attended births. Retrospective cohort study using electronic heath record data. A multihospital regional health system of community and academic hospitals on the Colorado Front Range. Data from the births of women admitted for labor and birth from January 1, 2018 to January 31, 2020 (N = 10,473). We identified cesarean births and categorized them by maternal race and ethnicity and the type of provider who managed the labor. We used descriptive statistics to characterize the sample. We used multivariable logistic regression to examine associations among cesarean birth, maternal race and ethnicity, and provider type accounting for hospital geographic location, maternal age, and insurance status by parity. Cesareans accounted for 13% of total births and 22.4% of births among nulliparous women with term singleton pregnancies with the fetus in vertex position. Nearly 33% of total births were attended by midwives. Compared with non-Hispanic White women, odds of cesarean birth were significantly higher for nulliparous Black/African American women (odds ratio (OR) = 1.55, 95% confidence interval (CI) [1.13, 2.13], p < .05), Asian women (OR = 1.54, 95% CI [1.02, 2.32], p < .05), Hispanic women (OR = 1.36, 95% CI [1.11, 1.65], p > .05), and women of all other races (OR = 1.70, 95% CI [1.27, 2.27], p < .001) as well as multiparous Hispanic women (OR = 1.60, 95% CI [1.18, 2.25], p < .05) and multiparous women of all other races (OR = 2.60, 95% CI [1.64, 4.13], p < .001). Cesarean birth was more likely when a physician compared with a midwife managed the labor course in nulliparous births (OR = 1.38, 95% CI [1.30, 1.50], p < .001) and multiparous births (OR = 1.60, 95% CI [1.36, 1.90], p < .001). Although overall rates of cesarean birth were low in comparison with state and national averages, racial disparities persisted. Our study findings are aligned with those from previous studies in which researchers demonstrated lower use of cesarean birth with midwifery care and reinforce the importance of examining multilevel influences on cesarean birth.

To identify consequences of falls in women during the perinatal period. Academic Search Complete (EBSCO), CINAHL Ultimate (EBSCO), MEDLINE Ultimate (EBSCO), Cochrane Central Register of Controlled Trials (EBSCO), Cochrane Clinical Answers (EBSCO), Cochrane Database of Systematic Reviews (EBSCO), Cochrane Methodology Register (EBSCO), MedicLatina (EBSCO), Reposit&#xf3;rios Cient&#xed;ficos de Acesso Aberto de Portugal (RCAAP), SciELO, Scopus, and Web of Science. We included quantitative or qualitative primary studies, literature reviews, systematic reviews, expert opinion papers, organizational guidelines, and conference abstracts regarding consequences of falls in women during the perinatal period, in any context of care, that were published until November 11, 2024, in English, French, Portuguese, and Spanish. We extracted the following data from the included reports: author(s), year, country, aim, study design, type of report, sample size, setting, types and consequences of falls, prevalence, and risk factors for falls. From a total of 33 articles, 27 were related to the consequences of falls during pregnancy, 3 were related to consequences of falls during both pregnancy and the postpartum period, 2 were related to consequences of falls during the perinatal period in which one does not identify the specific stage, and 1 was related to the postpartum period. We did not identify any reports of falls during childbirth. Injuries were common consequences of falls among women during the perinatal period, and the severity of falls varied from minor to severe. Obstetric injuries were severe and unique to pregnant women. Pregnant women sustain varied injuries after falls and often need health care. Further research is warranted regarding the consequences of falls during childbirth and the postpartum period.

To evaluate the effect of a nurse-initiated protocol on the times to order and implement prenatal care, nurses' intentions to change practice based on an educational session, and nurses' perceived barriers to initiation of the protocol in a carceral facility. Quality improvement project. Southeastern United States carceral facility. A total of 44 nurses employed by a state women's carceral facility. Participants attended a 30-min educational session on a nurse-initiated intake protocol, including use of the Clinical Opiate Withdrawal Scale. The session was offered multiple times during shifts to maximize attendance. Participants then completed an adapted Continuing Professional Development-Reaction Questionnaire. We abstracted de-identified data from the charts of adult incarcerated women in the pre-implementation (n = 26) and post-implementation (n = 24) phases. We compared time to order (interval from admission to entry of order for a laboratory test, medication, or intervention) and time to implementation (interval from entry of order to initiation of the laboratory test, medication, or intervention) before and after implementation of the protocol. We assessed barriers to implementing the protocol 3 months after implementation. The time to order a prenatal diet and schedule a first obstetric appointment decreased significantly (p < .001), whereas the time to order prenatal labs increased significantly (p = .03) after implementation of the protocol. We identified the following themes as barriers to implementing the protocol: Lack of Integration of the Protocol Into the Electronic Health Record, Interruptions in the Flow of Care, and Limited Resources. Use of a nurse-initiated protocol standardized and improved the timeliness of the delivery of prenatal care in a carceral facility and has the potential to enhance health care quality and maternal-fetal outcomes in this high-risk population.

To explore variations in maternal and infant outcomes among clusters of mother-infant dyads in the NICU characterized by intersecting social identity characteristics. Secondary exploratory analysis of data from a cluster randomized controlled trial conducted from December 2015 to July 2018. Ten Level II NICUs in six cities across Alberta, Canada. A total of 400 mothers and their preterm infants at 320&#x2044;7 to 346&#x2044;7 weeks gestation. We used two-step cluster analysis to identify clusters based on maternal ethnicity, education, age, and annual family income. We employed multiple regression models to examine whether cluster membership was associated with infant length of stay, maternal psychosocial distress, and parenting self-efficacy at discharge, controlling for relevant infant and maternal characteristics and hospital setting (urban vs. regional). We identified four mother-infant dyad clusters: (1) younger, lower-education, lower-income White mothers; (2) older, higher-education, higher-income BIPOC (Black, Indigenous, or people of color) mothers; (3) diploma-educated, highest-income White mothers; and (4) university-educated, highest-income White mothers. Although cluster membership was not associated with maternal outcomes, infants of mothers in Cluster 1 had shorter lengths of stay compared with those in Cluster 4. Hospital setting was a predictor of length of stay and parenting self-efficacy. Findings highlight the relevance of social identity and hospital setting in shaping NICU outcomes and support the need for equity-informed neonatal care.

To develop and evaluate a conceptual framework of the use of fetal myelomeningocele/myeloschisis (fMMC) repair. Exploratory sequential mixed methods study. Midwest Fetal Care Center, Minneapolis, Minnesota. Fetal care experts (n = 7) and health records of patients evaluated for fMMC repair (n = 159). Through an expert roundtable, we developed a conceptual framework for the use of fMMC repair based on Andersen's behavioral model of health service use (qualitative). We selected variables from our conceptual framework that were available in existing health records to examine associations between contextual and individual factors and eligibility for and use of fMMC repair (quantitative). Our conceptual framework (qualitative) included predisposing contextual factors (prenatal health care, community norms), enabling contextual factors (health care/insurance policies, referral patterns, center attributes), predisposing individual factors (demographics, beliefs), and enabling individual factors (finances, eligibility). In the quantitative analysis, we found that very few factors were associated with eligibility or use of fMMC repair, with the exception of private health insurance (p = .01), although we did not measure several contextual factors. Most participants (n = 148, 93%) resided in very low/low maternal vulnerability counties, and we observed no differences between the surgical disposition groups (p = .15). We developed a framework to identify and conceptually relate contextual and individual-level characteristics that may affect the use of fMMC repair. Our conceptual framework may be used by future researchers to fully evaluate the access to and use of fMMC repair.

To implement an interprofessional communication tool before non-emergent cesarean births and evaluate individual nurse cesarean rates for women with low-risk pregnancies. A quality improvement initiative using four Plan-Do-Study-Act cycles over a 6-month period in 2022. U.S. Mid-Atlantic maternity unit with a Level III NICU during the COVID-19 pandemic. Nulliparous women with term singleton pregnancies in which the fetus was in vertex presentation (NTSV) who underwent non-emergent cesareans (N = 868) and their interprofessional clinical teams, including nurses, certified nurse midwives, attending physicians, and resident physicians. Implementation of a validated, adapted communication tool for use by the clinical team before non-emergent cesareans. We added individual nurse cesarean rates for women with NTSV pregnancies to the existing clinical audit and feedback process. We collected compliance data through chart reviews and an Epic report. Rates of compliance with use of the tool and variation in individual nurse cesarean rates for women with NTSV pregnancies. Compliance with use of the tool averaged 62% and peaked at 77% during active education efforts but declined to 33% after implementation. We noted wide variation in individual nurse cesarean rates for women with NTSV pregnancies (0.00%-45.45%) among nurses who managed 10 or more eligible births over 5 months. We identified positive outliers or nurses who consistently had low cesarean rates. Achieving high compliance with the use of an interprofessional communication tool before non-emergent cesareans requires sustained education and engagement. Integrating the communication tool into existing workflows may enhance its long-term effect. The variability in individual nurse cesarean rates that we found suggests a need for further investigation into nursing practices that support physiological birth and reduce unnecessary cesareans.

To examine awareness of the vaginal microbiome and vaginal microbiota transplant, willingness to undergo vaginal microbiota transplant, and factors that influence the decision to undergo the procedure. Cross-sectional descriptive survey study. Online distribution from October 2024 to January 2025. Respondents (N = 210) who self-identified as women (n = 198), men (n = 2), gender nonconforming (n = 14), transgender (n = 3), other (n = 2), and not specified (n = 2) and had vaginas. The survey included questions about patient demographics, gynecologic and pelvic symptoms and conditions, and vaginal microbiota transplantation awareness and willingness. We used descriptive statistics to summarize the quantitative data and conducted conventional content analysis to examine responses to open-ended questions about factors to undergo vaginal microbiota transplantation. Most respondents (n = 176, 83.8%) had not heard of vaginal microbiota transplant. However, more than 50% of respondents were willing or very willing to undergo vaginal microbiota transplantation for each presented indication: prevent yeast infections, bacterial vaginosis, or cytolytic vaginosis (n = 131, 62.4%); reduce risk of sexually transmitted infections (n = 130, 61.9%); alleviate menstrual pain (n = 126, 60.0%); prevent urinary tract infections (n = 126, 60.0%); alleviate vaginal symptoms (n = 120, 57.1%); prevent preterm births (n = 119, 56.7%). We identified five categories from 180 responses about factors that influenced the decision to undergo vaginal microbiota transplantation: Evidence, Procedure Logistics, Health Care Factors, Personal Factors, and Donor Health. Increased awareness about the vaginal microbiome and vaginal microbiota transplantations is necessary. Factors that influence willingness to undergo the procedure should be addressed in designing and implementing this new intervention.

Unrelieved intraoperative pain during cesarean birth is an underrecognized complication with important clinical and psychological implications. Evidence indicates that intraoperative pain during cesarean birth is more common than previously recognized, particularly when measured using patient-reported outcomes rather than procedural proxies. Inadequate pain management has been associated with psychological distress, trauma symptoms, and dissatisfaction with care. Historical patterns that minimized women's pain and disparities related to race and language continue to influence clinical response. In this column, I synthesize the current evidence and clinical guidance to highlight opportunities for improved nursing assessment, communication, and escalation of care, with emphasis on the role of nurses in promoting patient safety and respectful maternity care.

Long-standing mandates in the United States require universal ophthalmic prophylaxis with erythromycin for all neonates, although recent evidence has led to reconsideration of this practice. This intervention was originally adopted to prevent blindness caused by Neisseria gonorrhoeae (gonococcal ophthalmia neonatorum, GON) and Chlamydia trachomatis (chlamydial ophthalmia neonatorum, CON). Today, however, prenatal screening and treatment have rendered such infections rare at birth. Current population data indicate that GON is exceedingly uncommon in the United States and that erythromycin is ineffective at preventing CON. Moreover, issues regarding antimicrobial resistance, medication shortages, and early microbiome disruption call into question the rationale for maintaining this policy raise concerns that question the continued rationale for this policy. In this analysis, we integrate contemporary epidemiologic and policy evidence to support the conclusion that continuing universal prophylaxis provides minimal clinical benefit, exposes newborns to unnecessary antibiotics, and conflicts with modern principles of antibiotic stewardship. Risk-based prevention models already adopted in many high-income countries offer a safer and more evidence-aligned alternative. Nurses are uniquely positioned to lead this transition through patient education, antibiotic stewardship, and advocacy for evidence-based neonatal care.

To explore the factors that influence the implementation of the Association of Women's Health, Obstetric and Neonatal Nurses POST-BIRTH Warning Signs education program. Qualitative focus groups. Online focus groups conducted via Microsoft Teams in the United States. A purposive sample of 23 registered nurses from 17 states who implemented the POST-BIRTH Warning Signs (PBWS) education program. Participants represented a variety of practice settings, including critical access hospitals (n = 14), a freestanding emergency department (n = 1), maternity care deserts (n = 2), high-resource emergency departments (n = 5), and a high-resource obstetric unit (n = 1). We conducted six focus groups and analyzed the data using Krippendorff's method for qualitative content analysis to cluster data units and identify emergent themes. We identified five convergent themes and ranked them in descending order based on the number of participants who described each thematic construct: Mountains to Climb in Achieving PBWS Implementation Success, Getting It Right Before They Go Home, The Cost of Unrecognized Warning Signs, Bridging the Gap Between Emergency Department and Obstetric Divides, and The Forgotten Year. We found that implementing the PBWS education program exposed systemic challenges and presented pathways to progress. Participants highlighted the need for collaboration, timely education, and sustained support to ensure successful implementation. Our findings can guide future implementation and strategies to improve safety after birth in a variety of practice settings.

To increase the percentage of women with severe-range blood pressure during the perinatal period who are treated within 30 min from 25% to at least 50% within 8 weeks. Plan-Do-Study-Act model comprising four 2-week cycles with data-driven tests of change every cycle. A high-volume, community, academic obstetric triage. We conducted interventions with women identified at risk for or diagnosed with hypertensive disorder of pregnancy (N = 182). In addition, we surveyed a convenience sample of women (n = 30) about their understanding of hypertension care and maternity care staff (n = 39) about their knowledge of treatment for hypertensive disorders of pregnancy. We implemented two interventions: standardized screening for hypertensive disorders of pregnancy using a modified preeclampsia early recognition tool and an algorithm-based checklist for effective treatment for hypertensive disorders of pregnancy. We measured use and outcomes through chart review and analyzed data with descriptive statistics. After the intervention, the percentage of women treated within 30 min increased to 97%. Mean medication administration times decreased from 41.4 to 11.2 min (p < .001), which demonstrated a significant improvement in care. Standardized screening and care improved time to treatment among women with hypertensive disorders of pregnancy. This advanced practice nurse-led initiative is adaptable for widespread implementation.