Publications by authors named "Ruth Lebet"

14 Publications

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Behavioral crisis management: A quality improvement pilot for improving teamwork in a primary care pediatric setting.

J Pediatr Nurs 2021 Apr 19;59:151-157. Epub 2021 Apr 19.

University of Pittsburgh School of Nursing 318A Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA. Electronic address:

Introduction: Children with behavioral escalations in the primary care office may pose safety risks to themselves and others. Interprofessional teams utilizing crisis resource management (CRM) skills more successfully manage behavioral crises. The purpose of this quality improvement (QI) pilot project was to improve team performance during a behavioral crisis in pediatric primary care, as well as evaluate learner satisfaction with the curriculum.

Method: We implemented an evidence-based curriculum using simulation and didactic techniques in primary care offices within a pediatric network. Using a one group pre-post design, we evaluated roles, communication, and patient-centered care with the KidSIM Team Performance Scale. Utilizing a post intervention survey, learner feedback was elicited regarding learning environment, facilitators and barriers to learning, skill of facilitator, and usability and applicability of content.

Findings: 101 interprofessional participants attended one of eight educational sessions. KidSIM Team Performance Scale results demonstrated statistically significant improved total team performance in a simulated behavioral crisis (Z = -2.52, p = 0.012). Post simulation evaluation demonstrated positive feedback about the program, content and facilitators.

Discussion: This pilot QI project demonstrated that a curriculum using behavioral simulation scenarios and CRM principles can improve teamwork in an interprofessional primary care office. Additionally, participants overwhelmingly indicated satisfaction with the curriculum.

Application To Practice: Ensuring staff have the appropriate skills to manage behavioral health crises facilitates safer and more effective patient care, enhances patient-centered care and solidifies a positive staff approach in the pediatric ambulatory setting.
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http://dx.doi.org/10.1016/j.pedn.2021.04.010DOI Listing
April 2021

CE: Multisystem Inflammatory Syndrome in Children: A Review.

Am J Nurs 2021 May;121(5):26-37

Kerry Shields, Kristin Atlas, and Jessica Strohm Farber are pediatric critical care NPs at the Children's Hospital of Philadelphia (CHOP). Ruth Lebet is a nurse scientist at CHOP's Center for Pediatric Nursing Research and Evidence-Based Practice. Contact author: Kerry Shields, The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com.

Abstract: The coronavirus disease 2019 (COVID-19) pandemic has impacted the health of children worldwide. Although overall mortality from COVID-19 in children remains low, an associated multisystem inflammatory disorder has emerged. The disorder has been recognized and named multisystem inflammatory syndrome in children (MIS-C) by the World Health Organization and the Centers for Disease Control and Prevention. This comprehensive review describes the epidemiology, pathophysiology, signs and symptoms, other potential diagnoses, and treatments relevant to MIS-C. The review also includes patient and family education and anticipatory guidance, and discusses nursing implications for nurses working in various roles and settings, including direct care, research, and public health.
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http://dx.doi.org/10.1097/01.NAJ.0000749756.12090.63DOI Listing
May 2021

Nurses' Perceptions of Workload Burden in Pediatric Critical Care.

Am J Crit Care 2021 01;30(1):27-35

Martha A. Q. Curley is the Ruth M. Colket Endowed Chair in Pediatric Nursing, Department of Family and Community Health, School of Nursing, University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, and Research Institute, Children's Hospital of Philadelphia.

Background: Quantifying nurses' perceptions of workload burden when managing critically ill patients is essential for designing interventions to ease nurses' workday.

Objectives: To explore pediatric intensive care unit (PICU) nurses' perceptions of their workload when caring for critically ill patients and managing protocolized therapies.

Methods: This study was embedded in a multicenter randomized clinical trial where participants were assigned to receive either lower-target or higher-target glucose control. Nurses from 35 participating PICUs completed a baseline survey containing questions about their perceptions of PICU workload in general. They completed an intervention survey after caring for a study patient. Two workload measurement instruments, the Subjective Workload Assessment Technique (SWAT) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), were embedded in these surveys.

Results: Baseline surveys were completed by 1476 PICU nurses, predominantly female with a bachelor's degree and a median (interquartile range) of 6 (3-11) years of nursing experience and 4 (2-9) years of PICU experience. Most nurses (65%) rated time burden as the most important component of their workload, followed by cognitive (22%) or psychological stress (13%) burden. Work performance was selected most often as contributing to workload, followed by cognitive demand, time pressure, effort, and physical demand. Intervention surveys were completed by 73% of enrolled participants (505 of 693). Nurses managing the lower glucose target group reported higher levels of workload burden as measured by the SWAT (P = .002) and NASA-TLX (P < .001).

Conclusions: This study describes the workload burden perceived by PICU nurses when managing critically ill patients in general and when managing protocolized therapies.
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http://dx.doi.org/10.4037/ajcc2021725DOI Listing
January 2021

Evidence in Hand: Optimizing the Unique Skill Set of a Hospital-Based Center for Nursing Research and Evidence-Based Practice.

J Pediatr Nurs 2021 Jan-Feb;56:60-63. Epub 2020 Nov 10.

Children's Hospital of Philadelphia, Department of Nursing & Clinical Care Services, PA 19104, United States of America; University of Pennsylvania, School of Nursing. PA 19104, United States of America.

This paper describes how, as the COVID-19 pandemic emerged, one hospital-based center for nursing research and evidence-based practice capitalized on its unique skill mix to quickly pivot to provide hospital administrators and staff with timely, relevant evidence regarding the care of patients and families, as well as the protection of direct care providers and all support staff. The products produced by this center, both proactive and in direct response, contributed to clinical operations decision-making and thus, tangibly impacted practice. The positive outcomes described speak not only to the clinical environment, but also to the presence and specialized contributions of a multiprofessional center for nursing research and evidence-based practice in such a way that was not possible prior to COVID-19.
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http://dx.doi.org/10.1016/j.pedn.2020.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655024PMC
February 2021

Developing Leadership Competencies in Midlevel Nurse Leaders: An Innovative Approach.

J Nurs Adm 2020 Sep;50(9):481-488

Author Affiliations: Nurse Manager (Ms Nghe and Ms Hart), Safety Quality Specialist (Ms Ferry), Director of Nursing (Ms Hutchins), and Nurse Scientist (Dr Lebet), Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Pennsylvania; and Lecturer (Dr Lebet), School of Nursing, University of Pennsylvania, Philadelphia.

A pediatric teaching hospital developed a comprehensive leadership training program for midlevel nurse leaders with varying levels of management knowledge and experience. Content was based on American Organization for Nursing Leadership nurse manager competencies and data from a comprehensive needs assessment. Learners identified differentiating between leadership and management, influencing behavior, managing change, and communication as areas of increased confidence. This program is applicable to any hospital with multiple midlevel nurse leaders new to the role.
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http://dx.doi.org/10.1097/NNA.0000000000000920DOI Listing
September 2020

Outcome-Focused Critical Care Orientation Program: From Unit Based to Centralized.

Crit Care Nurse 2020 Aug;40(4):54-64

Ruth Lebet is a nurse-scientist, Department of Pediatric Nursing Research and Evidence-Based Practice, Children's Hospital of Philadelphia, and Program Director for the pediatric and neonatal clinical nurse specialist programs, University of Pennsylvania School of Nursing.

Background: An effective orientation ensures that new nurses are prepared to deliver competent care to patients. In organizations with several critical care units, opportunities exist to achieve standardization of core content applicable to all critical care areas.

Purpose: This quality improvement project, conducted in a large children's hospital with multiple critical care units, was designed to centralize critical care orientation and standardize its content, as well as to measure learning outcomes of the revised program.

Methods: Before initiation of this project, a 2-day critical care orientation class was held regularly for newly hired critical care nurses. Nurses attended this class at different time points in their orientation. Critical care units also held unit-based orientation classes. Nursing professional development specialists and representatives from each critical care unit collaborated to redesign the 2-day critical care orientation class in order to standardize content taught across the organization, increase attendance at the class, and reduce redundancy of topics covered in unit-based classes.

Interventions: The redesigned program included online modules followed by 4-hour sessions that built on the knowledge gained in the modules. The sessions used multiple learner engagement strategies. Learning outcomes were evaluated using pretests and posttests.

Results: Between June 2017 and March 2018, a total of 150 nurses completed the redesigned program. Median posttest scores increased significantly from median pretest scores for each critical care orientation session.

Conclusion: The program achieved the goal of standardizing education and increasing critical care nurses' knowledge.
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http://dx.doi.org/10.4037/ccn2020585DOI Listing
August 2020

Implementation of a Centralized Mechanism to Enrich the Quality of Nursing Research within a Children's Hospital.

J Pediatr Nurs 2020 Jan - Feb;50:131-133. Epub 2019 Nov 20.

Children's Hospital of Philadelphia, Department of Nursing & Clinical Care Services, Philadelphia, PA, United States of America; University of Pennsylvania, Philadelphia, PA, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.pedn.2019.10.010DOI Listing
November 2020

CE: Knowledge of Precision Medicine and Health Care: An Essential Nursing Competency.

Am J Nurs 2019 10;119(10):34-42

Ruth Lebet is a nurse scientist at the Children's Hospital of Philadelphia and program director of the Pediatric and Neonatal Clinical Nurse Specialist Programs at the University of Pennsylvania School of Nursing, Philadelphia. Paule V. Joseph is a Lasker Clinical Research Scholar, tenure-track investigator, and National Institutes of Health (NIH) Distinguished Scholar in the Division of Intramural Research, National Institute of Nursing Research (NINR), NIH, U.S. Department of Health and Human Services, Bethesda, MD. Edwin N. Aroke is an assistant professor in the Nurse Anesthesia Program, University of Alabama at Birmingham School of Nursing. The authors acknowledge Joan Austin, PhD, RN, FAAN, distinguished professor emerita, Indiana University School of Nursing, Indianapolis, and Ann Cashion, PhD, RN, FAAN, NINR scientific director, for their helpful feedback on this manuscript. Contact author: Ruth Lebet, The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. The opinions expressed in this article are those of the authors, who are solely responsible for the interpretation and reporting of the data herein. No statements in this article should be construed as an official recommendation, interpretation, or policy of the NIH, the U.S. government, the University of Pennsylvania, or the University of Alabama at Birmingham.

Advances in genetic and genomic research, combined with the rapid development of new technologies, have reshaped our understanding of health and disease processes, generating what have collectively become known as "omics" sciences. These sciences are now an integral part of health care delivery, with nurses and nurse scientists at the forefront, implementing and adapting genomic technologies in the clinical setting while advancing knowledge in these areas. With the increasing focus on precision medicine and health care, integrating genetic and genomic knowledge has become an essential competency in nursing care, research, and education, as it enables nurses to collaborate effectively with patients in improving their health and well-being.
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http://dx.doi.org/10.1097/01.NAJ.0000586168.93088.3cDOI Listing
October 2019

Face and content validity of variables associated with the difficult-to-sedate child in the paediatric intensive care unit: A survey of paediatric critical care clinicians.

Aust Crit Care 2018 05 19;31(3):167-173. Epub 2018 Mar 19.

University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, USA; Children's Hospital of Philadelphia Research Institute, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA. Electronic address:

Background: Clinicians recognise that some critically ill children are difficult-to-sedate. It may be possible to identify this clinical phenotype for sedation response using statistical modelling techniques adopted from machine learning. This requires identification of a finite number of variables to include in the statistical model.

Objective: To establish face and content validity for 17 candidate variables identified in the international literature as characteristic of the difficult-to-sedate child phenotype.

Methods: Paediatric critical care clinicians rated the relevance of 17 variables characterising the difficult-to-sedate child using a four-point scale ranging from not (1) to highly relevant (4). Face and content validity of these variables were assessed by calculating a mean score for each item and computing an item-level content validity index. Items with a mean score >1 were rated as having adequate face validity. An item-level content validity index ≥0.70 indicated good to excellent content validity.

Setting And Participants: Web-based survey emailed to members of the Pediatric Acute Lung Injury and Sepsis Investigators Network or the Society of Critical Care Medicine Pediatric Sedation Study Group.

Results: Of 411 possible respondents, 121 useable surveys were returned for a response rate of 29%. All items had a mean score >1, indicating adequate face validity. Ten of 17 items scored an item-level content validity index ≥0.70. The highest scoring items were requiring three or more sedation classes simultaneously, daily modal sedation score indicating agitation, sedation score indicating agitation for 2 consecutive hours, receiving sedatives at a dose >90th percentile of the usual starting dose, and receiving intermittent paralytic doses for sedation.

Conclusions: Computation of an item-level content validity index validated variables to include in statistical modelling of the difficult-to-sedate phenotype. The results indicate consensus among paediatric critical care clinicians that the majority of candidate variables identified through literature review are characteristic of the difficult-to-sedate child.
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http://dx.doi.org/10.1016/j.aucc.2017.12.091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5936660PMC
May 2018

Maintaining Interrater Agreement of Core Assessment Instruments in a Multisite Randomized Controlled Clinical Trial: The Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Trial.

Nurs Res 2017 Jul/Aug;66(4):323-329

Ruth Lebet, MSN, CCNS-P, is Lecturer, School of Nursing, University of Pennsylvania, Philadelphia. Jennifer Hayakawa, DNP, PCNS-BC, CNRN, CCRN, is Clinical Nurse Specialist, Pediatric Intensive Care Unit, CHOC Children's Hospital, Orange, California, and Clinical Faculty, Western University of Health Sciences, Pomona, California. Tracy B. Chamblee, PhD, APRN, PCNS-BC, is Clinical Nurse Specialist, Pediatric Intensive Care Unit, Children's Medical Center Dallas, Texas. Joana A. Tala, MD, is Research Coordinator, Pediatric Intensive Care Unit, Yale New Haven Hospital/Yale University, Connecticut. Nakul Singh, ScM, is Biostatistician, Department of Cardiology, Boston Children's Hospital, Massachusetts. David Wypij, PhD, is Senior Biostatistician, Department of Cardiology, Boston Children's Hospital; Associate Professor, Department of Pediatrics, Harvard Medical School; and Senior Lecturer, Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. Martha A. Q. Curley, RN, PhD, FAAN, is Ellen and Robert Kapito Professor in Nursing Science, School of Nursing, University of Pennsylvania, Philadelphia, and Nurse Scientist, Boston Children's Hospital, Massachusetts.

Background: RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) was a cluster randomized clinical trial evaluating a sedation strategy in children 2 weeks to <18 years of age with acute respiratory failure supported on mechanical ventilation. A total of 31 U.S. pediatric intensive care units (PICUs) participated in the trial. Staff nurse rater agreement on measures used to assess a critical component of treatment fidelity was essential throughout the 4-year data collection period.

Objective: The purpose of the study is to describe the method of establishing and maintaining interrater agreement (IRA) of two core clinical assessment instruments over the course of the clinical trial.

Methods: IRA cycles were carried out at all control and intervention sites and included a minimum of five measurements of the State Behavioral Scale (SBS) and Withdrawal Assessment Tool-Version 1 (WAT-1). Glasgow Coma Scale scores were also obtained. PICUs demonstrating <80% agreement repeated their IRA cycle. Fleiss's kappa coefficient was used to assess IRA.

Results: Repeated IRA cycles were required for 8% of 226 SBS cycles and 2% of 222 WAT-1 cycles. Fleiss's kappa coefficients from more than 1,350 paired assessments were .86 for SBS and .92 for WAT-1, demonstrating strong agreement and similar to .91 for the Glasgow Coma Scale. There was no difference in Fleiss's kappa for any of the instruments based on unit size or timing of assessment (earlier or later in the study). For SBS scores, Fleiss's kappa was significantly different in larger and smaller PICUs (.82 vs. .92, p = .003); however, Fleiss's kappa for both groups indicated excellent agreement.

Conclusion: Monitoring measurement reliability is an essential step in ensuring treatment fidelity and, thus, the validity of study results. Standardization on the use of these core assessment instruments among participating sites was achieved and maintained throughout the trial.
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http://dx.doi.org/10.1097/NNR.0000000000000224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5488692PMC
July 2017

Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial.

J Pediatr 2017 05 2;184:204-208.e1. Epub 2017 Mar 2.

Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA; Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Critical Care and Cardiovascular Nursing, Boston Children's Hospital, Boston, MA.

Objective: To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their child's participation in a multisite pediatric critical care clinical trial.

Study Design: We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31-center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent.

Result: Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non-Hispanic White (White), non-Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56-2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10-1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37-3.36, P < .001).

Conclusions: Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their child's participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings.

Trial Registration: ClinicalTrials.gov: NCT00814099.
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http://dx.doi.org/10.1016/j.jpeds.2017.02.006DOI Listing
May 2017

Toward a more perfect (European) union*.

Pediatr Crit Care Med 2014 Jun;15(5):500-2

University of Pennsylvania School of Nursing Philadelphia, PA *See also p. e206.

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http://dx.doi.org/10.1097/PCC.0000000000000110DOI Listing
June 2014

Asking for parents' permission to enroll their child into a clinical trial: best practices.

Am J Crit Care 2013 Jul;22(4):351-6

University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania 19104-4217, USA.

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http://dx.doi.org/10.4037/ajcc2013352DOI Listing
July 2013

Comparison of arm and calf automatic noninvasive blood pressures in pediatric intensive care patients.

J Pediatr Nurs 2011 Feb 22;26(1):3-12. Epub 2010 Jan 22.

School of Nursing, University of Delaware, Newark, DE, USA.

The purpose of this study was to compare upper arm and calf automatic blood pressures (BPs) in a convenience sample of 221 children, ages 1 to 8 years, admitted to a pediatric intensive care unit of a 180-bed teaching hospital in the Mid-Atlantic region of the United States. Subjects were positioned in bed, with the head of bed elevated 30° and extremities resting on the bed. BP cuff size was based on arm and calf circumferences. BPs were measured simultaneously using bedside and portable Spacelabs monitors. Calf BPs were greater than arm BPs in approximately 73% of the sample. Paired t tests show statistically significant differences for systolic BPs and mean arterial pressures. Influence of demographics, agitation levels, medical diagnoses, and current medications was explored. Calf and arm BPs were not interchangeable in acutely ill children, ages 1 to 8 years.
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http://dx.doi.org/10.1016/j.pedn.2009.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053079PMC
February 2011