"Thai Nurses' and Midwives' Perceptions Regarding Barriers, Facilitators, and Competence in Neonatal Pain Management"

BACKGROUND

Effective neonatal pain management is reliant upon the expert care of nurses and midwives working in neonatal intensive care units (NICUs). Previous research has explored barriers, facilitators, and some aspects of nurse competence in managing neonatal pain; however, this research has been predominantly performed in Western countries. To date, little is known about the barriers, facilitators, and perceived competence of Thai nurses and midwives in relation to neonatal pain management in NICUs. Exploring Thai nurses' and midwives' perceptions in these areas is crucial for understanding the contextual nuances of neonatal pain management, which can guide the provision of care for these high-risk neonates.

PURPOSE

To investigate nurses' and midwives' perceptions of barriers, facilitators, and competence regarding effective neonatal pain management in Thai NICUs.

METHODS

Data were collected using virtual one-to-one, semistructured interviews with 12 neonatal nurses and midwives between July and August 2021 in 3 units of 2 tertiary hospitals in Southern Thailand. Inductive thematic analysis was used to examine interview data.

RESULTS

These data revealed following 3 major themes: ( a ) barriers to effective neonatal pain management, ( b ) facilitators of effective neonatal pain management, and ( c ) perceptions of competence.

IMPLICATIONS FOR PRACTICE

Assisting nurses and midwives in overcoming barriers and strengthening facilitators while enhancing their competence may result in better neonatal pain management.

IMPLICATIONS FOR RESEARCH

This study adds to our understanding that further research is needed to develop the interventions designed to change at individual, unit, and organizational levels, particularly implementing parent-friendly visitation and ongoing professional development in neonatal pain management.

Moral distress among acute mental health nurses: A systematic review

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes.

The experiences of trans (binary and non-binary) patients accessing care in the emergency department: An integrative review

Accessing care in the Emergency Department is often fraught with stress and heightened emotions due to illness or injury, and the complexity of navigating an often busy and overwhelming healthcare setting. For people who identify as trans (binary and non-binary), accessing Emergency Department care is often associated with additional stress or avoided due to fears of discrimination, or previous negative experiences (1). The aim of this integrative review was to identify and review the literature relating to the experiences of trans (binary and non-binary) people accessing Emergency Department care, to guide practice and future research. A structured search process was used to identify 11 articles published between January 2013 and November 2023. These articles were appraised using the mixed methods appraisal tool (MMAT) (2) and included in this review. Utilising the methodology outlined by Whittemore & Knafl (3), a constant comparison analytic approach identified five key themes; 1. emergency department context; 2. interactions with staff and language; 3. health professional knowledge; 4. advocacy; and 5. disclosing trans status. This review identified a perceived lack of competence for healthcare providers to deliver gender affirming healthcare in the Emergency Department due to perceptions of inadequate healthcare provider knowledge, and structural barriers founded on cisgender processes.

Predictors of compassion satisfaction among healthcare professionals working in intensive care units: A cross-sectional study

OBJECTIVE

To determine the prevalence of compassion satisfaction, related factors, and predictors among healthcare professionals in Thai intensive care units.

METHODS

A cross-sectional study was conducted in 12 intensive care units at a university hospital in Thailand from August to November 2022. All nurses and doctors were invited to complete an anonymous online survey which included: the Professional Quality of Life Scale version 5, Connor-Davidson Resilience Scale, Passion Scale, Flourishing Scale, and Acceptance and Action Questionnaire. Descriptive statistics, Pearson's correlation coefficients, and hierarchical multiple regressions were used for data analysis in SPSS 28.0.

RESULTS

A total of 178 nurses and doctors participated (92.13% nurses, 89.89% female, mean 32.10 years). Average compassion satisfaction (assessed using the Professional Quality of Life Scale) was moderate, with a mean score of 37.94 (SD = 5.58). The final regression model predicting compassion satisfaction was significant and explained 65% of the variance in compassion satisfaction, F (11, 154) = 26.00, p < 0.001. Four out of 11 predictor variables made unique statistically significant contributions to the final model: resilience (β = 0.48, p < 0.001), harmonious passion (β = 0.24, p < 0.001), being a nurse (not a doctor; β = 0.17, p < 0.05), and holding a postgraduate qualification (β = 0.10, p < 0.05).

CONCLUSION

Most healthcare professionals in critical care units have a moderate level of compassion satisfaction, which is correlated with resilience, flourishing, and harmonious passion. Resilience and harmonious passion predict compassion satisfaction. These factors are modifiable through intervention.

IMPLICATION FOR CLINICAL PRACTICE

Assessment of staff psychological well-being can identify those at risk for stress and impaired professional quality of life. Resilience and harmonious passion predict compassion satisfaction and can be modified through psychological interventions to promote psychological well-being and professional quality of life in healthcare workers in intensive care units.

Paediatric post-discharge pain and parent perceptions of support from an Australian nurse practitioner led acute pain service

Poorly managed post-operative pain remains an issue for paediatric patients. Post-discharge telephone follow-up is used by an Australian Nurse Practitioner Acute Pain Service (NpAPS) to provide access to effective pain management post-discharge from hospital. This cross-sectional survey design study aimed to determine the pain levels of children following discharge and parent views on participation in their child's pain management and perceptions of support from the NpAPS. Parents completed the Parents' Postoperative Pain Measure-Short Form (PPPM-SF) and factors affecting parents' participation in children's pain management questionnaire (FPMQ). Results indicated that pain score was high, especially on the day of discharge and 24 hours post-discharge. Parents, despite feeling supported by the NpAPS, experienced uncertainty, emotional responses and expressed concerns about communication and coordination of care. The clinically significant pain levels of the majority of children on the day of discharge and day post-discharge from hospital are a concern. Worry and uncertainty among parents, particularly on the day and first night of discharge, suggest this transition period where responsibility of clinical management of pain is handed over to parents may require greater focus for parental support.

Compassion satisfaction, resilience and passion for work among nurses and physicians working in intensive care units: A mixed method systematic review

OBJECTIVE

To identify, appraise, and synthesise current evidence on prevalence, correlates, and interventions to enhance compassion satisfaction, resilience, and passion for work among nurses and physicians working in intensive care units.

METHODS

A mixed methods systematic review was conducted. The comprehensive search used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seven databases (MEDLINE, EMBASE, CINAHL, JBI, ProQuest, PsycINFO, and Cochrane Library) were searched for literature published between January 2011 and June 2021. The Mixed Methods Appraisal Tool was used to assess methodological quality. Data from included studies were analysed using a convergent mixed methods design. The protocol was prospectively registered (PROSPERO 2021 CRD42021252051).

RESULTS

A total of 37 studies met the inclusion criteria. Most studies reported moderate levels of compassion satisfaction among intensive care health professionals, whereas levels of resilience varied. Compassion satisfaction and resilience were positively correlated, but relationships between compassion satisfaction and resilience and other correlates (personal factors, psychological factors, and work-related factors) were inconsistently reported. Only four interventions aimed to improve compassion satisfaction or resilience among intensive care health professionals. None of the included studies investigated passion for work.

CONCLUSION

Compassion satisfaction, resilience, and passion for work among staff in the intensive care unit are important in the current global COVID-19 pandemic. Health professionals report a moderate level of compassion satisfaction but findings in relation to resilience are mixed. No studies examined passion for work. Further research to determine ongoing psychological wellbeing and professional quality of life and evaluate tailored interventions to support intensive care staff well-being is recommended.

Suicide Awareness Training: A Literature Review with Application to Queensland Nurses

Despite decades of strategic intervention, Queensland's suicide rates exceed both national and global rates. This is surely an indicator that not enough is being done to address this cause of death. The authors suggest that this problem may be addressed, in part, by provision of improved suicide awareness training for nurses. The purpose of this review was to support this through examination of the contemporary status of suicide awareness training in Queensland nurses, the efficacy of suicide awareness training in general, and the experiences of nurses, other health professionals, and suicidal patients in healthcare settings. We concluded that while efficacious, suicide awareness training in Queensland nurses is presently inadequate, and that both nurses and patients may benefit from improved suicide awareness training.

Engaging students in a community of learning: Renegotiating the learning environment

Promoting student engagement in a student led environment can be challenging. This article reports on the process of design, implementation and evaluation of a student led learning approach in a small group tutorial environment in a three year Bachelor of Nursing program at an Australian university. The research employed three phases of data collection. The first phase explored student perceptions of learning and engagement in tutorials. The results informed the development of a web based learning resource. Phase two centred on implementation of a community of learning approach where students were supported to lead tutorial learning with peers. The final phase constituted an evaluation of the new approach. Findings suggest that students have the capacity to lead and engage in a community of learning and to assume greater ownership and responsibility where scaffolding is provided. Nonetheless, an ongoing whole of course approach to pedagogical change would better support this form of teaching and learning innovation.

The role of anaerobic power in human tolerance to simulated aerial combat maneuvers

The relationships of anaerobic power, blood lactate levels, and selected anthropometric measurements to +Gz tolerance were examined in 10 adult males. Upper and lower body anaerobic indices were determined by Wingate anaerobic tests (WT). Acceleration tolerance was measured as duration time for a simulated aerial combat maneuver (SACM) centrifuge profile with alternating 4.5 and 7 +Gz 15-s plateaus until exhaustion. Group mean (+/- SD) for SACM duration was 250 +/- 97 s. Peak blood lactate concentration was 4.9 +/- 1.5 mmol/L and overall rating of perceived exertion was 7.4 +/- 2.1 using the Borg Category-Ratio Scale. Group mean for WT lower body 30-s mean power (MP, index of anaerobic performance) was 620 +/- 128 W; peak power (PP, highest 5-s power output) was 851 +/- 169 W. Upper body MP and PP were 380 +/- 68 W and 497 +/- 81 W, respectively. SACM duration time was positively correlated (p < 0.05) with lower body MP and PP, upper body PP, various body circumferences, weight, fat-free body weight, and height; but did not correlate with WT power outputs relative to body weight, or with other SACM variables. Results suggest that anaerobic power is an important physiologic component in SACM tolerance.

G-LOC recovery with and without G-suit inflation

During acceleration (+Gz) training in the human centrifuge, the anti-G suit (AGS) is usually deflated as acceleration decreases upon termination of the exposure, regardless of the reason for termination, including +Gz-induced loss of consciousness (G-LOC). This is when the trainee most needs the support provided by the AGS. A method to reduce the time of incapacitation resulting from G-LOC was evaluated. The standard CSU15-P suit worn by 30 aircrew while undergoing +Gz tolerance training was inflated to 10 psi immediately upon G-LOC (GS group). Incapacitation times and flailing activity were recorded and compared with 51 aircrew whose AGS was not abruptly inflated upon G-LOC (NGS group). Absolute incapacitation was significantly different between both groups (p = 0.024). The GS group exhibited flailing behavior for a longer period of time during relative incapacitation than the NGS group (p = 0.0003). Total incapacitation remained unaffected. A brief period of confusion occasionally accompanied by mimic or myoclonic convulsions was observed more often in the GS group. Inflation of the AGS upon G-LOC seems to reduce absolute incapacitation by approximately 2 s, thereby causing the trainee to be aware of his environment and G-LOC more quickly, even though his motor function has not yet been fully restored.

Effect of pyridostigmine bromide on acceleration tolerance and performance

Pyridostigmine Bromide (PB) is used as a pre-exposure antidote for the prevention of potentially lethal effects of certain chemical warfare nerve agents by reversibly inhibiting acetylcholinesterase (AChE). This study was designed to determine whether PB has any deleterious effects on acceleration tolerance (+Gz) or performance. Double-blind placebo trials were conducted to evaluate the effects of PB (90 mg) per day on +Gz tolerances and performance. Three types of exposures were used: 1) gradual onset rate (GOR) exposures of 0.1 G/s; 2) a series of rapid onset rate (ROR) exposures of 6.0 G/s; and 3) a simulated aerial combat maneuver (SACM) of 4.5 to 9.0 +Gz. Performance tasks included the Unified Tri-Service Cognitive Performance Assessment Battery (UTC-PAB). The subjects were not able to correlate their symptoms with PB, placebo, or the acceleration exposure itself. Plasma PB individual levels ranged between 6 and 31 ng/ml and AChE levels of inhibition had a range of 12 to 45%. There were no significant effects on +Gz tolerance or performance related to PB. Based on the results of this study, PB does not significantly alter +Gz tolerance or performance. Therefore, we do not expect aircrew taking prophylactic doses of PB to be adversely affected during aerial combat operations.

Heart rate response of aircrew during recovery from gradual onset rate +Gz exposures

A quantitative study of cardiac recovery from +Gz was accomplished to define recovery heart rate (HR) of aircrew exposed to the acceleration environment in the centrifuge. Electrocardiographic data from 30 pilots were analyzed. The profiles considered were gradual onset rate exposure of 0.1 G/s. Continuous R-R interval measurements were recorded prior to +Gz and immediately after peak +Gz was attained. In 57% of the subjects, HR decreased 57 +/- 18 bpm an average of 11 +/- 4 s after maximum HR was attained. This rate was maintained for 17 +/- 5 s. The remaining 43% of the subjects exhibited a gradual decline in HR until reaching a steady state 60 s after the exposure. Heart rate was also observed to oscillate 42 +/- 15 bpm about the mean values before achieving a steady state during both types of recovery. The oscillatory HR did not have fixed upper and lower limits. Description of the recovery HR during +Gz exposures establishes a baseline for comparison with atypical responses and a basis for describing cardiovascular response to alternate and more complex +Gz profiles.

The effect of G-LOC on psychomotor performance and behavior

Acceleration (+Gz) induced loss of consciousness (G-LOC) and its effect upon cognitive and motor performance were evaluated in seven male volunteers who were exposed to closed-loop acceleration exposures at the Naval Air Warfare Center--Aircraft Division, Warminster (NAWCADWAR) human centrifuge (DFS). The +Gz profile consisted of several aerial combat environment simulations (ACES) of up to +12 Gz. In the event of G-LOC, the DFS was brought down to a base +Gz level. As the subject recovered consciousness, he was required to complete various tasks to regain control of the aircraft. Psychomotor performance was measured before, immediately after, and 20-40 min post-G-LOC. These tasks included: 1) extinguishing master caution signals initiated upon G-LOC by an observer; 2) entering a control code on a head-down display to initiate DFS trim mode; and 3) matching own aircraft altitude, airspeed and heading to that of a displayed target. Absolute (6 +/- 2 s), relative (5 +/- 3 s) and total (12 +/- 3 s) incapacitations were briefer than those reported in the literature. The time intervals to execute the performance tasks tended to be longer for post-G-LOC than for pre-G-LOC. Recovery of psychomotor performance, as measured in this study, occurred approximately 60 s post G-LOC. There were no performance decrements during those tasks assigned 20-40 min after G-LOC.

Dynamic cardiovascular response to +Gz stress in aerobically trained individuals

Very high onset sustained +Gz stress requires rapid cardiovascular response to support human tolerance. This study was conducted following a previous study concerning +Gz tolerance in aerobically trained individuals, and was initiated to determine if intense aerobic conditioning might affect cardiovascular +Gz tolerance through reduction in heart rate response to +Gz stress. The study compared heart rate response data on 22 aerobically trained runners and 13 less-conditioned individuals. All subjects were exposed to a standard medical evaluation protocol, which consisted of a gradual-onset (0.1 G/s) acceleration exposure (GOR1), followed by a series of rapid-onset (1.0 G/s) acceleration exposures (ROR), a second gradual-onset rate exposure (GOR2), and a third gradual-onset rate exposure with the subjects performing anti-G straining maneuvers (GORS). Aerobic conditioning was not found to be associated with a reduced heart rate response to +Gz stress, compared to the response of unconditioned subjects, when the following variables were considered; heart rate change from rest to maximum exposure heart rate, heart rate change from rest to the heart rate achieved at the onset of maximum G, and the rate of change in heart rate per unit +Gz. Although enhanced parasympathetic tone, induced by long-term aerobic conditioning (running) results in a reduced heart rate at rest and during +Gz stress, it does not alter the responsiveness of the heart rate to +Gz stress.

Physiologic correlates of protection afforded by anti-G suits

A new uniform-pressure pneumatic anti-G suit (UPS) was compared with the standard CSU-13B/P anti-G suit, using measurements of: blood lactate, heart rate changes, and segmented lower-body blood pooling (by impedance plethysmography). Subjects were exposed to a series of gradual-onset-rate (GOR) runs (0.1 G.s-1), rapid-onset-rate (ROR) runs (6 G.s-1), and simulated aerial combat maneuvers (SACM) on the USAF School of Aerospace Medicine human-use centrifuge. All measured parameters and subjective reports indicated that increased protection was afforded by the UPS. The impedance plethysmography measurements indicated that prevention of blood pooling in all lower-body segments is the predominant mechanism whereby uniform pressure permits significantly longer times-to-fatigue during SACMs.

Recovery from Gz-induced loss of consciousness: psychophysiologic considerations

Eight healthy male volunteer members of the USAFSAM acceleration panel were exposed to two consecutive acceleration runs of +1 Gz to +7 Gz at 6 G.s-1 onset rates. The subjects were instructed to relax during the acceleration exposure in order to voluntarily induce loss of consciousness (LOC). The subjects were asked to relate dreams, thoughts, or other mental illusions experienced during G-LOC episodes. Most subjects were amused and surprised, as well as interested in, relating their experience, although they were embarrassed about the G-LOC episode itself. Early post-G-LOC transient paralysis, as well as late LOC myoclonic (flailing) movements, were evident. Heart-rate response to the acceleratory stress was uneventful; maximum heart rate occurred 3.2 s after the onset of LOC. The study of dreams during normal sleep stages has been reviewed by many investigators, but this research has not extended to acceleration/hypoxic types of unconsciousness where dreams also seem to occur. G-LOC dream-state analysis, post-G-LOC paralysis, and their possible repercussions upon performance and incapacitation periods should be investigated, not only as curious events, but as operationally important and psychophysiologically significant.

Reflex heart rate response to variable onset +Gz

Rapid onset high sustained +Gz is a frequent requirement in air combat maneuvering. The cardiovascular response is inadequate to fully compensate for this rapid +Gz change. The rate of change in heart rate (HR) during gradual (0.1 G.s-1, GOR), rapid (1.0 G.s-1, ROR), and very high (6.0 G.s-1, VHOG) onset acceleration exposures to sustained (15 s) +7Gz, +8Gz, and +9Gz levels was measured in 81 healthy male subjects in a human centrifuge. The time (s) to reach maximum heart rate (T7) was measured as the time for the preacceleration exposure resting heart rate (RHR) to reach maximum heart rate (MHR). The change in heart rate upon reaching maximum +Gz level (delta HRA) from rest was calculated along with the change in HR from rest to the maximum heart rate achieved before maximum +Gz level was attained. During the ROR and VHOG runs, MHR was not achieved until after maximum +Gz level was attained. The change in heart rate from resting HR (immediately prior to acceleration) to the heart rate achieved at the onset of maximum +Gz level (delta HRA), decreased by 50% as the onset rate increased from GOR to ROR and VHOG. The delta HRB for very high onset rates exposures was significantly greater than that for ROR and GOR exposures. Acceleration exposure to levels of +7Gz and above (+7Gz, +8Gz and +9Gz) exhibited similar HR responses. VHOG to sustained +Gz stress levels of +7 to +9Gz for 15 s did not provide a sufficient length of time to allow maximum cardiovascular response.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaerobic energetics of the simulated aerial combat maneuver (SACM)

The role of anaerobic metabolism in +Gz duration tolerance was measured using venous blood lactate concentrations before G exposure and after subjects had been fatigued from exposure to one of several levels of G: low (4.5 G) sustained G (LSG); high (7-9 G) sustained G (HSG); and simulated aerial combat maneuver (SACM) of 4.5/7 G levels. A mean +/- S.E. blood lactate of six subjects fatigued from LSG was 29.8 +/- 4.0 mg%. Four subjects fatigued from HSG had blood lactates of 42.4 +/- 3.2 mg%, and six had blood lactates of 46.7 +/- 7.2 mg% from the SACM. Blood lactates appeared to correlate directly (on a group basis) with maximum heart rates found during G exposures. Six subjects exposed to 8 or 9 G for 10 s or less demonstrated an anaerobic alactate capacity. These G findings were related to fatigue produced with isometric muscle contraction in physiologic studies conducted at 1 G. We concluded that anaerobic metabolism and isometric exercise physiology are directly related to duration tolerances of fatigue at all levels of +Gz.