The use of projected autonomy in antenatal shared decision-making for periviable neonates: a qualitative study

BACKGROUND

In this study, we assessed the communication strategies used by neonatologists in antenatal consultations which may influence decision-making when determining whether to provide resuscitation or comfort measures only in the care of periviable neonates.

METHODS

This study employed a qualitative study design using inductive thematic discourse analysis of 'naturally occurring data' in the form of antenatal conversations around resuscitation decisions at the grey zone of viability. The study occurred between February 2017 and June 2018 on a labor and delivery unit within a large Midwestern tertiary care hospital. Participants included 25 mothers who were admitted to the study hospital with anticipated delivery in the grey zone of viability and practicing neonatologists or neonatology fellows who partnered in antenatal consultation. We used a two-stage inductive analytic process to focus on how neonatologists' discourses constructed SDM in antenatal consultations. First, we used a thematic discourse analysis to interpret the recurring patterns of meaning within the transcribed antenatal consultations, and second, we theorized the subsequent effects of these discourses on shaping the context of SDM in antenatal encounters.

RESULTS

In this qualitative study, that included discourse analysis of real-time audio conversations in 25 antenatal consults, neonatologists used language that creates projected autonomy through (i) descriptions of fetal physiology (ii) development of the fetus's presence, and (iii) fetal role in decision-making.

CONCLUSION

Discourse analysis of real-time audio conversations in antenatal consultations was revelatory of how various discursive patterns brought the fetus into decision-making, thus changing who is considered the key actor in SDM.

Moral distress among neonatologists working in neonatal intensive care units in Greece: a qualitative study

BACKGROUND

Working as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration.

METHODS

This prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach.

RESULTS

A variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists' moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists' moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant's best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists' colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time.

CONCLUSIONS

We concluded that neonatologists' moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.

The care of critically ill infants and toddlers in neonatal intensive care units across Italy and Europe: our proposal for healthcare organization

Numerous studies have shown that critically ill infants and toddlers admitted to paediatric intensive care units (PICUs) have a lower mortality than those admitted to adult ICUs. In 2014, there were only 23 registered PICUs in Italy, most of which were located in the north. For this reason, in Italy and elsewhere in Europe, some neonatal ICUs (NICUs) have begun managing critically ill infants and toddlers. Our proposal for healthcare organization is to establish "extended NICUs" in areas where paediatric intensive care beds are lacking. While some countries have opted for a strict division between neonatal and paediatric intensive care units, the model of "extended NICUs" has already been set up in Italy and in Europe. In this instance, the management of critically ill infants and toddlers undoubtedly falls upon neonatologists, who, however, must gain specific knowledge and technical skills in paediatric critical care medicine (PCCM). Postgraduate residencies in paediatrics need to include periods of specific training in neonatology and PCCM. The Italian Society of Neonatology's Early Childhood Intensive Care Study Group is supporting certified training courses for its members involving both theory and practice.

CONCLUSION

Scientific societies should promote awareness of the issues involved in the intensive management of infants and toddlers in NICUs and the training of all health workers involved. These societies include the Italian Society of Neonatology, the European Society of Paediatric and Neonatal Intensive Care, and the Union of European Neonatal and Perinatal Societies. They should also act in concert with the governmental institutional bodies to establish the standards for the "extended NICUs."

WHAT IS KNOWN

• The mortality of critically ill infants and toddlers admitted to PICUs is lower than that for those admitted to adult ICUs. • In Italy, there are only a handful of PICUs, located mainly in the north.

WHAT IS NEW

• Critically ill infants and small toddlers can be managed in "extended NICUs" in areas with a lack of paediatric intensive care beds. • "Extended NICUs" is our proposal for healthcare organization to compensate for the paucity of paediatric intensive care beds, but neonatologists must be trained to provide them with specific knowledge and technical skills in PCCM.

Effects of parent-provider communication during infant hospitalization in the NICU on parents: A systematic review with meta-synthesis and narrative synthesis

OBJECTIVE

To synthesize and analyse the literature on the effects of parent-provider communication during infant hospitalization in the neonatal (intensive) care unit (NICU) on parent-related outcomes.

METHODS

Systematic review with meta-synthesis and narrative synthesis. Databases (PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, Scopus) were searched in October/November 2019. Studies reporting, observing, or measuring parent-related effects of parent-provider communication in the NICU were included. Study quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs. Qualitative studies were meta-synthesized using deductive and inductive thematic analysis. Quantitative studies were analysed using narrative synthesis.

RESULTS

5586 records were identified; 77 were included, reporting on N = 6960 parents, N = 693 providers, and N = 300 NICUs. Analyses revealed five main (positive and negative) effects of parent-provider interaction on parents' (1) coping, (2) knowledge, (3) participation, (4) parenting, and (5) satisfaction. Communication interventions appeared impactful, particularly in reducing parental stress and anxiety. Findings confirm and refine the NICU Communication Framework.

CONCLUSIONS

Parent-provider communication is a crucial determinant for parental well-being and satisfaction with care, during and following infant hospitalization in the NICU. R. Practice Implications: Providers should particularly consider the impact on parents of their day-to-day interaction - the most occurring form of communication of all.

[What Makes a Pediatrician a Neonatologist]

On behalf of Comissão Técnica Secção Subespecialidade de Neonatologia Do Colégio de Pediatria

Knowledge, attitudes and practices of neonatal professionals regarding pain management

Pain management is an important issue which impacts the prognosis of neonates in neonatal intensive care units. Evidence has shown that professionals' knowledge and attitudes regarding pain management can impact the quality of their practice. The purpose of this study was to evaluate the knowledge, attitudes, and practices of neonatal professionals regarding neonatal pain management. A cross-sectional study was performed involving neonatal physicians and nurses, using a research questionnaire to investigate the knowledge and attitudes of professionals as well as to assess their practice of pain management. Research found an apparent discrepancy between the knowledge levels of neonatologists and nurses regarding pain assessment and management, with nurses displaying weaker professional knowledge and more negative attitudes toward pain management than did neonatologists. Additionally, research revealed a lack of knowledge and negative attitudes among participants regarding the provision of sufficient opioid analgesics to sick infants during invasive procedures and even for dying neonates. There is an urgent need for continuing education regarding neonatal pain management with the goal of empowering neonatal professionals; further research is needed into the question of how to translate education into more reliable practice.Conclusion: This research provides useful information regarding the knowledge, attitudes, and clinical practice of neonatal pain management among neonatologists and nurses and points out some differences in the knowledge levels of these two groups. What is Known: •Neonates can perceive and respond to pain stimuli by showing their biological signals similarly to children and adults. •Untreated or insufficient pain management for high-risk neonates has short-term. negative effects and may also induce long-term negative effects. What is New: •The level of knowledge, the attitudes, and the practices regarding neonatal pain in intensive care are different among neonatal professionals. •There is an urgent need to provide interdisciplinary continuing education to improve the knowledge of neonatal professionals and encourage them to more highly prioritize neonatal pain management.

Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist

OBJECTIVES

Functional echocardiography is a valuable tool in the neonatal intensive care unit, but training programs are not standardized. The aim was to report an functional echocardiography training program for neonatologists and to describe the agreement of their measurements with the pediatric cardiologist.

METHODS

Functional echocardiography training lasted 32h. After training program, the neonatologists performed functional echocardiography in the neonatal intensive care unit and were required to measure left cardiac chambers dimensions, left ventricle systolic function, right and left ventricular output, ductus arteriosus diameter, and flow pattern. Images were recorded by the equipment and reviewed offline by the pediatric cardiologist. The Bland-Altman test was used for quantitative variables and the kappa test, for qualitative variables.

RESULTS

Twenty-two trained neonatologists performed 100 functional echocardiography exams. Ductus arteriosus identification and flow pattern had substantial agreement (kappa=0.91 and 0.88, respectively), as well as its diameter (mean difference=0.04mm). The mean difference for the aortic root was -1.2mm; left atrium, 0.60mm; left ventricle diastolic diameter, -0.90mm; left ventricle systolic diameter, -0.30mm. Shortening fraction and ejection fraction correlated well with broad limits of agreement, -2.96% (14.88; -20.82%) and --3.43% (15.54; -22.40%), respectively. Right and left ventricular output had broad limits of agreement, 16.69mL/kg/min (222.76; -189.37) and 23.57mL/kg/min (157.88; -110), respectively. There was good agreement between interpretations of normal or low cardiac output (76.7% for right ventricular output; 75.7% for left ventricular output).

CONCLUSION

This functional echocardiography training program enabled neonatologists to obtain adequate skills in performing the images, obtaining good agreement with the cardiologist in simple hemodynamic measurements and ductus arteriosus evaluation.

Perceptions of European medical staff on the facilitators and barriers to physical closeness between parents and infants in neonatal units

Aim

Studies have provided insights into factors that may facilitate or inhibit parent–infant closeness in neonatal units, but none have specifically focused on the perspectives of senior neonatal staff. The aim of this study was to explore perceptions and experiences of consultant neonatologists and senior nurses in five European countries with regard to these issues.

Methods

Six small group discussions and three‐one‐to‐one interviews were conducted with 16 consultant neonatologists and senior nurses representing nine neonatal units from Estonia, Finland, Norway, Spain and Sweden. The interviews explored facilitators and barriers to parent–infant closeness and implications for policy and practice, and thematic analysis was undertaken.

Results

Participants highlighted how a humanising care agenda that enabled parent–infant closeness was an aspiration, but pointed out that neonatal units were at different stages in achieving this. The facilitators and barriers to physical closeness included socio‐economic factors, cultural norms, the designs of neonatal units, resource issues, leadership, staff attitudes and practices and relationships between staff and parents.

Conclusion

Various factors affected parent–infant closeness in neonatal units in European countries. There needs to be the political motivation, appropriate policy planning, legislation and resource allocation to increase measures that support closeness agendas in neonatal units.

Variation in the diagnosis and management of patent ductus arteriosus in premature infants

OBJECTIVES

To determine variations in neonatology practice regarding the diagnosis and management of patent ductus arteriosus (PDA) in premature infants.

DESIGN

Standardized telephone interview of preferences and practices.

SUBJECTS

Canadian neonatologists in active clinical practice.

RESULTS

Of 136 eligible Canadian neonatologists, 100 respondents (74%) estimated the proportion of infants with suspected PDA who have echocardiography to be a median of 80% (range 0% to 100%), with considerable variation both within and between centres. Only two centres had written guidelines. More recent medical school graduates were significantly more likely to use echocardiography. Increased use of echocardiography was also significantly related to increased availability. Fluid restriction and indomethacin was used as initial therapy by 89% of respondents, with the indomethacin dose standardized for 83%; surgical ligation was used when indomethacin therapy was contraindicated or had failed. Personal guidelines directed decisions regarding therapy for the majority of neonatologists.

CONCLUSIONS

Among Canadian neonatologists, there is considerable variation regarding practices related to the diagnosis and management of PDA in premature infants. This variation may potentially affect the cost effectiveness of care for these patients.