Moral distress in the neonatal intensive care unit: caregiver's experience

Professional Guidelines for the Care of Extremely Premature Neonates: Clinical Reasoning versus Ethical Theory

AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international guidelines by Guillen et al. found considerable variability between statements' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this "ethical gray zone." How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25 guidelines. Ten guidelines lacked any ethical theme. Guidelines with an identified ethical theme were more likely to recommend comfort care than guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the "gray zone" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.

Systematic scoping review on moral distress among physicians

BACKGROUND

Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians.

METHODS

A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows.

RESULTS

A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions.

CONCLUSIONS

Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.

A systematic scoping review moral distress amongst medical students

BACKGROUND

Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students.

METHODS

The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion.

RESULTS

Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD.

CONCLUSIONS

MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

Longitudinal medical needs for periviable NICU survivors

OBJECTIVE

To evaluate the technologies required, medications needed, and early intervention services utilized from discharge to 12 months post-discharge for periviable infants (22 0/7 to 24 6/7 weeks gestational age) followed in a comprehensive NICU follow-up clinic.

STUDY DESIGN

Information regarding medication use, technology requirement, and early intervention services was collected prospectively at one, six, and twelve months after discharge. Neurodevelopmental assessment was completed at 12 months corrected age.

RESULT

69 periviable infants were actively treated and survived to discharge during the study period. 54 infants were enrolled and followed in the comprehensive NICU follow-up clinic. Use of technology and prescribed medications decreased with a 46% reduction of infants requiring ≥1 technology device (74.1% vs. 40.4%, p < 0.01) and 64% reduction in infants requiring ≥1 medication (88.9% vs 31.9%, p < 0.01) 12 months post discharge. There was an increase in early intervention services with 83% of infants receiving services by 12 months post discharge.

CONCLUSION

Technology and medication requirements were high at discharge but notably decreased in the first year after discharge concurrent with increased enrollment in early interventional services. Many periviable infants survive without severe short-term developmental delays.

Moral Distress and Burnout in NICU Nurses

The objectives of this study were to factor analyze the Moral Distress Scale-Revised (MDS-R) in NICU nurses and to evaluate the relationships among dimensions of the MDS-R and the demoralization, exhaustion, and loss of motive dimensions of the Burnout Measure (BM). A total of 142 NICU nurses completed modified pen-and-paper versions of the MDS-R and BM. Exploratory and confirmatory factor analyses showed that the MDS-R-14 was a relatively good fit for the data. The compromised care dimension predicted BM demoralization (β = 0.24) and exhaustion (β = 0.22), the futile care dimension predicted BM exhaustion (β = 0.18), and the untruthful care dimension predicted BM demoralization (β = .25). Strategies to mitigate moral distress and resulting burnout in NICU nurses should address futile care, compromised care, and untruthful care.

Moral Distress and Perception of Futile Care among Nurses of Neonatal Care Units

Objectives:

Moral distress (MD), which is affected by several factors such as futile care provision and is considered the cause of adverse effects such as job dissatisfaction and decreased care quality, is a new concept attracting increasing academic interest. This study aims to assess the correlation between nurses’ perception of futile care and MD in neonatal care units.

Material and Methods:

This descriptive-correlational study was carried out among 115 nurses working in the neonatal intensive care units and neonatal special care units of two hospitals in West Azerbaijan Province during 2020. A demographic information form, the 21-item MD-Pediatric version scale, and the 17-item perception of futile care questionnaire were used to collect data and analysed using SPSS 16 software.

Results:

The results confirmed the direct correlation between MD and the perception of futile care. In addition, MD and the nurses’ perceptions of futile care were estimated to be moderate.

Conclusion:

The results of this study provide evidence to emphasise the need for further studies to investigate other causes of MD in neonatal units and find the solutions to make the work environment more ethical. Furthermore, the results provide the platform needed for hospital and university managers to make the necessary decisions and create the required changes in the educational curriculum of nursing students and provide the appropriate courses for neonatal unit nurses to improve their ability to cope with the MD caused by providing futile care.

Moral Sensitivity and Emotional Intelligence in Intensive Care Unit Nurses

Moral sensitivity helps individuals resolve moral dilemmas as a precursor to moral decision-making. Intensive care unit (ICU) nurses are at high risk for encountering moral dilemmas and should have the moral sensitivity to recognize moral issues. The activities of ICU nurses in moral decision-making are guided by moral sensitivity but are also based on emotional intelligence (EI). EI, be recognized as an integral part of moral sensitivity with long-standing theoretical foundations. It is necessary to explicate the true role of EI in moral sensitivity through empirical research. To measure the level of moral sensitivity of ICU nurses and determine the relationship between moral sensitivity and EI. We recruited 467 ICU nurses of ten hospitals from March to June 2021 in Hunan Province, China for a cross-sectional questionnaire survey. The moral sensitivity and EI were measured using the Moral Sensitivity Questionnaire-Revised Version into Chinese (MSQ-R-CV) and the Wong and Law Emotional Intelligence Scale-Version into Chinese (WLEIS-C). A self-report questionnaire covered sociodemographic characteristics. The average moral sensitivity score of ICU nurses was 39.41 ± 7.21. The average EI score was significantly positively correlated with the moral sensitivity score (p < 0.001). This study demonstrated that the moral sensitivities of ICU nurses were at medium levels. EI of ICU nurses can indeed affect their moral sensitivity, and the impact of each element of EI should be clarified for practical application.

Developing a digitally innovative ethics and professionalism curriculum for neonatal-perinatal medicine fellows: a 3-year multicenter pilot study

OBJECTIVES

The purpose of this study was to develop and regionally pilot a digitally innovative curriculum in ethics and professionalism in neonatology and study the effects on trainee knowledge and confidence.

STUDY DESIGN

We developed 13 modules in ethics for neonatology fellows and piloted them at three academic institutions utilizing a flipped-classroom approach. Baseline surveys in ethics knowledge and confidence in approaching ethical dilemmas were compared with repeat surveys after curriculum completion. Pre- and post-tests were also administered for all 13 modules.

RESULTS

Forty-four of 49 eligible fellows participated (90% response rate). Pre/post comparisons demonstrated significant improvements in overall knowledge and in 8/13 modules, as well as improvement in overall confidence and individually when navigating 16/22 ethical dilemmas.

CONCLUSIONS

After completing this curriculum, participants' knowledge scores and reported confidence in approaching ethical challenges significantly improved. Future steps include assessing the effects of this innovative curriculum via an ongoing international pilot.

Redirecting Care: Compassionate Management of the Sick or Preterm Neonate at the End of Life

The primary moral commitment of medical care has traditionally been based on a belief in the intrinsic value and significance of human life and a desire to protect the most vulnerable from harm. In this respect, the care of newborn infants who are at the border of viability is no different. Despite the intrinsic value of the life of every newborn, all agree that there is no moral duty of doctors to provide every possible treatment where the prognosis is hopeless. Instead, every action and treatment should be orientated towards the best interests of the individual child and towards the minimisation of serious harm. Decisions about the withholding or withdrawal of life-supportive treatment should be made collaboratively between professionals and parents, with discussion starting prior to delivery wherever possible. The goals of neonatal palliative care are to prevent or minimise pain and distressing symptoms and to maximise the opportunity for private, loving interaction between the dying baby and his or her parents and the wider family. Physical contact, gentle stroking, cuddles and tender loving care are of central importance for the dying baby. At the same time, we must provide psychological support for parents and family as they go through the profound and painful life experience of accompanying their baby to death. To enable a baby to die well, pain-free and in the arms of loving parents and carers is not a failure but a triumph of neonatal care.

Whom are we seeking to protect? Extremely preterm babies and moral distress

Advances in perinatal care bring with them ethical challenges and difficult questions. When should we provide life-sustaining interventions, and who should decide? Particularly at the edges of viability, some clinicians may feel required to provide a level of care that they believe is not in the patient's interests, resulting in moral distress. This article will discuss the complex nature of moral distress arising during the care of extremely preterm babies. It will describe the challenges and cognitive biases present when contemplating potential harms to the baby and recognize the possible costs to both healthcare provider and baby when moral distress arises. Both clinicians caring for extremely preterm babies and the families themselves can experience moral distress. This article argues that for clinicians, recognizing the range of possible sources of moral distress is vital in order to appropriately address moral distress. Moral distress may arise from a desire to protect the baby, but also from an impulse to protect oneself from the emotional burdens of care. Addressing moral distress requires reflection on the factual beliefs, experiences and personal values which lie behind the distress, both within oneself and in discussion with colleagues. Moral distress indicates that a situation is ethically challenging, but it does not necessarily mean that a wrong decision has been made.

Moral distress among Iranian neonatal intensive care units' health care providers: a multi-center cross sectional study

Due to the unique nature of the neonatal intensive care unit (NICU) and its moral distress, this study aimed to investigate moral distress in the NICU. This cross-sectional study was conducted on 234 physicians and nurses working in the neonatal wards of eight hospitals. The Corley’s Moral Distress Scale was used to collect data. Findings showed that 25 of the participants were physicians and 209 were nurses. The intensity and frequency of distress among physicians and nurses were assessed as moderate. The mean intensity and frequency of moral distress among nurses and physicians were 48.3%, 41.5% and 46.46%, 15.62% respectively. The results showed that the mean intensity and frequency of distress were higher, however not significantly, among nurses. The intensity and frequency of moral distress had a statistically significant and direct correlation with the intention to leave and the number of staff in each working shift among the nurses. Moral distress in the NICU practitioners was moderate, so addressing this issue and trying to alleviate it was important. Identifying the causes behind moral distress can help adopt appropriate measures to prevent and reduce them.

An evaluation of moral distress among healthcare workers during COVID-19 pandemic in Palestine

BACKGROUND

Moral distress among healthcare workers (HCWs) is considered a serious issue in all aspects of healthcare divisions, which needs an urgent intervention.

AIMS

The study aims at evaluating moral distress among HCWs which will help the healthcare management and decision-makers in hospitals and health centers to act in a comprehensiveness and effective way by reinforcing moral thinking and behavior in selected coronavirus (COVID-19) quarantine centers across Palestine.

METHODS

Ninety-four HCWs were selected by convenience sampling method. Data were collected using revised Corley's Standard Moral Distress (MD) Scale and analyzed using SPSS software version 23.

RESULTS

The mean score of MD for HCWs was low (1.24 ± 0.71). The mean score of MD severity was moderate (1.4 ± 0.93). The severity and frequency of MD in HCWs had a significant reverse relationship with years of experience, number of children of worker, and duration of work with COVID-19 patients.

CONCLUSION

It is important to create a professional psychological support system for HCWs to decrease MD when facing moral issues.

Relationship Between Moral Distress and Intent to Leave a Position Among Neonatal Intensive Care Nurses

BACKGROUND

The phenomenon of moral distress is prevalent in the literature, but little is known about the experiences of nurses working in the neonatal intensive care unit (NICU). In addition, a paucity of literature exists exploring the relationship between moral distress and intent to leave a position in NICU nurses.

PURPOSE

To explore the phenomenon of moral distress in NICU nurses using the Measure of Moral Distress for Health Care Professionals (MMD-HP) survey.

METHODS

A cross-sectional, descriptive, correlational study was conducted nationally via an electronic survey distributed to NICU nurses who are members of National Association of Neonatal Nurses (NANN). Participants were asked to electronically complete the MMD-HP survey between March 27 and April 8, 2020.

FINDINGS

A total of 75 NICU nurses completed the survey, and 65 surveys were included for data analysis. Five situations from the survey had a composite MMD-HP score of more than 400. Results indicated that 41.5% of the NICU nurses surveyed considered leaving a clinical position due to moral distress, and 23.1% of the nurses surveyed left a position due to moral distress.

IMPLICATIONS

for Practice: NICU nurses experiencing high MMD-HP scores are more likely to leave a position. Further research is needed to develop strategies useful in mitigating moral distress in and prevent attrition of NICU nurses.

IMPLICATIONS FOR RESEARCH

Many NICU nurses experiencing high levels of moral distress have left positions or are considering leaving a clinical position. Longitudinal interventional studies are vital to understand, prevent, and address the root causes of moral distress experienced by NICU nurses.

Physician Perceptions on Quality of Life and Resuscitation Preferences for Extremely Early Newborns

OBJECTIVE

 The study aimed to explore physician views on whether extremely early newborns will have an acceptable quality of life (QOL), and if these views are associated with physician resuscitation preferences.

STUDY DESIGN

 We performed a cross-sectional survey of neonatologists and maternal fetal medicine (MFM) attendings, fellows, and residents at four U.S. medical centers exploring physician views on future QOL of extremely early newborns and physician resuscitation preferences. Mixed-effects logistic regression models examined association of perceived QOL and resuscitation preferences when adjusting for specialty, level of training, gender, and experience with ex-premature infants.

RESULTS

 A total of 254 of 544 (47%) physicians were responded. A minority of physicians had interacted with surviving extremely early newborns when they were ≥3 years old (23% of physicians in pediatrics/neonatology and 6% in obstetrics/MFM). The majority of physicians did not believe an extremely early newborn would have an acceptable QOL at the earliest gestational ages (11% at 22 and 23% at 23 weeks). The majority of physicians (73%) believed that having an extremely preterm infant would have negative effects on the family's QOL. Mixed-effects logistic regression models (odds ratio [OR], 95% confidence interval [CI]) revealed that physicians who believed infants would have an acceptable QOL were less likely to offer comfort care only at 22 (OR: 0.19, 95% CI: 0.05-0.65, p < 0.01) and 23 weeks (OR: 0.24, 95% CI: 0.07-0.78, p < 0.02). They were also more likely to offer active treatment only at 24 weeks (OR: 9.66, 95% CI: 2.56-38.87, p < 0.01) and 25 weeks (OR: 19.51, 95% CI: 3.33-126.72, p < 0.01).

CONCLUSION

 Physician views of extremely early newborns' future QOL correlated with self-reported resuscitation preferences. Residents and obstetric physicians reported more pessimistic views on QOL.

KEY POINTS

· Views of QOL varied by specialty and level of training.. · Contact with former extremely early newborns was limited.. · QOL views were associated with preferred resuscitation practices..

Evaluation of NICU Healthcare Providers' Experience of Patient Ethics and Communication Excellence (PEACE) Rounds

BACKGROUND

Neonatal intensive care (NICU) providers may experience distress due to controversial orders or the close relationships they form with neonates' families. A "Patient Ethics and Communications Excellence [PEACE] Rounds" intervention developed at Indiana University proved to significantly relieve distress by facilitating interdisciplinary discussions of clinically and ethically challenging issues associated with pediatric intensive care (PICU) patient care. NICU healthcare providers face similar challenges and will benefit from understanding the potential efficacy of PEACE Rounds in this setting.

PURPOSE

This study describes the experiences of NICU healthcare providers who participate in PEACE Rounds and evaluates their perceptions of how it affects their distress levels, contributes to interdisciplinary collaboration, and influences their understanding of ethical decision-making.

METHODS

Researchers conducted semi-structured interviews with 24 intervention participants, observed 12 interventions, facilitated a validation focus group, and performed a constructionist thematic analysis and triangulation based on data from transcribed recordings.

FINDINGS

PEACE Rounds improved interdisciplinary communication and collaboration and demonstrated restorative value through the benefits of voice and collective support. The intervention may reduce, but not replace, the need for formal ethics consultations.

IMPLICATIONS FOR PRACTICE

PEACE Rounds may potentially improve interdisciplinary communications and collaboration, relieve employee distress, and reduce ethics consultations.

IMPLICATIONS FOR RESEARCH

Studies of PEACE Rounds undertaken in other clinical settings, and facilitated by a nurse educator, will help assess the potential benefits of greater reach and access and the efficacy of less structured ethics discussions.

The Association between Moral Distress and Moral Courage in Nurses: A Cross-Sectional Study in Iran

Background:

Moral distress and moral courage among healthcare professionals have received considerable attention in recent years. However, there is a paucity of studies investigating these topics among nurses. Thus, the present study aimed to evaluate the association between moral distress and moral courage among nurses in an Iranian sample population.

Materials and Methods:

The present cross-sectional study was conducted during February–December 2018. Corley's Moral Distress (MDS-R) and Sekerka's moral courage scales were used to collect the data. MDS-R is a 21-items scale which includes frequency and intensity ranges from 0 (never) to 4 (very frequently) and 0 (none) to 4 (great extent), respectively. In addition, the moral courage scale contains 15 items ranging from “never true” (1 point) to “always true” (7 points). In total, 225 eligible nurses were entered into this study. Finally, SPSS-16 was used for statistical analysis at the α = 0.05 level.

Results:

The mean scores of the frequency and intensity of moral distress and moral courage were 45.41 (95% CI = 43.37-47.45), 44.24 (95% CI = 42.98-45.42), and 59.63 (95% CI = 58.50-60.87), respectively. Eventually, a significant relationship was found between the moral courage and frequency of moral distress (r = 0.46, p < 0.001) and the intensity of moral distress (r = 0.73, p < 0.001).

Conclusions:

In general, encouraging healthcare managers and administrators is considered as crucial for developing supportive structures and highly sensitive management which promotes moral courage while reducing moral distress in nurses' work setting.

Exploring implicit bias in the perceived consequences of prematurity amongst health care providers in North Queensland - a constructivist grounded theory study

Background

A study was done to explore the attitudes of relevant health care professionals (HCP) towards the provision of intensive care for periviable and extremely premature babies.

Methods/design

Applying a constructivist grounded theory methodology, HCP were interviewed about their attitudes towards the provision of resuscitation and intensive care for extremely premature babies. These babies are at increased risk of death and neurodisability when compared to babies of older gestations. Participants included HCP of varying disciplines at a large tertiary centre, a regional centre and a remote centre. Staff with a wide range of experience were interviewed.

Results

Six categories of i) who decides, ii) culture and context of families, iii) the life ahead, iv) to treat a bit or not at all, v) following guidelines and vi) information sharing, emerged. Role specific implicit bias was found as a theoretical construct, which depended on the period for which care was provided relative to the delivery of the baby. This implicit bias is an underlying cause for the negativity seen towards extreme prematurity and is presented in this paper. HCP caring for women prior to delivery have a bias towards healthy term babies that involves overestimation of the risks of extreme prematurity, while neonatal staff were biased towards suffering in the neonatal period and paediatricians recognise positivity of outcomes regardless of neurological status of the child. The implicit bias found may explain negativity towards intensive care of periviable neonates.

Conclusion

Understanding the presence and origins of role specific implicit bias may enable HCP to work together to improve care for parents preparing for the delivery of extremely premature babies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03539-5.

Moral Distress in Pediatric Residents and Pediatric Hospitalists: Sources and Association With Burnout

OBJECTIVE

Moral distress is increasingly identified as a major problem affecting healthcare professionals, but it is poorly characterized among pediatricians. Our objective was to assess the sources of moral distress in residents and pediatric hospitalist attendings and to examine the association of moral distress with reported burnout.

METHODS

Cross-sectional survey from January through March 2019 of pediatric residents and hospital medicine attending physicians affiliated with 4 free-standing children's hospitals. Moral distress was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Burnout was measured using 2 items adapted from the Maslach Burnout Inventory.

RESULTS

Respondents included 288 of 541 eligible pediatric residents (response rate: 53%) and 118 of 168 pediatric hospitalists (response rate: 70%; total response rate: 57%). The mean MMD-HP composite score was 93.4 (SD = 42.5). Residents reported significantly higher frequency scores (residents: M = 38.5 vs. hospitalists: M = 33.3; difference: 5.2, 95% confidence interval [CI], 2.9-7.5) and composite scores (residents: M = 97.6 vs hospitalists: M = 83.0; difference:14.6, 95% CI, 5.7-23.5) than hospitalists. The most frequent source of moral distress was "having excessive documentation requirements that compromise patient care," and the most intense source of moral distress was "be[ing] required to work with abusive patients/family members who are compromising quality of care." Significantly higher mean MMD-HP composite scores were observed among participants reporting that they felt burned out at least once per week (M= 114.6 vs M= 82.3; difference: 32.3, 95% CI, 23.5-41.2).

CONCLUSIONS

Pediatric residents and hospitalists report experiencing moral distress from a variety of patient-, team-, and system-level sources, and this distress is associated with burnout.

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Moral distress is prevalent in the neonatal intensive care unit (NICU), where decisions regarding end-of-life care, periviable resuscitation, and medical futility are common. Due to its origins in the nursing literature, moral distress has primarily been reported among bedside nurses in relation to the hierarchy of the medical team. However, it is increasingly recognized that moral distress may exist in different forms than initially described and that healthcare professions outside of nursing experience it. Advances in medical technology have allowed the smallest, sickest neonates to survive. The treatment for critically ill infants is no longer simply limited by the capability of medical technology but also by moral and ethical boundaries of what is right for a given child and family. Shared decision-making and the zone of parental discretion can inform and challenge the medical team to balance the complexities of patient autonomy against harm and suffering. Limited ability to prognosticate and uncertainty in outcomes add to the challenges faced with ethical dilemmas. While this does not necessarily equate to moral distress, subjective views of quality of life and personal values in these situations can lead to moral distress if the plans of care and the validity of each path are not fully explored. Differences in opinions and approaches between members of the medical team can strain relationships and affect each individual differently. It is unclear how the various types of moral distress uniquely impact each profession and their role in the distinctively challenging decisions made in the NICU environment. The purpose of this review is to describe moral distress and the situations that give rise to it in the NICU, ways in which various members of the medical team experience it, how it impacts care delivery, and approaches to address it.

Pediatric Program Leadership's Contribution Toward Resident Wellness

BACKGROUND

Residency program leaders are required to support resident well-being, but often they do not receive training in how to do so.

OBJECTIVE

To determine frequency in which program leadership provides support for resident well-being, comfort in supporting resident well-being, and factors associated with need for additional training in supporting resident well-being.

METHODS

National cross-sectional web-based survey in June 2015 of pediatric program directors, associate program directors, and coordinators about their experiences supporting resident well-being. Univariate and bivariate descriptive statistics compared responses between groups. Generalized linear modeling, adjusting for program region, size, program leadership role, and number of years in role determined factors associated with need for additional training.

RESULTS

The response rate was 39.3% (322/820). Most respondents strongly agreed that supporting resident well-being is an important part of their role, but few reported supporting resident well-being as part of their job description. Most reported supporting residents' clinical, personal, and health issues at least annually, and in some cases weekly, with 72% spending >10%of their time on resident well-being. Most program leaders desired more training. After adjusting for level of comfort in dealing with resident well-being issues, program leaders more frequently exposed to resident well-being issues were more likely to desire additional training (P < .02).

CONCLUSIONS

Program leaders spend a significant amount of time supporting resident well-being. Although they think that supporting resident well-being is an important part of their job, opportunities exist for developing program leaders through including resident wellness on job descriptions and training program leaders how to support resident well-being.

Navigating the Dangerous Terrain of Moral Distress: Understanding Response Patterns in the NICU

Moral distress is a well-recognized and ubiquitous aspect of health care professional practice in the neonatal intensive care unit (NICU) context. We used interpretive description methodology to guide a critical exploration of the dynamics of moral distress experience as reflected in the accounts of 28 health care professionals working in this setting. We learned about the kinds of clinical scenarios which triggered distressing experiences, and that the organizational and relational context of clinical work constituted a complex and dynamic working environment that profoundly affected both the individual and the collective experiences with moral distress in these situations. These findings shed light on possibilities for supporting NICU practitioners and developing the collaborative team cultures that may reduce the risk of unresolved effects of moral distress to the benefit of patients as well as the professionals who care for them.

Survey highlights the need for specific interventions to reduce frequent conflicts between healthcare professionals providing paediatric end-of-life care

AIMS

This study explored how paediatric healthcare professionals experienced and coped with end-of-life conflicts and identified how to improve coping strategies.

METHODS

A questionnaire was distributed to all 2300 professionals at a paediatric university hospital, covering the frequency of end-of-life conflicts, participants, contributing factors, resolution strategies, outcomes and the usefulness of specific institutional coping strategies.

RESULTS

Of the 946 professionals (41%) who responded, 466 had witnessed or participated in paediatric end-of-life discussions: 73% said these had led to conflict, more frequently between professionals (58%) than between professionals and parents (33%). Frequent factors included professionals' rotations, unprepared parents, emotional load, unrealistic parental expectations, differences in values and beliefs, parents' fear of hastening death, precipitated situations and uncertain prognosis. Discussions with patients and parents and between professionals were the most frequently used coping strategies. Conflicts were frequently resolved by the time of death. Professionals mainly supported designating one principal physician and nurse for each patient, two-step interdisciplinary meetings - between professionals then with parents - postdeath ethics meetings, bereavement follow-up protocols and early consultations with paediatric palliative care and clinical ethics services.

CONCLUSION

End-of-life conflicts were frequent and predominantly occurred between healthcare professionals. Specific interventions could target most of the contributing factors.

[Bioethics in end-of-life decisions in neonatology: Unresolved issues]

This document is the result of previous work carried out by different expert groups and submitted to multidisciplinary debate at a Conference about controversial, deficient, or new aspects in the field of neonatal palliative care, such as: 1) the deliberative decision-making process, 2) hospital and domiciliary palliative care, 3) donation after controlled cardiac death, and 4) moral stress in professionals. The most relevant conclusions were: the need to instruct professionals in bioethics and in the deliberative method to facilitate thorough and reasonable decision-making; the lack of development in the field of perinatal palliative care and domiciliary palliative care in hospitals that attend newborns; the need to provide neonatal units with resources that help train professionals in communication skills and in the management of moral distress, as well as delineate operational procedure and guidelines for neonatal organ donation.

Neonatal nurses' response to a hypothetical premature birth situation: What if it was my baby?

BACKGROUND:

Evolving technology and scientific advancement have increased the chances of survival of the extremely premature baby; however, such survival can be associated with some severe long-term morbidities.

RESEARCH QUESTION:

The research investigates the caregiving and ethical dilemmas faced by neonatal nurses when caring for extremely premature babies (defined as ≤24 weeks' gestation). This article explores the issues arising for neonatal nurses when they considered the philosophical question of 'what if it was me and my baby', or what they believed they would do in the hypothetical situation of going into premature labour and delivering an extremely premature baby.

PARTICIPANTS:

Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia.

ETHICAL CONSIDERATIONS:

Relevant ethical approvals have been obtained by the researchers.

FINDINGS:

A qualitative approach was used to analyse the data. The theme 'imagined futures' was generated which comprised three sub-themes: 'choice is important', 'not subjecting their own baby to treatment' and 'nurses and outcome predictions'. The results offer an important and unique understanding into the perceptions of nursing staff who care for extremely premature babies and their family, see them go home and witness their evolving outcomes. The results show that previous clinical and personal experiences led the nurses in the study to choose to have the belief that if in a similar situation, they would choose not to have their own baby resuscitated and subjected to the very treatment that they provide to other babies.

CONCLUSION:

The theme 'imagined futures' offers an overall understanding of how neonatal nurses imagine what the life of the extremely premature baby and his or her family will be like after discharge from neonatal intensive care. The nurses' past experience has led them to believe that they would not want this life for themselves and their baby, if they were to deliver at 24 weeks' gestation or less.

Moral distress within neonatal and paediatric intensive care units: a systematic review

OBJECTIVE

To review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs).

DESIGN

Pubmed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus were searched using the terms neonat*, infant*, pediatric*, prematur* or preterm AND (moral distress OR moral responsibility OR moral dilemma OR conscience OR ethical confrontation) AND intensive care.

RESULTS

13 studies on moral distress published between January 1985 and March 2015 met our inclusion criteria. Fewer than half of those studies (6) were multidisciplinary, with a predominance of nursing staff responses across all studies. The most common themes identified were overly 'burdensome' and disproportionate use of technology perceived not to be in a patient's best interest, and powerlessness to act. Concepts of moral distress are expressed differently within nursing and medical literature. In nursing literature, nurses are often portrayed as victims, with physicians seen as the perpetrators instigating 'aggressive care'. Within medical literature moral distress is described in terms of dilemmas or ethical confrontations.

CONCLUSIONS

Moral distress affects the care of patients in the NICU and PICU. Empirical data on multidisciplinary populations remain sparse, with inconsistent definitions and predominantly small sample sizes limiting generalisability of studies. Longitudinal data reflecting the views of all stakeholders, including parents, are required.

Psychometric evaluation of the Moral Distress Scale–Revised among Iranian Nurses

Background:

Experiencing moral distress is traumatic for nurses. Ignoring moral distress can lead to job dissatisfaction, improper handling in the care of patients, or even leaving the job. Thus, it is crucial to use valid and reliable instruments to measure moral distress.

Objective:

The purpose of this study was to determine the reliability and the validity of the Persian version of the Moral Distress Scale–Revised among a sample of Iranian nurses.

Research design:

In this methodological study, 310 nurses were recruited from all hospitals affiliated with the Qazvin University of Medical Sciences from February 2014 to April 2015. Data were collected using a demographic questionnaire and the Moral Distress Scale–Revised. The construct validity of the Moral Distress Scale–Revised was evaluated using principal component analysis and confirmatory factor analysis. Internal consistency reliability was assessed with Cronbach’s alpha.

Ethical considerations:

This study was approved by the Regional Committee of Medical Research Ethics. The ethical principles of voluntary participation, anonymity, and confidentiality were considered.

Findings:

The construct validity of the scale showed four factors with eigenvalues greater than one. The model had a good fit ( χ2(162) = 307.561, χ2/ df = 1.899, goodness-of-fit index = .904, comparative fit index = .927, incremental fit index = .929, and root mean square error of approximation (90% confidence interval) = .049 (.040–.057)) with all factor loadings greater than .5 and statistically significant. Cronbach’s alpha coefficients were .853, .686, .685, and .711for the four factors. Moreover, the model structure was invariant across different income groups.

Discussion and conclusion:

The Persian version of the Moral Distress Scale–Revised demonstrated suitable validity and reliability among nurses. The factor analysis also revealed that the Moral Distress Scale–Revised has a multidimensional structure. Regarding the proper psychometric characteristics, the validated scale can be used to further research about moral distress in this population.

Moral Distress in Pediatric Healthcare Providers

Pediatric providers across professions and clinical settings experience moral distress. Higher moral distress correlates with intent to leave for all professionals. Physicians as professional group had the highest moral distress. Intensive care nurses had the highest moral distress for nurses. While all providers describe distressing scenarios as disturbing, physicians report situations as occurring more frequently. The most distressing situations include requests for aggressive treatments not in child's best interest, poor team communication and lack of provider continuity. Understanding moral distress as experienced by all pediatric providers is needed to create interventions with a goal of reducing provider turnover.

Moral sensitivity and moral distress in Iranian critical care nurses

BACKGROUND

Moral sensitivity is the foremost prerequisite to ethical performance; a review of literature shows that nurses are sometimes not sensitive enough for a variety of reasons. Moral distress is a frequent phenomenon in nursing, which may result in paradoxes in care, dealing with patients and rendering high-quality care. This may, in turn, hinder the meeting of care objectives, thus affecting social healthcare standards.

RESEARCH OBJECTIVE

The present research was conducted to determine the relationship between moral sensitivity and moral distress of nurses in intensive care units.

RESEARCH DESIGN

This study is a descriptive-correlation research. Lutzen's moral sensitivity questionnaire and Corley Moral Distress Questionnaire were used to gather data. Participants and research context: A total of 153 qualified nurses working in the hospitals affiliated to Shahid Beheshti University of Medical Sciences were selected for this study. Subjects were selected by census method. Ethical considerations: After explaining the objectives of the study, all the participants completed and signed the written consent form. To conduct the study, permission was obtained from the selected hospitals.

FINDINGS

Nurses' average moral sensitivity grade was 68.6 ± 7.8, which shows a moderate level of moral sensitivity. On the other hand, nurses also experienced a moderate level of moral distress (44.8 ± 16.6). Moreover, there was no meaningful statistical relationship between moral sensitivity and moral distress (p = 0.26).

DISCUSSION

Although the nurses' moral sensitivity and moral distress were expected to be high in the intensive care units, it was moderate. This finding is consistent with the results of some studies and contradicts with others.

CONCLUSION

As moral sensitivity is a crucial factor in care, it is suggested that necessary training be provided to develop moral sensitivity in nurses in education and practical environments. Furthermore, removing factors that contribute to moral distress may help decrease it in nurses.

End-of-life care in a regional level IV neonatal intensive care unit after implementation of a palliative care initiative

OBJECTIVE

We hypothesized that the implementation of a neonatal palliative care initiative will result in improved markers of end-of-life care.

STUDY DESIGN

A retrospective and prospective chart review of neonatal intensive care unit deaths was performed for 24 months before, 16 months during and 24 months after the implementation of palliative care provider education and practice guidelines (n=106). Ancillary care, redirection of care, palliative medication usage and outcome meetings in the last 48 h of life and basic demographic data were compared between epochs. Parametric and nonparametric analysis was performed.

RESULT

There was an increase in redirection of care and palliative medication usage and a decrease in variability of use of end-of-life interventions (P=0.012, 0.022 and <0.001).

CONCLUSION

The implementation of a neonatal palliative care initiative was associated with increases in palliative interventions for neonates in their final 48 h of life, suggesting that such an initiative may enhance end-of-life care.

Moral distress in the neonatal intensive care unit: an Italian study

OBJECTIVE

The objective of this study was to evaluate the frequency, the intensity and the level of moral distress experienced by nurses working in neonatal intensive care units (NICUs).

STUDY DESIGN

We conducted a cross-sectional questionnaire survey involving 472 nurses working in 15 level III NICUs. Frequency, intensity and level of moral distress was evaluated using a modified version of Moral Distress Scale Neonatal-Pediatric Version. Socio-demographic data were also collected.

RESULT

Four hundred six nurses completed the study material indicating a low-to-moderate experience of moral distress. The situations receiving the highest scores for frequency, intensity and level of moral distress related to the initiation of extensive life-saving actions and participation to the care of ventilator-dependent child. No difference in the mean scores of moral distress was found according to the socio-demographic characteristics investigated.

CONCLUSION

The present study provides further insight into the moral distress experienced by nurses working in Italian NICUs.

Ethical challenges in neonatal intensive care nursing

BACKGROUND

Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice.

RESEARCH OBJECTIVE

The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns.

RESEARCH DESIGN

Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to interpret the data.

PARTICIPANTS AND RESEARCH CONTEXT

Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site.

ETHICAL CONSIDERATIONS

The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration.

FINDINGS

Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement.

DISCUSSION

A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality.

CONCLUSION

The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care.

Ethical issues related to caring for low birth weight infants

BACKGROUND

Currently preterm births are the leading causes of newborn deaths and newborn mortality in developed countries. Infants born prematurely remain vulnerable to many acute complications and long-term disabilities. There is a growing concern surrounding the moral and ethical implications of the complex and technological care being provided to extremely low birth weight infants in neonatal intensive care units in the developed nations.

RESEARCH PURPOSE

The purpose of this study was to describe the ethical and moral issues that neonatal intensive care nurses experience when caring for low birth weight preterm infants and their families.

RESEARCH DESIGN

A phenomenological method design was used to describe the lived experiences of nurses with ethical and moral issues encountered in the neonatal intensive care unit. One-on-one, semi-structured interviews using open-ended questions were used to gather data from the participants.

RESEARCH PARTICIPANTS

The setting for this study was a 97-bed neonatal intensive care. A total of 16 female nurses were interviewed.

ETHICAL CONSIDERATIONS

Approval to conduct the research study was obtained from the institutional review board of the hospital where the study was conducted. Formal signed consent was obtained from each participant. To ensure confidentiality, each participant was asked to choose a confederate name to be used in the interview and the transcriptions.

FINDINGS

The thematic analysis identified five recurring themes: (a) at the edge of viability, (b) infant pain and discomfort, (c) crucial decisions, (d) communicating with parents, and (e) letting go.

CONCLUSION

Neonatal intensive care unit nurses indicated that they often had challenges to their own sense of morality as they struggled to protect the infant from pain and unnecessary discomfort, provide care to an infant and their family whom they thought was faced with a lifetime of challenges and poor health, accepting decisions made by parents, and feeling as if parents were not adequately informed about outcomes.

The educational needs of neonatal nurses regarding neonatal palliative care

BACKGROUND

Studies have shown that education can improve the knowledge, attitudes, and beliefs of neonatal nurses regarding neonatal palliative care. However, no study has investigated the need for neonatal nurse education in neonatal palliative care in Taiwan.

OBJECTIVE

The purpose of this study was to explore neonatal nurses' experiences in caring for dying neonates and their educational backgrounds regarding palliative care, as well as to assess their educational needs.

METHODS

A cross-sectional survey was used for this research. A research structural questionnaire was used to investigate the research goals.

RESULTS

One hundred fifteen nurses participated in this survey. Few participants indicated having received neonatal palliative care education (13%), but most responded that palliative care is necessary in neonatal nursing education (97.4%). Participants also responded that they were often or always exposed to death in NICU (62.6%), but few reported providing pain management to dying neonates (8.7%) and few had experience providing symptomatic care for dying neonates (19.1%). Fifty percent ranked "pain control" as the area in which they most required training. Another high-ranked need was in discussing with parents and families the outcomes of CPR and their neonate's progress.

CONCLUSION

Research indicates that the education currently provided to neonatal nurses does not meet their distinctive needs. Neonatal nurses in Taiwan expressed an urgent desire for training in pain control and communication. Research suggests that the most important topics to trainees are pain management and end-of-life communication. Additionally, non-pharmacological pain control interventions are valuable and should be included in an educational program.

Perinatal palliative care: Parent perceptions of caring in interactions surrounding counseling for risk of delivering an extremely premature infant

OBJECTIVE

When infants are at risk of being born at a very premature gestation (22-25 weeks), parents face important life-support decisions because of the high mortality for such infants. Concurrently, providers are challenged with providing parents a supportive environment within which to make these decisions. Practice guidelines for medical care of these infants and the principles of perinatal palliative care for families can be resources for providers, but there is limited research to bridge these medical and humanistic approaches to infant and family care. The purpose of this article is to describe how parents at risk of delivering their infant prior to 26 weeks gestation interpreted the quality of their interpersonal interactions with healthcare providers.

METHODS

Directed content analysis was employed to perform secondary analysis of data from 54 parents (40 mothers and 14 fathers) from the previously coded theme "Quality of Interactions." These categorized data described parents' encounters, expectations, and experiences of interactions that occurred prenatally with care providers. For this analysis, Swanson's theory of caring was selected to guide analysis and to delineate parents' descriptions of caring and uncaring interactions.

RESULTS

Parents' expectations for caring included: (a) respecting parents and believing in their capacity to make the best decisions for their family (maintaining belief); (b) understanding parents' experiences and their continued need to protect their infant (knowing); (c) physically and emotionally engaging with the parents (being with); (d) providing unbiased information describing all possibilities (enabling); and (e) helping parents navigate the system and creating a therapeutic environment for them in which to make decisions (doing for).

SIGNIFICANCE OF RESULTS

Understanding parents' prenatal caring expectations through Swanson's theory gives deeper insights, aligning their expectations with the palliative care movement.

Nurse Activism in the newborn intensive care unit

Nurses working in a newborn intensive care unit report that treatment decision disagreements for infants in their care may lead to ethical dilemmas involving all health-care providers. Applying Rest’s Four-Component Model of Moral Action as the theoretical framework, this study examined the responses of 224 newborn intensive care unit nurses to the Nurses Ethical Involvement Survey. The three most frequent actions selected were as follows: talking with other nurses, talking with doctors, and requesting a team meeting. The multiple regression analysis indicates that newborn intensive care unit nurses with greater concern for the ethical aspects of clinical practice (p = .001) and an increased perception of their ability to influence ethical decision making (p = .018) were more likely to display Nurse Activism. Future research is necessary to identify other factors leading to and inhibiting Nurse Activism as these findings explained just 8.5% of the variance.

Moral distress and avoidance behavior in nurses working in critical care and noncritical care units

Nurses facing impediments to what they perceive as moral practice may experience moral distress. The purpose of this descriptive, cross-sectional study was to determine similarities and differences in moral distress and avoidance behavior between critical care nurses and non-critical care nurses. Sixty-eight critical care and 28 non-critical care nurses completed the Moral Distress Scale and Impact of Event Scale (IES). There were no differences in moral distress scores (F = 0.892, p = 0.347) or impact of event scores (F = 3.80, p = 0.054) between groups after adjusting for age. There was a small positive correlation between moral distress and avoidance behaviors for both the groups. Moral distress is present in both critical care and noncritical care nurses. It is important that nurses are provided with opportunities to cope with this distress and that retention strategies include ways to reduce suffering and mitigate the effects on professional practice.

Ethical decision making in the resuscitation of extremely premature infants: the health care professional's perspective

Across Canada, the rate of preterm birth (i.e., at < 37 weeks' gestation) has been steadily increasing. Advances in perinatal medicine and neonatal intensive care have resulted in an increased capacity to intervene at the extremes of prematurity, leading to an increase in the overall survival of infants born at early gestations. There has been little corresponding decrease in long-term complications. As a result, additional stresses are placed on neonatal intensive care units across the country, impacting families, health care professionals, and society as a whole. Moral distress and moral residue are often cited in the neonatal-perinatal literature as stressors experienced by those who participate in the resuscitation decision-making process. They are directly related to the challenge of making a concrete decision about life and death at extremely early gestations in the context of long-term uncertainty. In this review, we performed a systematic search of medical and ethics literature pertaining to resuscitation at the extremes of prematurity. The perspective of health care professionals is explored, including how definitions of viability and parental perspectives contribute to the decision-making process. We argue for the necessity of further research exploring the inter-professional context of ethical decision making at the extremes of prematurity.

Challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations

OBJECTIVE

To study attitudes regarding life-saving interventions.

STUDY DESIGN

An Internet questionnaire describing 6 patients of different ages needing resuscitation was sent to members of the Norwegian Pediatric Association (n = 676): a 24-week gestational age infant, a term infant, a 2-month-old infant, a 7-year, a 50-year, and an 80-year-old individual. Neonates had similar or better described outcomes than older patients.

RESULTS

A total of 266 people responded (39.4%). The majority would resuscitate all the patients except the 80-year-old. The majority thought that resuscitation was in the best interest of the younger 5 patients, but fewer thought so for neonates (P < .05). Although the majority of the respondents thought that resuscitation was in the neonates' best interest (71% for 24-week-old and 75% for term infant), significantly more would accept comfort care at parental demand (62% for 24-week-old and 72% for term infant), unlike for other scenarios. Quality of life was used to justify decision making; 25% used the length of the life for neonates to motivate their answers. Patients were prioritized for resuscitation in the following order: 2-month-old infant, 7-year-old child with multiple disabilities, 50-year-old adult, the neonates, and lastly the 80-year-old individual.

CONCLUSION

There are challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations. Neonates seem to be devalued.

Moral distress in nurses in oncology and haematology units

One of the difficulties nurses experience in clinical practice in relation to ethical issues in connection with young oncology patients is moral distress. In this descriptive correlational study, the Moral Distress Scale-Paediatric Version (MDS-PV) was translated from the original language and tested on a conventional sample of nurses working in paediatric oncology and haematology wards, in six north paediatric hospitals of Italy. 13.7% of the total respondents claimed that they had changed unit or hospital due to moral distress. The items with the highest mean intensity in the sample were almost all connected with medical and nursing competence and have considerably higher values than frequency. The instrument was found to be reliable. The results confirmed the validity of the MDS-PV (Cronbach’s alpha = 0.959). This study represents the first small-scale attempt to validate MDS-PV for use in paediatric oncology-ematology nurses in Italy.

Withholding or withdrawal of life sustaining treatment for newborn infants

In the last two decades the survival of extreme preterm infants and sick newborn infants has improved significantly due to the advances in perinatal medicine. Despite this advance, for some babies, withholding or withdrawal of life sustaining treatment may be the best option in the interest of the baby. An overview of when to consider withholding or withdrawal of life sustaining treatment is described. The decision making process and factors influencing parents decision, how to resolve disagreement, what treatment can be withheld or withdrawn are explained. High quality palliative care must be provided after withholding or withdrawal of life sustaining treatment.

Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act

OBJECTIVE

The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation.

STUDY DESIGN

We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios.

RESULTS

Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled.

CONCLUSION

Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.

The challenge of integrating justice and care in neonatal nursing

The aim of this study was to explore neonatal nurses’and mothers of preterm infants’experiences of daily challenges. Interviews took place asking for good, bad and challenging experiences. Data were analysed using qualitative content analysis and findings were clustered in two categories: good and challenging experiences, each containing three themes. The good experiences were: managing with success as a nurse, small things matter for mothers, and a good day anyhow for mothers and nurses. The challenging experiences were: mothering in public, being pulled between responsibilities, and adverse things stick under the nurses’skin. The study shows that small daily clinical matters become big issues and could lead to moral distress, and that nurses integrate ethics of justice and ethics of care while mothers are concerned about health and well-being of their specific infant only. The challenge for nursing to integrate fairness and sensitive care in family-oriented neonatal care is discussed.

An overview of ethics in maternal-child nursing

Ethical issues across the childbearing year are multiple and complex. This article addresses ethical challenges facing maternal-child nurses and identifies strategies for making ethical decisions utilizing ethical principles and frameworks. Coping strategies for dealing with moral distress, how nurses demonstrate moral courage, and the attributes of an effective ethical decision maker are described. Ethical issues related to healthcare team relationships are discussed, with implications for nurses provided.

NNP education in neonatal end-of-life care: a needs assessment

PURPOSE

To determine from practicing neonatal nurse practitioners (NNPs) their perceived end-of-life (EOL) care learning needs.

DESIGN AND METHOD

A needs assessment-based evaluation methodology was used to answer the research questions. A neonatal EOL needs assessment survey was developed, pilot tested, and then mailed to 260 NNPs across the United States.

RESULTS

NNPs in clinical practice regarded their education on EOL for neonates and their families as inadequate. Twenty-three percent ranked "delivery room decisions to resuscitate infants considered at edge of viability" as the item for which they most wanted more training. The other top-ranked EOL items included balance between giving parents false hopes and removing all hopes, and communicating and giving bad news to families.

CLINICAL IMPLICATIONS

Based on these findings, specific neonatal EOL education and communication skill workshops are warranted for graduate nursing core and advance practice continuing education courses. Additionally, there needs to be a mechanism to provide EOL content and support for the NNP already in clinical practice; it is suggested that learning about EOL issues can be integrated into existing (continuing nursing education CNE) educational activities. Further research is needed on what issues, tools, and methods in CNE programs make a difference in the experience of NNPs.