Barriers to and Facilitators of Neonatal Palliative Care Among Neonatal Professionals in China

OBJECTIVES

This study investigated institutional and personal barriers to and facilitators of neonatal palliative care facing neonatal professionals in China.

METHODS

A cross-sectional questionnaire surveyed 231 neonatal clinicians employed in 5 neonatal intensive care units from 2 children's hospitals and 3 medical centers in China.

MEASUREMENTS

The translated modified version of the Neonatal Palliative Care Attitude Scale was used to survey neonatal clinicians' attitudes and beliefs regarding neonatal palliative care.

RESULTS

Findings highlight 4 facilitators and 5 barriers among participating clinicians. Participants gave contradictory responses regarding the relative importance of curative treatment versus palliative care in the NICU. Negatively traumatic feelings, cultural issues and moral distress may impact this contradictory response and discourage clinicians from providing neonatal palliative care. Additionally, neonatologists and nurses held differing attitudes on several topics (p < 0.05).

CONCLUSION

Further research should address strategies to improve knowledge and attitudes and relieve moral distress in NICU clinicians. Neonatal clinicians providing neonatal palliative care should receive regular palliative care training addressing culture-specific issues and communication skills.

PRACTICE IMPLICATIONS

Study findings will be beneficial to inform clinical education and practice. Regular interdisciplinary team training is needed to enhance support for palliative care and decrease clinicians' moral distress during end-of-life care.

Chinese Parental Awareness of Children's COVID-19 Protective Measures

Objectives: In this research our aim was to investigate Chinese parents' awareness of pediatric COVID-19 in relation to protecting their children. Methods: A cross-sectional study was conducted in Fujian provinces in China using a Web-based questionnaire to survey parents of children aged 6 to 16 years old. Results: The sample included 1222 participants. Overall, 99.2% of participants were aware of respiratory transmission of COVID-19, and 75.6% also believed fecal-oral transmission to be possible. Although 98.3% of participants claimed to know how to wear and remove masks properly, some parents were unaware of good handwashing techniques and answered incorrectly regarding cough etiquette. Parents also seemed uncertain about pediatric COVID-19 symptoms. Awareness scores significantly differed across parental role, educational attainment levels, and social-economic levels (p value < .005), with fathers, more educated parents, and those of higher income showing greater levels of awareness.Conclusion: Research results suggest an urgent need for parental education regarding COVID-19 in children, especially regarding handwashing techniques and cough etiquette; educational outreach for both parents and schoolchildren is critical.

Knowledge and attitudes of pediatric clinicians regarding pediatric pain management

BACKGROUND

The professional knowledge and personal attitudes of pediatric clinicians regarding pediatric pain are the most important factors impacting pediatric pain relief care. Few studies have investigated the knowledge and attitudes regarding pediatric pain management of clinicians in Taiwan.

PURPOSE

Research purposes were to evaluate the knowledge and attitudes of pediatric clinicians regarding pain management and to describe the barriers of applying pain management across pediatric and neonatal settings.

DESIGN AND METHODS

A cross-sectional descriptive comparative design was used. Pediatric clinicians from two medical centers and three general hospitals in Taiwan were recruited to complete a questionnaire.

RESULTS

A total of 264 clinicians participated. On 33 questions measuring knowledge of pain management, the average correct response rate was 23.67. A significantly positive relationship was identified between clinicians' knowledge and prior training experience. Professional degree attainment significantly impacted clinicians' attitudes about pediatric pain management. Clinicians at pediatric wards showed more positive attitudes than did clinicians at either pediatric intensive care units or neonatal intensive care units. Five barriers to pediatric pain management were found.

CONCLUSION

The findings of this study suggest that pediatric clinicians in Taiwan need further education regarding pediatric pain management. This study will also helpful in implementing multidisciplinary pediatric pain management programs to improve the quality of pediatric practice in pediatric care settings of hospitals.

Resilience enhancement among student nurses during clinical practices: A participatory action research study

BACKGROUND

Clinical practice is an essential component of nursing students' preparation for applying theoretical knowledge in a real-life setting. However, students often experience clinical practice as extremely stressful, which may disrupt their clinical performance, impact the quality of patient care they provide as well as their own physical and psychological health, and hinder their continuation into nursing careers. Resilience, understood as the capability to overcome challenges, is critical for these students.

PURPOSE

To develop and implement a resilience enhancement (RE)-based project for Taiwanese nursing students during their Last Mile practicum.

DESIGN AND METHODS

A participatory action research (PAR) approach was used in which ongoing planning, action, and reflection informed real-time progress. Twenty-eight nursing students in clinical practice participated in the study. A six-workshop RE project was completed over the course of two months. Evaluation methods involved group discussion, individual interviews, and reflective diaries. Content analysis was applied to the data.

RESULTS

Through a PAR-based project, participants achieved positive results. Three outcome themes were identified: Increasing self-exploration, Furthering confidence and competency, and Constructing resilience.

CONCLUSIONS

The PAR-based RE project helped students to develop resilience by enhancing their nursing knowledge and skills and practicing positive thinking and behavior.

CLINICAL RELEVANCE

The findings can be a reference for nursing educators in designing RE programs for students during clinical practice to increase their professional competence and provide psychological supports.

Evaluation of Comfort and Confidence of Neonatal Clinicians in Providing Palliative Care

BACKGROUND

Research found that low levels of professional confidence and personal comfort among neonatal clinicians regarding palliative care may indicate a lack of competence and hesitancy to offer neonatal palliative care services.

PURPOSE

This study evaluated the factors associated with the confidence and comfort levels of neonatal clinicians providing neonatal palliative care.

METHODS

A cross-sectional survey and questionnaire were used to investigate the confidence and comfort levels of neonatal clinicians regarding neonatal palliative care.

RESULTS

Research subjects included 154 neonatal clinicians. Clinicians' confidence in providing neonatal palliative care was significantly impacted by age, marital status, years of professional experience (p < 0.05), and prior palliative care training. Comfort levels were significantly impacted by educational degree, marital status, and years of working experience. Clinicians with a supportive workplace reported increases in both professional confidence (r = 0.286, p < 0.001) and personal comfort (r = 0.521, p < 0.001).

CONCLUSION

Research reveals the importance of neonatal palliative education and suggests further development of interdisciplinary neonatal palliative care teams to improve clinicians' professional confidence and personal comfort.

Effectiveness of Pediatric Palliative Care Education on Pediatric Clinicians

A lack of knowledge and skills in pediatric palliative care may create hesitation in caring for children with serious life-threatening conditions and their families. Our research examined the effectiveness of pediatric palliative care training for pediatric clinicians. A pretest–posttest study provided educational training in pediatric palliative care to pediatric clinicians and used a pretest and a posttest to assess outcomes. Fifty pediatric clinicians attended this research with 83.3% response rate. After training, participants reported significantly increased confidence in a variety of areas, including providing emotional support to clinicians, personal knowledge, skills, and communication; ethical and legal concerns; and providing emotional support to dying children and their families. Results showed a significant main effect of training on confidence levels ( p < .000). This suggests that education can effectively boost pediatric clinicians’ confidence regarding providing pediatric palliative care and therefore should regularly be provided to clinicians.

The effect of positioning on preterm infants' sleep-wake states and stress behaviours during exposure to environmental stressors

Previous studies separately examined the effects of positioning or environmental stressors on preterm infants' sleep and stress. Since positioning and environmental stressors occur simultaneously during infant hospitalization exploring these variables in the same study may offer new insights. A quasi-experimental study by one-group interrupted time-series design. In the current study, a total of 22 preterm infants were enrolled. Each infant was moved to either the supine or prone position for an hour at a time. Infants were videotaped and the sleep-wake states, stress behaviours and environmental conditions (light, noise and stimulation/handling) were recorded during the observation period. A total of 80 observations from 22 infants were accrued. In the supine position, preterm infants demonstrated more frequent waking states after adjusting for various environmental stressors (p < .01). These infants demonstrated more frequent stress behaviours in the supine position after adjusting for various environmental stressors (p < .01). These results suggest that the prone position is a more favourable position for facilitating sleep and reducing stress for preterm infants exposed to varying environmental stressors. Preterm infants present different stress behaviours in response to varying types of environmental stimuli.

Comparison of the Educational Needs of Neonatologists and Neonatal Nurses Regarding Palliative Care in Taiwan

BACKGROUND

Education and training are very critical to development of high-quality neonatal palliative care. However, little investigation has been done into Taiwanese neonatal clinicians' educational needs regarding neonatal palliative care.

PURPOSES

The purposes of this study were to characterize and identify neonatal clinicians' educational needs regarding neonatal palliative care.

METHODS

A cross-sectional descriptive surveyed method via a self administered questionnaire was used in this research. Thirty neonatologists were recruited by a convenience sampling and 30 nurses were recruited by a randomized sampling.

RESULTS

Out of sixty neonatal clinicians' survey, few had received the education in neonatal palliative care. Most reported minimal training in, experience with, and knowledge of neonatal palliative care. For neonatologists, two of twelve most strongly-felt educational needs were "discussing palliative care and ethical decision-making with parents" (70%) and "informing parents the poor progress in neonates" (63.3%). In contrast, neonatal nurses wanted more training regarding pain control (50%). Communication skills, including the discussing poor prognosis, bad news, and code status and talking with neonates about end-of-life care, were the educational need most commonly felt by both neonatologists and nurses.

CONCLUSIONS

Survey data from neonatologists and neonatal nurses in Taiwan indicate a need for further training on a range of neonatal palliative care competencies.

Relationship between energy expenditure and stress behaviors of preterm infants in the neonatal intensive care unit

PURPOSE

This research evaluated the relationship between behaviors and energy expenditure in preterm infants receiving nursing interventions.

DESIGN AND METHODS

This study was an explorative secondary data analysis from a previous study. The current study investigated energy expenditure calculated using heart rate-based energy expenditure-estimate across 500 repeated measures for 37 infants.

RESULTS

Research results indicate that preterm infants expend more energy when they show the following seven behaviors: grimace, sucking, diffusion squirm, fist, gape face, salute, and sneezing.

PRACTICE IMPLICATIONS

The interventions for preterm infants should be flexible, according to the infant's stress behaviors and conditions of energy expenditure.

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.

The attitudes of neonatal professionals towards end-of-life decision-making for dying infants in Taiwan

The purposes of research were to describe the neonatal clinicians' personal views and attitudes on neonatal ethical decision-making, to identify factors that might affect these attitudes and to compare the attitudes between neonatal physicians and neonatal nurses in Taiwan. Research was a cross-sectional design and a questionnaire was used to reach different research purposes. A convenient sample was used to recruit 24 physicians and 80 neonatal nurses from four neonatal intensive care units in Taiwan. Most participants agreed with suggesting a do not resuscitate (DNR) order to parents for dying neonates (86.5%). However, the majority agreed with talking to patients about DNR orders is difficult (76.9%). Most participants agree that review by the clinical ethics committee is needed before the recommendation of 'DNR' to parents (94.23%) and nurses were significantly more likely than physicians to agree to this (p=0.043). During the end-of-life care, most clinicians accepted to continue current treatment without adding others (70%) and withholding of emergency treatments (75%); however, active euthanasia, the administration of drug to end-of-life, was not considered acceptable by both physicians and nurses in this research (96%). Based on our research results, providing continuing educational training and a formal consulting service in moral courage for neonatal clinicians are needed. In Taiwan, neonatal physicians and nurses hold similar values and attitudes towards end-of-life decisions for neonates. In order to improve the clinicians' communication skills with parents about DNR options and to change clinicians' attitudes for providing enough pain-relief medicine to dying neonates, providing continuing educational training and a formal consulting service in moral courage are needed.

Self-efficacy of first aid for home accidents among parents with 0- to 4-year-old children at a metropolitan community health center in Taiwan

Although accidental injury is the main factor involved in the death of young children in many countries, few studies have focused on parents' competence with regard to self-efficacy of first aid for their children following injuries occurring at home. The purpose of this cross-sectional study was to investigate parental self-sufficiency of first aid for home accidents in children aged 0-4 years. The study is a cross-sectional designed. Data from 445 parents recruited were collected by purposive sampling at eight metropolitan community health centers in central Taiwan. Measurements were taken from a self-developed questionnaire that included 37 questions. Logistic regression analysis was applied to explore the associations between factors and parents' self-efficacy of first aid at home accident. Our findings show that parents' overall rate of knowledge of first aid was 72%. The mean score for 100% certainty in parents' self-efficacy of first aid was 26.6%. The lowest scores for self-efficacy were with regard to choking and cardiopulmonary resuscitation (CPR). There was a significantly positive correlation between parents' knowledge and self-efficacy of first aid (p<0.01), and thus knowledge of first aid is a predictor of parents' self-efficacy. Knowledge of first aid is also a partly mediator between participants' attending first aid program, participants' first aid information obtained from health personnel and self-efficacy of first aid. Our findings suggest that medical services should provide first aid resources to help manage accidental injuries involving children, particularly information on how to deal with choking and CPR. With an appropriate program provided by health professionals, parents' self-efficacy of first aid for home accidents will be positively enhanced.

Cultural practices and end-of-life decision making in the neonatal intensive care unit in Taiwan

The purpose of this research was to describe conditions of decision making for dying infants and cultural effects on the process of infant death in the neonatal intensive care unit. A retrospective chart review was used in this research. Fifty charts were reviewed; the major cause of death for the research subjects was complications of prematurity (52%). Eighty-two percent of the charts documented a do not resuscitate order, and 16% of parents allowed discontinuation of ventilator support when they realized the futility of continued care. In 30 nursing records, parents and their dying infants were offered a quiet place in which to grieve. In 10 cases, nurses accompanied these parents and allowed them to express their emotions. Research findings showed great outward expression of religion at the time of death. Various cultural issues affected both the grieving process of the families and the dying process of their infants.

To explore the conditions of dying infants in NICU in Taiwan

PURPOSES

Research purposes were to document the symptoms characteristic of neonates during their last week of life and to describe the activities undertaken in nursing care of dying neonates in neonatal intensive care unit (NICU).

METHODS

A retrospective chart review was used in this research. All charts of neonatal inpatients who died in the NICU between 2002 and 2008 and who met entry criteria were included the research review.

RESULTS

Sixty-one charts were evaluated in this research. The major underlying disease was the complications of prematurity (33%). Major physiological distress signs in the last week of life included respiratory distress (67.2%), cyanosis (54.1%), bradycardia (36.1%), oliguria (31.1%), and generalized edema (37.7%). All infants were intubated and received artificial ventilation in the last week of life. Physicians prescribed an analgesic medicine for 7 infants, and 7 infants received comfort interventions to manage their distress signs. Forty-one infants had preexisting do-not-resuscitate order at the time of death.

CONCLUSIONS

Research findings suggest that the application of palliative care paradigm and more aggressive comfort care to manage signs in NICU might be beneficial to dying infants.

To explore relationships between physiological stress signals and stress behaviors in preterm infants during periods of exposure to environmental stress in the hospital

The purpose of this exploratory descriptive study was to examine relationships among physiological stress signals (heart rate (HR), respiratory rate (RR), and oxygen saturation) and stress behaviors (6 stress behaviors related to sleep-wake states, 10 self-regulatory behaviors, and 17 behavioral stress cues) in preterm infants during periods of environmental stress. This research used a prospective repeated-measures design in a convenience sample of preterm infants of <37 weeks' gestational age and <28 days' postnatal age. All infants were in the incubator in a neonatal intensive care unit or a sick baby care unit in one of two hospitals at the time of data collection. Multiple linear regressions of generalized estimating equations were used to determine relationships. Variables were measured every 2 min over 4 hr, for a total of 4,164 observations in 37 preterm infants. There were statistically significant relationships between 9 stress behavioral responses and changes in HR (seven stress behaviors and two self-regulatory behaviors; p < .05), between 9 stress behavioral responses and changes in RR (seven stress behaviors and two self-regulatory behaviors; p < .05), and between 11 stress behavioral responses and changes in oxygen saturation (seven stress behaviors and four self-regulatory behaviors; p < .05). Findings demonstrate that the functions of self-regulatory behaviors and some special behaviors in preterm infants during environmental stress are related to physiological stress signals. However, results should be investigated further in larger samples.

CEO- CNE relationships: building an evidence-base of chief nursing executive replacement costs

OBJECTIVE

Explore professional relationships between Chief Nurse Executives (CNEs) and Chief Executive Officers (CEOs); CNE ethnic diversity; and CNE replacement costs.

BACKGROUND

Theoretical frameworks - Marilyn Ray's Theory of Bureaucratic Caring, and Turkel's Theory of Relational Complexity espousing economic as well as caring variables.

METHODS

Exploratory mixed-method descriptive design using CNE mailed survey.

RESULTS

CNE- cited opportunities for maintaining a positive relationship with the CEO: respect for CEO; goal- sharing (r=.782, p<0.01); having a strong relationship (r= .718, p<0.01); co-problem-solving (r=.437, p<0.01); having an interesting job (r=.406, p<0.01); having similar interests with CEO (r= .346, p<0.01); CEO and CNE maintaining specific roles (r= .261, p<0.05); satisfaction with CNE income (r=.251, p<0.05); willingness to improve relationship with CEO (r=.254, p<0.05). CNE positions demonstrated an ethnic diversity factor of 0.03%. CNE replacement costs to healthcare facilities were over 1.5 million dollars.

CONCLUSION

CNE/CEO relationships have identified cohesive factors that may contribute to CNE longevity in position; an ethically diverse CNE deficit exists; and, CNE turnover and vacancy rates impact an organization's financial health and quality of care.

Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU

Although research has demonstrated that the neonatal intensive care unit (NICU) is a stressful environment for preterm and high-risk infants, little research validates the suspected relationships between infant biobehavioral responses and environmental stress in the NICU. This exploratory study examined the relationship between environmental stress and biobehavioral responses of preterm infants. The study used a repeated-measures research design to examine research variables in one group of preterm infants. Measurements of research variables were recorded every 2 minutes during two 60-minute observation periods for each research day (1 hour in the morning and 1 hour in the afternoon) and conducted over 2 days. A convenience sample of 37 preterm infants was recruited from 2 medical centers in Taiwan. A total of 4164 observations were made and recorded during the study. There was a statistically significant (P < .05) relationship between environmental stressors and changes in physiological signals. There were also statistically significant (P < .05) relationships between environmental stress and some specific stress behaviors. This research is applicable to neonatal clinical practice because it demonstrates the importance of recognizing the preterm infant's biological stress responses to environmental stressors, allowing for early interventions to reduce the possibility of more serious physiological or pathological changes in the status of the preterm infant.

[Effects of light intensity on the physiological parameters of the premature infant]

This study attempts to find out the effects of light intensity on premature infants' physiological parameters. The research method adopted utilized a quasiexperimental repeated measures design. Thirty-five premature infants born in no more than thirty seven gestation weeks and with birth weight less than 2500g were targeted. The first step was to examine the original arrangement of the blankets over the incubators, the second step was to investigate the effect of placing blankets on the top of the incubator and draped down the top 1/3 of the sides. The third step was conducted without blankets. Factors including light intensity and volume in the incubator and heart rate, respiration rate, and blood oxygen saturation of the premature infants were recorded in all three steps. During the experimental period, no nursing treatment or interventions were allowed. Instruments used in the study included a photometer, a phonometer, a V8 camera, a heart rate monitor, a respiration monitor, and a blood oxygen saturation monitor. The study was conducted in the NICUs in three district hospitals in northern Taiwan. To analyze the data, descriptive statistics and the General Estimation Equation (GEE) were applied. The study shows: (1) Light intensity had a significant statistical relationship with the premature infants' physiological parameters (p = .00). (2) The heart rate and respiration rate increased and the blood oxygen saturation decreased as the intensity of light went up. (3) Placing a blanket over the top and sides of the incubator effectively reduces light levels inside (p = .00). The results of this study suggest a treatment principle for premature infants and provide a basis further research.

[Continuous infusion of morphine in use of pain relief after upper abdominal surgery]

This study was designed as a prospective randomized comparative trial of continuous infusion of morphine (CIM) controlled by a micro-electric pump and traditional intermitted intramuscle injection of pethidine (IMP) to relieve pain after surgery. 40 patients submitted from upper abdominal surgery were divided into two groups, 20 patient receiving CIM and others using IMP. The amount of morphine used during the 24 hours was 0.5 mg/kg in CIM group. In IMP group, 20 patients were given standard intramuscular dosages of 1.5 mg/kg of pethidine, then, every 4-6 hours repeatedly within 24 hours after operation. An analgesic scale was observed by WHO's pain score from I to IV degree. The result showed that all patients of CIM group had good analgesic effect (I and II degree), however, 10% of the patients in IMP group had only analgesic effect of I and II degree during the first 24 hours after operation. Their respiratory frequency, heart rate, BP and SpO2 had no significant difference in two groups. It woule appear that CIM is an efficacious and safe method for providing postoperative pain relief.